Waiting to Inhale: An exploration into treatment of the growing public health problem
Asthma.
Written By: John
Cooper BBA, CSCS
Introduction
For the majority of
Canadians, nothing in life is as simple as breathing. Breathing is a function
of life that most Canadians never have to be concerned with. This integral part
of human survival is easy to take for granted, unless of course, you are one of
the millions of Canadians that suffer from chronic asthma. Asthma is a serious
chronic lung disease affecting over 2 million Canadians (Glaxo Wellcome Inc.,
2000). In fact, 10 to 15% of all the children in
- What
is asthma, and how does it affect those that suffer from it?
- What
are some of the current asthma trends in
-
What are the current treatments available to the asthma patient? - What
are the advantages and disadvantages of the various treatments?
- Which
asthma treatments are the most effective for adult chronic asthma
sufferers?
- What
are some of the major obstacles associated with asthma therapy and disease
management?
- Can
asthmatics live normal healthy lives?
Asthma comes in many different forms and affects different
people in different ways. Given the huge variety of situations associated with
asthma, this report will focus primarily on adult populations with chronic
asthma.
What is Asthma?
According to a comprehensive 1997 study on asthma, conducted by Robert Lemanske Jr. and William Busse, asthma is “a chronic breathing disease of wheezing and shortness of breath, caused by airway obstruction and inflammation” (p. 1855). The inflammation that occurs in asthma can become chronic, which in turn, causes the individual’s lungs to be easily irritated and hypersensitive (Glaxo Wellcome Inc., 2000). Asthma causes the lung airways to contract, swell, and clog up with mucus (Mosby’s Medical Encyclopedia, 1997). Figure 1 outlines the anatomy of the human lungs.
Figure 1: Anatomy of
the Lungs
Normal lungs prior to an asthma attack are clear and open (see Figure 2). During an asthma attack, the body releases chemicals that cause the muscles surrounding the airways to constrict and narrow, the lining of the airways becomes inflamed or swollen and begins to fill with mucus, further blocking the airway (Figure 3) (Asthma in Canada, 2000).
Figure 2: Lungs Before an Asthma Attack
Figure 3: Lungs During an
Asthma Attack
The list of asthma triggers is long and growing. According
to the Mosby’s Medical Encyclopedia (1997), some of the most common triggers
are:
- Certain
foods (e.g. chocolate, nuts, eggs, shellfish, milk, oranges, wine, beer)
- Pollen
& mold spores
- Tobacco
smoke
- Animals
dander (e.g. fur, skin flakes, feathers)
- Dust
and dust mites
- Smog
and automobile fumes
- Cold
air, hot air, high humidity, or very dry air
- Personal
care products (e.g. hair spray, cosmetics, perfumes)
- Aerosol
sprays of any kind
- Changes
in weather temperature
- Respiratory
infections and colds
- Emotions
(e.g. anger, fear, crying, laughing too hard, stress)
- Exercise
Asthma also has a strong heredity factor. It is estimated
that 75% of children with asthma have a family history of the disorder (Mosby’s
Medical Encyclopedia, 1997). With so many potential triggers its
no wonder that this chronic lung disease affects so many people.
Who is Affected by Asthma?
This disease affects any Canadian that contributes to health
care in
- Direct
costs associated with asthma in
- Asthma
is the leading cause of absenteeism from school, and the third leading
cause of work loss.
- Asthma
is the number one cause of emergency room visits
- In
1994, the cost of hospitalization in
- Worldwide,
the economic costs associated with asthma are estimated to exceed the
costs associated with tuberculosis, and HIV & Aids combined.
What makes these figures even more alarming is that in
Canada, the majority of these asthma related expense are preventable, and are
primarily due to poorly controlled asthma, with 6 in 10 Canadians not having
their asthma adequately controlled (Asthma in Canada, 2000).
In
Figure 4: Increase
in Prevalence of Asthma in Canadian Adults
Although the prevalence of asthma has been on the rise,
thankfully the death rate from asthma is on the decline, and has been since
1990 (Canadian Lung Association, 1994). According to the Canadian lung
association, there are still approximately 10 asthma deaths per week (1999).
The association also reports that on a worldwide basis respiratory diseases are
the second largest cause of death and disability among adults, only cancer
ranks higher (1999). Unlike cancer however, it is estimated that 80% of asthma
deaths could be prevented through administration of proper asthma education
(Harrison and Pearson, 1992). According to a 1998 Statistics
“Despite advances in
understanding the disease, and the availability of more efficacious
medications, asthma is still a major cause of morbidity. This
is often a result of under diagnosis, under treatment, lack of public
understanding and knowledge about the disease, and inadequate asthma
supervision” (p.24).
