Cortico-phobia? No, steroids are the asthma controllers

In its issue of February 1st 2007, The American Journal of Respiratory and Critical Care Medicine published results of a trial developed by The American Lung association Asthma Clinical Research Centers (AJCCM 175:235-242). They conducted a double-masked, randomized, placebo-controlled trial to assess the effectiveness of low-dose Theophyline compared to Montelukast (both given once daily) in controlling asthma.

Poorly Controlled Asthma requires…

Guidelines for management of Poorly Controlled Asthma (PCA) recommend the prescription of controller (instead of reliever) drugs for this group of patients. There is no doubt that Inhaled Corticosteroids (ICS) are the key drugs for accomplish this guide. However, the misunderstanding about corticosteroids due to confusion with anabolic steroids and the misbelief of all corticosteroids are exactly the same as Cortisone, has created fear for using ICS. It is expected that some day media helps to clarify these thoughts.

“But I don’t want steroids”…

… some patients have been saying and doctors need to talk about these drugs to help them understand the benefits behind their use. This requires a comprehensive talk between physician and patient to support the indication (including the potential consequences of not receiving controller for their asthma).

The other drugs

Theophyline and leukotriene antagonists (leukotriene modifiers or anti-leukotrienes – ALt) have been used as add-on therapy for patients with PCA. They are effective agents with different mechanisms of action and intended to reduce the inflammatory component of the disease. Both of them are to be used once daily. Some concerns about theophyline are not new (adverse effects) but the drug is still effective.

Recent analysis have questioned the efficacy of ALt as add-on therapy to ICS. Their efficacy in PCA had to be understood.

The trial

In the trial made by the Centers, 489 patients participated and were monitored for 24 weeks looking for the occurrence of episodes of poor asthma control (decreased peak flow, increased beta-agonists use, increased oral corticosteroid use, or unscheduled care visits). It was shown that low-dose theophyline and montelukast (the ALt) do not improve asthma control in patients with PCA. Low-dose theophyline did improve asthma control in those who were not receiving ICS.

Then: an alternative to inhaled corticosteroids?

Based on those results, we can say that ICS can not be substituted for neither Theophyline nor ALt. It is required to make it clear that ICS are “The Therapy” and patients need to understand the relevance of their ICS as their controller when they don’t get a complete control of their PCA.

Physicians let’s help patients understand this. Patients don’t get asphyxiated by some media confusion and talk to your doctor.

Provocation in the lungs

Recently I had some discrepancies with senior respiratory specialists regarding some dificulties differentiating some cases of moderate/severe persistent asthma versus some COPD cases. The discrepancy was based on the usefulness of bronchial provocation as an aid in supporting one or other diagnosis. If there is a clear response to bronchial provocation in a smoker with less than 10 pack-year, then the patient should be considered asthmatic. If it is not but the obstruction at spirometry is evident, the balance favors COPD. That was my position and I tried to document myself with more background.

Excess Response at the lungs

Excess airway response is usually a clinical feature of asthma. It is called airway hyperresponsiveness (AH) (reactivity). Patients with normal spirometry (measurement of airway flows) may have AH. Other conditions associated to AH include allergic rhinitis (seasonal or perennial and intermittent or persistent), exposure to toxins or occupational substances, and respiratory infections.

Who deserves a challenge

The tests indicated for assessing the constriction of airways after the exposure to a particular stimulus are called Bronchoprovocation Tests, Bronchial Provocation Challenge Tests, Tests of Bronchial Reactivity (BT as acronym in this article). BT has a main indication: history of bronchospasm (bronchoconstriction: contraction of tiny muscles surrounding airways leading to obstruction) in a subject with normal spirometry. Then, if the patient says “I have dry cough and wheezing after this or that, but not always” and you perform spirometry with normal results, you may need to challenge with chemicals or physical triggers to evaluate if there is a hyperresponse. The doctor has now a patient with history of symptoms and normal spirometry and the logical conduct is to perform a BT which includes a new spirometry to be compared with the former.

Usefulness of BTs

The BTs are sensitive for asthma but nonspecific, which means that a positive BT supports asthma or other type of hyperresponsiveness. However a negative one just says that symptoms are not due to hyperresponsivenes.

Other applications of BTs include:

• Uncovering asthma when skin tests are equivocal
• Confirming occupational asthma

BT methods

I would classify the methods for BT according to the type of challenge: a) Chemical, b) Biological, and c) Mechanical or Physical.

• Chemical include challenges based on exposure to quantified amounts of pharmacologic non pharmacologic agents. Pharmacologic agents used with this purpose are: Methacholine, Histamine, and Carbacholine. Non-pharmacologic agents (but still chemical) include Toluene diisocyanate.
• Biological agents to be used as triggers during BT may include antigens (moieties able to generate an extreme response of our defense system) like Bacillus subtilis, Pollen, Molds, House dust.
• Mechanical and physical agents found during active exercise: cold air, dry air, hyperventilation (deep and rapid breathing).

In a next post I will focus on each of the BTs. The final point here is that symptoms of asthma help to say if a patient has the disease but physicians should try to find the reason instead of applying guidelines of therapy without confirming a diagnosis or finding the rationale for having the condition.

