Asthma Treatment: Balancing Safety and Effectiveness with LABAs

  • Asthma treatment involves a combination of prevention/avoidance and medication. Most people with a persistent class of asthma, whether mild, moderate or severe, will be on some type of medication.


    For several years now, the recommended starting treatment of choice for asthma is an inhaled steroid. Examples are:

    • Qvar
    • Pulmicort
    • Flovent
    • Azmacort

    These medications are taken by inhaling a mist or dry powder through an inhaling device at least once a day, but usually twice a day. Steroids have been found to be highly effective in reducing the airway inflammation associated with asthma and in reducing symptoms, while having a very low incidence of serious side effects. The inhaled variety of steroids are much safer to take, even for children, than steroids given in oral form or by injection.

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    "Old School" LABAs for Asthma


    But there are other choices in medication treatment for asthma. One of the choices is a class of drug called long-acting beta agonists (LABAs for short), which are also sometimes referred to as long-acting bronchodilators. They differ from the short-acting bronchodilators found in most rescue inhalers.


    Examples of LABAs are:

    • Serevent (salmeterol)
    • Foradil (formoterol)

    LABAs were used quite a bit as first-line asthma treatment for quite some time; I took Serevent myself during the 1990s for my asthma. However, several years ago, such LABAs received a "black box warning" from the FDA.


    This came about as a result of a study that looked at salmeterol (Serevent). The study found that there was an increased risk of death from asthma in people taking only salmeterol for their asthma. Although many people assumed this meant the drug was unsafe, what it really came down to is that salmeterol is not a sufficiently effective therapy for asthma.


    While the LABAs are effective in dilating the airways, that alone is not sufficient to control asthma. You also need the power of a drug that reduces the inflammation in the airways. That's why medicines like Advair and Symbicort also got black box warnings, but are actually effective asthma treatment approaches.


    Advair and Symbicort are combination medicines. They contain a LABA, but they also contain an inhaled steroid. So they work and though they have a black box warning, they are probably more than safe for most people to use.


    But Many Physicians Still Prescribe LABAs for Asthma


    The disturbing thing about all this is that a recent study conducted by Medco Research Institute found that there are still quite a few doctors prescribing LABAs as the sole treatment for asthma. And that is putting a lot of asthmatics at risk unnecessarily.


    Here are the details of the study:

    • Looked at 9,841 patients who were taking LABAs alone or in combination with other controller medications during 2009
    • Patients who'd filled a prescription for an inhaled steroid or a leukotriene modifier (such as Singulair) were not counted
    • 30.9 percent (3,043/9,841) of the patients studied were taking only an LABA for their asthma
    • Patients treated by an asthma specialist (20.9 percent) were less likely to be prescribed only an LABA than a non-asthma specialist (36.4 percent), a difference of 43 percent

    These findings are pretty significant, because they show us that despite the fact that the FDA and the media have made physicians aware of the safety risks of prescribing only LABAs for asthma, use of LABAs without controller medications is still occurring quite frequently. This is happening less so among patients treated by asthma-related specialists, but it is still happening.


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    Prescribing medication for any condition, including asthma, is always a case of balancing possible risk or safety against potential benefits. So it could be that the doctors still prescribing LABAs are doing so because in their judgment, it's the best overall therapy for those particular patients. Or, it could just be that they're not that well-informed.


    What This Means for You


    Are you taking only an LABA for your asthma? If so, how well controlled are your symptoms? Are you having to use your rescue inhaler more than twice a week? If asthma control is an issue for you, then you should definitely have a conversation as soon as possible with your doctor about whether adding (or substituting) an inhaled steroid might be in order.


    But even if you're not having asthma symptoms on a regular basis, you should discuss your treatment with your physician, based on what you know now about the safety risks of using only an LABA over the long-term for asthma.


    And if your doctor is not an asthma specialist (in other words, not a pulmonologist, allergist or immunologist), then you might want to consider getting a consultation with such a specialist. Even if you don't want to see that specialty doctor on a regular basis, it can be helpful to get a review of your asthma treatment plan to make sure you're on the right track.


    Breaking News


    Just as this post was due to go to publication, word came through that the U.S. Food and Drug Administration (FDA) is now going to require pharmaceutical manufacturers of Serevent, Foradil, Advair and Symbicort to add new labeling to their products. The labeling must capture the facts that:

    • Patients who are taking an LABA with an inhaled steroid should be weaned off the LABA in a step-by-step fashion once their asthma gets under control
    • Children should only be prescribed an LABA in a combination product, to ensure they can never take the LABA by itself

    This just reinforces the fact that LABAs are NOT appropriate as a stand-alone treatment for asthma. So, don't be afraid to question your doctor about that if you're taking only an LABA!

Published On: June 21, 2010