What Asthma Treatments Are Currently Available?
Asthma affects different people in different ways. Some
asthmatics experience symptoms primarily because of the development of mucous
in the bronchioles, others have symptoms due primarily to smooth muscle spasms
surrounding the airways, these symptom are also influenced by what initially
triggers the attack (e.g. exercise or allergens) (Lemanske & Busse, 1997).
Obviously, if a patient’s asthma is a result of a specific identified allergen,
then that allergen should be avoided. However, as the extensive list of
triggers identified earlier demonstrates, avoidance is typically unrealistic.
It is for these complicated reasons that a variety of treatments are available
for today’s asthmatics. Generally speaking, most asthmatics are prescribed two
kinds of asthma medicine: one for quick relief and one for long term control
(American Family Physician, 2001). These
two types of medication are beginning to become commonly known as ‘relievers’
and ‘controllers (Lemanske & Busse, 1997). Other common terms for relievers
and controllers are ‘rescuers’ and ‘preventers’ (Gross & Ponte, 1998). The
relievers are used to instantly relive symptoms of an attack and the
controllers are used to prevent attacks and increase the patient’s control over
their asthma.
The long-term controllers are typically taken everyday, and
include anti-inflammatory medications such as inhaled corticosteroids,
leukotrine receptor antagonist, and combination products (Asthma in
The most common asthma medications are (Gross & Ponte,
1998):
- Corticosteroids
- Cromolyn Sodium & Nedocromil
- Salmeterol and Extended Release-Albuterol
- Theophylline
- Zafirlukast and Zileton (Leukotrines)
- Short
Acting [Beta.sub.2] Agonists
With so many options it is no wonder that lack of patient
awareness and education is contributing significantly to the poor level of
asthma control in
What Are The Advantages & Disadvantages of the Various Asthma
Treatments?
Corticosteroids
In the June, 2001, Journal of Respiratory diseases, T.H.
Horiuchi states that inhaled corticosteroids (IC’s) are the most effective
anti-inflammatory agents available for the treatment of asthma. According to Horiuchi, some of the advantages
of IC’s are:
- Decreased
airway inflammation by reducing the number of inflammatory cells
- Decreased
airway hyperactivity
- Improved
lung function (Figure 4)
- Decreased
hospitalization
Some of the disadvantages associated with IC’s include
(Horiuchi, 2001):
- Reduced
secretion of cortisol from the adrenal gland and
a potential reduced adrenal response to stress
- Potential
adverse effects on bone metabolism, leading to osteoporosis and increased
risk of fractures
- Decreased
sex hormone secretion
- Increased
renal loss of calcium
- Growth
suppression in children with long-term treatment
- Recognized
risk factor for the development of posterior subcapsular
cataracts
- Thinning
of the skin and easy bruising depending on dose levels (>800mcg)
- Dysphonia (hoarseness) is the most common side effect,
and occurs in about 40% of patients and is reversible when IC’s are
discontinued
Figure 4:
Corticosteroids and Lung Function
Despite what appears to be along list of side effects, when
used in recommended doses there are minimal adverse effects (Lemanske &
Busse). For long-term use, inhaled
steroids are generally preferred over oral steroids because of the decrease in
side effects associated with inhaled IC’s (Gross & Ponte, 1998).
Cromolyn Sodium &
Nedocromil
Cromolyn Sodium & Nedocromil are considered very safe agents with mild to
moderate anti-inflammatory effects (Gross & Ponte, 1998). These medications
are not bronchodilators, but have been shown to inhibit inflammatory cell
activation, early and late bronchoconstriction, and airway hyper responsiveness
(Lemanske and Busse, 1997). Cromolyn Sodium & Nedocromil are both well tolerated in patients, although
side effects such as cough, throat irritation, and unpleasant taste have been
reported (Gross & Ponte, 1998).
Salmeterol and Extended
Release-Albuterol
Salmeterol is basically a long acting version of [beta.sub.2]
agonist, with a similar mechanism of action and side effect profile (Gross
& Ponte, 1998). For detailed information refer to the section on short
acting [beta.sub.2] agonists below.
Theophylline
Theophyline was once considered a
mainstay for asthma treatment, but is currently prescribed more as a second or
third line agent because of its adverse side effects, and its interactions with
many other drugs (Gross & Ponte, 1998). In addition to these problems,
serum levels have to be monitored during treatment, which can be extremely
inconvenient (Gross & Ponte, 1998). The drugs side effects include
(Lemanske and Busse, 1997):
- Intolerable
gastrointestinal symptoms (even well within therapeutic drug levels)
- Potential
adverse effects of performance in school for children
- Slower
onset action and a lower peak bronchodilator effect
Theophyline is an effective
bronchodilator, and can have beneficial effects to allergen induced asthma,
improved exercise tolerance, and a steroid sparring effect (Lemanske and Busse,
1997).
Leukotrienes
Antagonists (a.k.a.: Anti –leukotrienes)
Basically leukotrienes contribute to the increased mucus
production and subsequent bronchoconstriction associated with asthma attacks
(Gross & Ponte, 1998). As the name suggests, anti-leukotrienes reduce the
production of the leukotrienes. One of the advantages associated with
leukotrienes is the ease of administration (usually taken as a once daily or
twice daily oral medication) (Salvi, 2001). Current
studies indicate that these drugs are highly effective in patients with aspirin
induced asthma and exercise induced asthma, and are recommended for patients
that fit those categories (Salvi, 2001). Long-term
administration has also lead to reductions in oral and inhaled corticosteroids
(Lemanske & Busse, 1997). Some of
the side effects associated with Leukotriene
Antagonist include: headache, infection, diarrhea, nausea, dyspepsia, and
occasional irritation of asthma symptoms (Gross & Ponte, 1998).
Short Acting
[Beta.sub.2] Agonists
Short acting inhaled [beta.sub.2] agonists are the agents of
choice for relieving bronchospasms and preventing exercise induced
bronchospasms (Figure 5)(Gross & Ponte, 1998).
Figure 5: Inhaled
[Beta.sub.2] Agonists and Lung Function
The drug’s availability in
multiple forms (short, intermediate, and long acting), and multiple delivery
systems gives these drugs a huge amount of versatility (Lemanske & Busse,
1997). The short acting agonists are
widely prescribed because of their fast action (i.e. less than five minutes)
and longer lasting action (i.e. 3-8 hours) (Gross & Ponte, 1998). Despite
the obvious advantages to using short acting [beta.sub.2] agonists, some
precautions need to be considered. Some disadvantage
associated with the use of these drugs include:
- Several
studies suggest that chronic daily usage may lead to worsening asthma
control and decreased pulmonary function, particularly in moderate to
severe asthma (Gross & Ponte, 1998).
- Because
of the effectiveness of these drugs for short term relief, control over
asthma can deteriorate if the asthmatic uses the drugs in exclusion of
anti-inflammatory medications (Lemanske & Busse, 1997).
Frequent use of these
drugs indicated that the asthmatic has poor control over their asthma and
signals the need for additional treatment (Lemanske and Busse, 1997). It should
also be mentioned that many studies regarding the development of tolerance to
these drugs have been inconclusive (Lemanske & Busse, 1997).
Which Asthma Treatments are the Most Effective
for Adult Chronic Asthma Sufferers?
There is no quick answer to this complicated question. The
treatment that is most effective for the chronic asthma sufferer depends on
several factors. One of the first considerations in making a decision should be
to determine the severity of the disease (Lemanske and Busse, 1997). At
present, no single test accurately classifies the level of asthma severity;
however, the Global Initiative for Asthma (GINA) has proposed a general
classification system, which can be helpful in formulating an asthma management
plan (Lemanske & Busse, 1997). These
classifications are: mild intermittent, mild persistent, moderate persistent,
and sever persistent. A physician should be consulted to determine where an
asthmatic fits in the classification. Asthmatics with persistent asthma require
medications that provide long-term control of their disease and medications
that can also provide quick relief (Gross & Ponte, 1998). Research
suggests that inhaled corticosteroids are the most effective anti-inflammatory
medications available to the chronic asthmatic (Horiuchi, 2001). Horiuchi
states that Inhaled corticosteroids are the mainstay of therapy for patients
who have persistent symptoms (2001). The huge amount of research available and the
various approaches taken by asthma experts, leads one to believe that effective
asthma management varies from individual to individual, and that a systematic
approach to treatment should be taken. New guidelines from
the National Asthma Education and Prevention Program Expert Panel II recommend
an aggressive “step care” approach. In this approach, therapy is
prescribed at a step higher than the patient’s current level of asthma
severity, and is gradually “stepped down” as control is achieved (Gross &
Ponte, 1998).
What are Some of the Major Obstacles
Associated with Asthma Therapy and Disease Management?
Despite recent advances in asthma treatment and medications,
six in ten Canadians do not have their asthma in control (Glaxo Wellcome Inc.,
2000). Canadian asthma sufferers are suffering a lower quality of life then
necessary, and the Canadian health care system is bearing a completely
unnecessary burden (Glaxo Wellcome Inc., 2000). As previously discussed the
majority of the costs associated with asthma hospitalization are completely
preventable. According to the Asthma In Canada Study,
conducted by the Angus Reid Group, asthma patients and physicians both
underestimate the extent to which asthma is out of control in
According to the United Kingdoms National
Asthma Campaign, “equipping people with asthma with the tools they need to
manage their condition is as important as writing the prescription” (Thoonen and Weel, 2000, p.1482). One of the major problems with asthma
treatment is misunderstanding and/or poor communication with respect to the
role that asthma medications play in keeping the disease under control (Phipatanaku and Wood, 1998). Asthmatics are taking IC’s and
relievers without an understanding of why they are taking them. Consider these
facts uncovered by the Asthma in Canada Survey (2000):
- 50%
of patients with poorly controlled asthma are unaware of the role of
inhaled corticosteroids
- One
third of patients with poorly controlled asthma do not understand the role
of rescue medications
- One
third of patients with poorly controlled asthma use rescue medication
daily
Another study conducted by the Archives of Internal Medicine
found that one in six asthma patients overused inhaled ‘rescuers’ and nearly
two thirds underused inhaled corticosteroids (2000). A Canadian study found that half of the
people surveyed with poorly controlled asthma were unaware that inhaled
corticosteroids reduced airway inflammation, the underlying cause of asthma
(Glaxo Wellcome Inc., 2000). The same study found that 45% mistakenly take an
inhaled corticosteroid when having an attack.
In addition to poor physician-to-patient communication,
other factors that play a role in poor adherence include: prolonged therapy,
delayed consequences from non-adherence, expensive and hard to use medications,
and concerns regarding side effects (D’Eprio, 1999).
One of the considerations of the physician should be to pick the most
acceptable medication, considering the poor adherence or potential poor
adherence of patients (D’Eprio, 1999). For example,
research suggests that children are more likely to take oral medications than
inhaled ones (Kelloway, Wyatt, and Adlis, 1994).
Despite the fact that corticosteroids have been highly recommended by
experts as offering great potential for asthma treatment, many patients have a
steroid-phobia (Kelloway et. al., 1994). It becomes
apparent that increased education on behalf of the physician and the patient is
needed.
Can Asthmatics Live A Normal Healthy
Life?
Yes. Asthmatics can live a normal, healthy, and long life.
Although asthma cannot be cured, it can be well controlled (Glaxo Wellcome
Inc., 2000). Asthma care needs to become part of a lifestyle,
with proper management asthmatics can be free of symptoms (Glaxo Wellcome Inc.,
2000). Despite the fact that 73% of Canadian asthmatics surveyed limit their
involvement in sports, this doesn’t have to be the case (Glaxo Wellcome Inc.,
2000). Many world class Olympic Athletes suffer from asthma, yet they are able
to compete and win at a world class level.
- Minimize
or eliminate chronic symptoms including nocturnal symptoms
- Reduce
frequency of attacks, including the need for emergency visits and
hospitalizations
- Minimize
the need for acute rescue therapy such as inhaled [bete.sub.2] agonists
- Establish
a normal lifestyle with no limitations on activities including exercise
- Normalize
pulmonary functions
- Minimize
or eliminate adverse effects from medications
Conclusions
Asthma in
Reference List
Archives of Internal Medicine.
(2000). Many patients are improperly self-dosing their asthma medications. Geriatrics, 55, 28.
Asthma in
Asthma in
Asthma in
Asthma in
Canadian Lung Association. “Lung Facts.” 1994 Update.
Eprio, P.D. (1999). Improving adherence to asthma medications. Patient Care,
33, 61-71.
Glaxo Wellcome
Inc. (2000). Asthma in
Gross, K.M. & Ponte, C.D. (1998). New
strategies in the medical management of asthma. American Family
Physician, 58, 89-112.
Health
Helgason, G. (2001). Olympians win
big over asthma. Second Wind. Retrieved
Horiuchi, T.K. (2001). Using inhaled
corticosteroids as the mainstay of asthma therapy. Journal of
Respiratory Diseases, 22, 358-368.
Kelloway, J.S., Wyatt, R.A., &
Lemnske Jr., R.F., & Busse, W.W. (1997). Asthma: Primer on
allergic and immunologic diseases. The Journal of the American Medical
Association, 278, 1855-1900.
Phatanakul, W. & Wood, R.A. (1998). Perception of the role and
potential side effects of inhaled corticosteroids among asthma patients. Chest,
113, 587-592.
Sundeep, S.S. (2001). The anti-inflammatory effects of leukotriene-modifying
drugs and their use in asthma. Chest, 119, 463-482.
The Lung Association. (1999). To nebulize or puff? Second Wind. Retrieved
Thoonen, B. & van Weel, C. (2000). Self management in
asthma care. British Medical Journal, 321, 1482-1483.