This is a common question in my office and invariably leads to several minutes of discussion with asthma patients and parents. There is no cure for asthma and, contrary to widely held belief, people do not “outgrow” asthma. It took a long time for me to convince my asthmatic wife that asthma is life-long but, with good treatment, it may go into remission (our two adult children have asthma too). The good news is that more than 95% of the time it can be well controlled.
Most asthma medications are categorized as either asthma symptom relievers (for example, brands of albuterol) or asthma “controllers” (for example, Flovent, Intal, Advair). Controllers should be taken regularly to prevent symptoms. The most effective controllers are inhaled steroids which have anti-inflammatory characteristics. The National Institutes of Health (NIH) guidelines for asthma treatment recommend periodic assessment of asthma control and subsequent adjustment of asthma medications based on the level and duration of control. The NIH guidelines recommend three or more months of well controlled asthma before stepping down or off inhaled steroids.
What is well controlled asthma?
According to NIH guidelines well controlled asthma means:
* Reliever inhalers have not been needed any more than twice in a week
* Shortness of breath and other chest symptoms have occurred no more than twice in a week
* Your daily routine is without breathing limitations
* Night time awakening should be less than three times in a 30 day period for the previous 3 or more months.
* Peak Flow Rates or spirometry must demonstrate expiratory flow rates of 80% or higher.
* Your ACT score (Asthma Control Test) is greater than 19 (there are other screening tests that are equally acceptable based on the 2007 NIH revised guidelines for asthma management)
* No more than one asthma attack requiring oral steroid within the previous 12 months.
All the above criteria must be met in order to consider asthma well controlled. If any one of the above benchmarks has not been achieved, asthma is not well controlled. Remember, these criteria must be maintained for 3 or more consecutive months (I prefer 6 months of well controlled asthma). Your doctor should determine when the time has come to reduce or stop asthma controller medication.
Why so many criteria?
Although many medications for control of asthma are available they often remain underused. Inhaled steroids are the preferred medication for asthma control yet many surveys show that half of asthmatics who should be taking them are not. Several long-term research studies have shown a fall off in lung function within weeks after inhaled steroids have been stopped. Impairment (the frequency of symptoms and functional limitations caused by active asthma) and risk (the potential for a future asthma attack, loss of lung function over time, adverse impact of requiring more medications) may be reduced by using the inhaled steroids and avoiding the under-treatment of asthma.
Does this mean I have to take inhaled steroids for the rest of my life?
Some people may require inhaled steroid controllers for several years in order to remain well controlled and reduce impairment and risk. Others may more easily achieve sustained asthma control and gradually have controller medication reduced and eliminated. The NIH asthma guidelines provide a framework for the achievement of well controlled asthma with the minimum amount of drug intervention.
So, what do I have to say about stopping asthma medication? Truth be told, I become more interested in finding out how much and how often controller medication is actually being taken by the patient who asks this question. But “compliance of patients with controllers” will be a topic of another day.