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Patient Education - Inhaled Steroids - What every asthma sufferer should know

by Neil Gershman, M.D.

There may not be a perfect drug for any particular disease, but for asthma, inhaled steroids come pretty close. There are extremely effective in the great majority of patients. Also, for the great majority of patients, they can be used at doses that are essentially free of side effects. The main problem with inhaled steroids is that they are not used often enough or the patient doesn't take them correctly.

So, what are inhaled steroids, and why should they be used so often? These drugs are basically anti-inflammatory drugs. This is important since asthma is a chronic inflammatory disease. Up until the last two decades or so, asthma was widely looked at as a disease where the symptoms were caused by constriction of the airways. Consequently, the treatment was aimed at just opening the airways with medications such as bronchodilator inhalers (e.g. albuterol).

As we learned more about the disease, we found that the constriction of the airways was a result of an inflammatory process. This inflammation leads to damaged, "twitchy" airways that would get easily constricted by triggers such as cold air, irritants or viruses. This, in turn, resulted in a fundamental change in how asthma was treated - that is, to the use of anti-inflammatory inhalers in patients who needed to use their bronchodilators on a frequent basis. The two types of anti-inflammatory inhalers were, and still are, the cromolyn-type and the inhaled steroids. Most asthma specialists agree that the inhaled steroids are a better choice since they are the much more effective.

The first problem is that some doctors don't prescribe inhaled steroids as much as they should. There are many possible reasons for this:

1. They believe that patients will have a hard time using the inhalers correctly, and the doctors may not have the time to teach them.
2. They may not perform lung function test, and so do not realize that the patient has significant enough asthma to warrant the use of inhaled steroids.
3. They are concerned about the possible side effects.
4. They may not appreciate that inflammation of the airways is important in asthma.

Secondly, patients can be the problem when it comes to the under-use of these drugs. Again, the reasons are many and are very similar to the reasons that doctors don’t prescribe them as much as they should:

1. They are afraid of "steroids", or have "steroid phobia" as we like to call it. That is, they are afraid of the side effects.
2. They don't know that they have an inflammatory disease and need a daily anti-inflammatory medicine.
3. They prefer to take a pill instead of an extra inhaler.

To start off with, there is now a great number of experiments that have shown inhaled steroids, at low dose, are both extremely effective and safe. Because of the confusion with oral steroids or injectable steroids, which do have some serious side effects, people may think the same applies to the inhaled steroids. This is not true, because the inhaled form remains mostly in the lungs, and doesn't get to the rest of the body to any significant extent. This would be similar to the mild steroid creams used for rashes (e.g. hydrocortisone cream) just working at the surface of the skin.

In particular, low dose inhaled steroids do not significantly effect the growth of children and very rarely lead to eye problems or to meaningful bone loss or osteoporosis. One important point to note, inhaled steroids are the only drug ever shown to prevent the rare deaths associated with asthma.

The rest of the problem with the under-use of inhaled steroids comes down to education of the patient. All asthma patients should know the following:

  1. All asthmatics who have symptoms more than twice a week, on average, (these are the "persistent asthmatics") should be on an anti-inflammatory drug like inhaled steroids.
  2. Inhaled steroids or other anti-inflammatory drugs need to be taken daily, regardless of how they feel on that day.
  3. Patients should be taught how to use the inhaler devices (the newer ones are getting quite easy to use correctly).
  4. Leukotriene modifiers like singulair (montelukast), when used by themselves, are appropriate for only the mildest of persistent asthmatics.
  5. At some point, all persistent asthmatics should have their lung function tested.
  6. Asthmatics still need to use their short-acting bronchodilator (e.g. albuterol) for acute symptoms in addition to the anti-inflammatory drugs.
  7. Patients should not be satisfied with their anti-inflammatory treatment if they still need to use their bronchodilator frequently, and/or if their disease is interfering with their daily activities or sleep.

What about those patients who aren't well controlled on low dose inhaled steroids alone? Other medications or treatments can be added to keep the dose of inhaled steroids low. Examples include adding a long-acting bronchodilator, a leukotriene modifier, avoidance of allergens, or perhaps allergy injections. The newer ant-IgE drug Xolair is also an option. All of the above have proven effective in this regard. The situation is more controversial when it comes to medium or high dose inhaled steroids, as these doses may have some concerning side effects. However, the great majority of patients don't need these higher doses.

In summary, all asthmatics who have symptoms more that twice a week, on average, need to be on some form of daily maintenance therapy. Many asthma experts believe that low dose inhaled steroid treatment is the best choice, in that it is both an extremely effective and safe treatment for the great majority of asthma sufferers.

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