Activity in smokers patients

In 2007 Judith Garcia-Aymerich and coworkers (Am J Respir Crit Care Med 175:458-463) shared their results from a population-based study to estimate the longitudinal correlation between activity and lung function decline as well as COPD risk in more than 6000 patients.

Studying smokers and their activity level

After assessing the population in terms of physical activity, smoking behavior, lung function, etc, they looked for the association between physical activity (classified as low, moderate, and high) and FEV1 and FVC decline as well as COPD occurrence in the sample of active smokers.

For many years, researchers have been trying to find out any other element that, being modified, could stop the accelerated rate of FEV1 decline. Of course, the smoking behavior has been the best informed: the most effective way to decrease the rate of decline of lung function in susceptible smokers is quitting smoking. However, investigators have been trying to find out any other measure that might help.

Smoking and physical attitude

It has been said previously here, that smoking is more than a habit or a simple behavior. It’s more complicated and perhaps based on individual reasons (an addiction?, a perversion?, a compulsion?) that Psychiatrists help to treat.

Smokers may be always looking for breaks, for a dining table, for a bench, or a corner to quit activity. Then the spiral starts with the deconditioning and eventual disability described by Cooper et al., Decramer et al, and Reardon et al.

Now, Garcia-Aymerich et al. seems to be finding out one of the lost links between the accelerated lung function and smoking (in susceptible subjects): reduced physical activity.

Active smokers with moderate and high levels of physical activity show slower lung function decline compared with those less physical activity.

What to do?

The issue now could be if recommending smokers to do more physical work or use their smoking time in physical activity. A new subject for consideration with patients in the intent to protect their lung health.

According to Garcia Aymerich: “It is plausible that regular physical activity counteract the smoking effects through an anti-inflammatory and anti-oxidant mechanism” because it has been shown that regular physical activity inhibits the production of inflammatory markers, potentiate the effects of anti-inflammatory markers as well as other protective mechanisms of the body (Athletes look younger and healthier).

Of course quitting smoking is the path and regular exercise should be added to the therapy of most smokers in way to become healthier human beings. Smokers: start moving and stop smoking.

Communication with the COPD patient

Patient with respiratory diseases may realize that they have some respiratory problems a little late in the course of their disease. Respiration is an involuntary process. It has to occur and we adapt to many of its requirements. Witnessing own respiration is a difficult exercise. It’s so difficult that if one start to focus on it, breathlessness will appear at some point. The COPD patient, unfortunately, feels guilty bout their condition. Who or what is responsible for the new diagnosis, the new therapeutic approach to a condition in their body? Why the disease is happening?

Physician must understand the COPD patient as more complicated ill subject. It’s one of those diseases related to an addiction or a bad habit that flower very late in the process. Understanding the causes of addictions like cigarette, alcohol, cigars, etc will help the therapy of the patient definitely. COPD patient is more than a set of chest X rays and values of air flows and volumes. When we explain patients the importance of lungs as related to their existence and the interests that they may have developed, a journey to the right starts.

Breathing is key, so is inhaling and exhaling and keeping the airways opened most of the time. Patients need to understand that damage is done but there are ways to maintain their status or bringing back some of their quality of life. If patients become interested in gaining control of their bodies we can help easier.

Quitting Smoking

Quitting smoking should be part of the instructional process. Why the patient started? Why should stop smoking? How smoking affects their lungs’ function and the synchrony with their heart and their brain? Telling patients about the impact on their bodies because of cigarette smoking and being sure they understand (without criticism) support the path toward a successful quit. Patients understand that it is not easy but we need to agree with them and let them know we can help. A combined approach will be fundamental giving importance to non-pharmacological and pharmacological measures.

Activities of daily living

Maintaining a level of activity will help them to assess their improvement when they receive the appropriate management. Don’t let your patient lay down due to their disease. Don’t let your physician forget to talk about how active you can be if you’re a COPD patient. Set goals to return to activities, to get more healthy lifestyle.

Maintenance medication

There’s no doubt that a narrowed airway needs to be re-opened. Airway narrowing is the main physiological event in terms of consequences. To help revert this situation, bronchodilators are the right drugs. Inhaled bronchodilators have shown to provide COPD patients with improvements in lung function and symptoms. These drugs can be inhaled to be delivered to the airway walls directly. They may attack two mechanisms of the airway narrowing: the excessive contraction or the low relaxation (cholinergic and adrenergic mechanisms). Inhaled corticosteroids may be required for those patients categorized as frequent exacerbators (those who have crisis very frequently = more than twice in a year). Corticosteroids may affect the sudden or subacute inflammations related to respiratory viral infections, for example.

Other components of COPD therapy

Oxygen, vaccinations, rescue medications, pulmonary rehabilitation, psycotherapy are important components of the management that should be discussed with patients and care givers to get more advantage from the medical management. All topics that patients bring to the office should be discussed carefully to give them more power over their disease and avoid frequent fluctuations in their fight for their health.

“Talk to your doctor” is a common advise for patients. “Talk to your patient” should be part of our commitment with their health.