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Additive therapy regimens and new combination medications that simplify dosing offer improved effectiveness and better patient compliance in the treatment of asthma, according to speakers at the American College of Allergy, Asthma and Immunology's (ACAAI) 2000 Annual Meeting in Seattle.
"We are at the threshold of an era in which combinations of long-acting beta agonists and corticosteroids will be available worldwide for the treatment of asthma," said Robert P. Schleimer, Ph.D., Johns Hopkins University School of Medicine, Baltimore, Md. "Both of these classes of drugs were originally derived from hormones (adrenaline and cortisol). Since they comprise the mainstays for the treatment of asthma, to a certain extent this combination has been in de facto use for some time.
"Their pharmacological effects are overtly distinct. Acute bronchodilation, one of the most useful effects of long-acting beta agonists, is not observed with corticosteroids," Dr. Schleimer said. "Likewise, the profound anti-inflammatory effects of steroids are not observed in most studies of beta agonists in asthma. Numerous studies have now established that the addition of a beta agonist to an inhaled corticosteroid regimen improves lung function more than simply doubling the dose of the steroid."
The revised National Institutes of Health treatment guidelines recommend that patients with persistent asthma who are not adequately controlled on low to medium doses of inhaled corticosteroids increase the inhaled steroid or add a second long-acting bronchodilator (such as a long-acting beta agonist), including salmeterol or a sustain released theophylline preparation.
"A leukotriene modifier also may be considered, although this indication has not been firmly established," said Stanley P. Galant, M.D., of the University of California at Irvine. "Leukotriene modifiers and theophylline are two other classes of drugs that have been evaluated as adjuncts to inhaled corticosteroid in inadequately controlled patients."
One of the benefits of the combination is the convenience of having one rather than two delivery devices, which should increase a patient's adherence to their individual treatment plan.
1. Lack of perception of immediate relief.
2. Concerns over safety.
3. Need for multiple medications.
4. Ease of use.
"The fixed combination of long-acting beta agonists and corticosteroids appears to address each of these issues, which should improve compliance," Dr. Galant said. "Because of the addition of a bronchodilator, patients will feel improvement within minutes, in addition to the steady improvement over a longer period of time. In addition, patients can be assured the safety profile has proven excellent in the proposed dosages of each.
"The fixed combination with one inhaler has been shown to be equally effective to each given separately," he said. "Finally, the breath activated dry powder inhaler (DPI) is easier to use for most patients than the metered dose inhaler (MDI). A dose counter, multiple dosage per unit and several dosage forms should also help with compliance. The drawbacks for the fixed combination appear to be few."
Evidence is accumulating that asthma is an inflammatory disease of the total lung.
"Several investigators have demonstrated that the inflammatory process is not confined to the large airways but also extends to the most peripheral small airways, including the alveoli," said Richard J. Martin, M.D., of the National Jewish Medical & Research Center and University of Colorado in Denver. "New formulations and delivery devices, which result in smaller particle size, target the large airways and also the small airways, where anti-inflammatory effects can be most beneficial."
An estimated 17 million Americans suffer from asthma, and 5.3 million are under the age of 18. It is the leading serious chronic illness in children and the leading cause of school absences attributed to chronic conditions. Projected cost related to asthma in the United States is expected to total $14.5 billion this year.
Most asthma is allergic in origin, caused by inappropriate activation of immune mechanisms in response to materials in the environment. More than 80 percent of people with asthma have rhinitis, and presence of allergic rhinitis is a risk factor for developing asthma.
Asthma usually starts during the first years of life. Studies show early intervention may prevent irreversible airway injury. Structural changes in the airway wall caused by chronic inflammation of asthma - called airway remodeling - can lead to irreversible decline in lung function. Data suggests that anti-inflammatory medication, particularly inhaled corticosteroids, may be effective in preventing or reducing this process.
Recent studies indicate that allergy shots, also known as allergen immunotherapy, not only control the symptoms of allergies and asthma but help keep people from developing new allergies or more severe asthma. They also can reduce the need for medication.