Asthma: Best Combination for Achieving Controlby James Thompson, M.D. Health Professional, Medical Reviewer
Are you one of the 25 million people in the U.S. who has asthma? Have you had bothersome asthma symptoms (cough, wheezing, shortness of breath or chest tightness) three or more days, or more than two times in the last week? Have you used your reliever inhaler three or more times over the last seven days or had night time awakenings because of asthma symptoms more than twice in the last four weeks?
If you have asthma and answered "Yes" to any one of the above questions, your asthma is poorly controlled. In fact, if you are not regularly taking a preventive asthma medication (for example an inhaled steroid, Cromolyn or Montelukast) control would not be expected. Having the above symptoms as described, without a controller being taken is considered persistent asthma (a level of severity described in the National Institute of Health asthma guidelines).
What Does This Mean?
Uncontrolled or poorly controlled asthma puts you at risk for continued breathing problems which may cause limitations in activities, loss of sleep, missed work or school, poor quality of life and possibly death. Much has been learned from decades of research on bronchial asthma. National guidelines for the management of asthma have been published and updated since 1991. At that time, there were almost 5,000 deaths annually in the United States (about 13 deaths per day). The last revision was in 2007 and emphasized the importance of assessing severity and control followed by implementing a stepped care treatment approach with asthma medications. Soon guidelines will be further updated and revised based on more recent developments in asthma management.
A recent article in British Medical Journal (BMJ) reviewed 64 clinical studies on asthma treatment in a comparison analysis. Over 59,000 asthma patients were involved in the clinical studies.The analysis compared low-dose inhaled steroid treatment as a controller to combined steroid inhaler plus Labas (long-acting beta agonists). Examples of these combination inhalers include Advair, Symbicort and Dulera. The most common Labas are brands of salmeterol and formoterol (Serevent and Foradil). Many other combinations of controller medications were also compared to low-dose steroid inhaler.
The investigators wanted to determine the effectiveness and safety of current maintenance strategies used to prevent flare-ups of asthma. They limited the included studies to adults who had been followed for a minimum of 24 weeks and compared rates of moderate to severe asthma flare-ups over the time of each study.
They concluded with overwhelming evidence that asthma inhalers containing a combination of corticosteroid and Laba (examples noted above) were most effective in preventing asthma flare-ups compared to all other maintenance strategies.
The other medications/strategies used to maintain asthma were:
-low-dose inhaled steroid alone -* reliever inhalers (albuterol containing inhalers) or Labas (salmeterol or formoterol) used alone
-leukotrien modifiers (medications similar to including montelukast) alone
* Current U.S. guidelines warn never to use Labas as reliever inhalers and to avoid using them without inhaled steroid or some other form of controller.
Take Home Lesson
Achieving good control of persistent asthma is a challenge that can be met by most people if they partner up with their asthma care provider and establish the most effective inhalant strategy. Combination steroid/Laba inhalers, when used consistently and with good inhaler technique, have been instrumental in this process. Some patients may not tolerate them because of adverse effects but for most people they are safe to use as long-term controllers.
Many of my patients can achieve control of their asthma with lower doses of inhaled steroids when maintained on combination controllers for several months. Some patients may be rewarded for their adherence to controller therapy by eventually being able to step off steroid containing inhalers.
The above study highlights the importance of continued asthma research and subsequent changes to asthma management. Over the past 15-20 years, daily fatalities from asthma in the U.S. have fallen from 13 to 9. One day perhaps the number will fall to zero.
Centers for Disease Control and Prevention (CDC). National Vital Statistics Report.2013;61(4).http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf.