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Breathing easier.

In our August 1990 issue, we referred briefly to a new view on the treatment of asthma held by Dr. Peter Barnes of England's National Heart and Lung Institute. Dr. Barnes believes that the medical profession has previously mistaken the symptoms of asthma for its cause. Bronchospasm (constriction of the muscles of the air passages in the lungs) restricts air flow and thus causes the asthmatic person to have difficulty in breathing. It is caused by inflammation of the lining of these air passages. It is this underlying inflammation that should be treated, says Dr. Barnes, not just the symptoms it produces. It now appears that many agree with Dr. Barnes; therefore, this article will deal more fully with this important health problem.

Asthma affects an estimated one in 20 persons at some time or another. Death from asthma is not common. Nevertheless, there has been a noticeable increase in the fatality rate of this disease in the past decade, in spite of widespread use of new medications to treat it. Earlier this year, a National Institutes of Health panel, chaired by Dr. Albert Sheffer of the Harvard Medical School, reported that, among other things, the disease is becoming more common in children and teenagers, and for no apparent reason. Some think it may have to do with poorer quality of the air we breathe.

Whatever the factors involved, it now seems clear that we have been overtreating the disease with more conventional drugs and ignoring the much more effective ones. Conventional wisdom has held that treatment of asthma should be directed at the obvious problem, bronchospasm, which can be relieved by a number of different drugs. For people who have mild or infrequent attacks, inhalers containing bronchodilators (such as Proventil, Ventolin, Alupent, and Metaprel) are widely prescribed and have proved in most cases to be very useful. For those with more protracted asthma, an old remedy, theophylline (Primatene, Theo-Dur, etc.), has been the drug of choice. Given orally, it also acts directly on the bronchial muscles, but it must be used regularly. It may also produce undesirable side effects, such as nausea, a feeling of tension, or sleeplessness.

It has long been known that oral (and, in extreme cases, injected) steroids (cortisone and its derivatives) are effective against asthma. However, because of their potency and potentially adverse effects when used for more than a few weeks, they have been used only in very severe cases that could not be relieved by the other drugs. When delivered directly to the linings of the air passages by inhalers, however, there is only slight absorption into the general circulation, thus making regular, long-term usage feasible. Inhaled steroids act to reduce the inflammation of the bronchial lining that causes the bronchial muscles to go into spasm, rather than merely relieving the spasm itself. Because of this, the more conventional bronchodilator inhaler may be necessary for a time after beginning steroid therapy, but can then be discontinued, or used much less frequently, in favor of regular use of the steroid inhaler.

Given this evidence, it is unfortunate that many physicians' outdated fears of side effects have kept moderate to severe asthma patients from enjoying the relief that may be available. Not all patients will respond to steroid therapy, however. For these more intractable cases, other, more powerful agents are being used in experimental programs around the country. It is hoped, however, that the panel's report may reverse the trend of overtreatment with bronchodilators in favor of inhaled steroids.
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Title Annotation:new treatment for asthma combines steroids and bronchodilator therapy
Publication:Medical Update
Date:Jul 1, 1991
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