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Inhaled steroids best for asthma in pregnancy: good control, good outcomes.

TORONTO -- Inhaled corticosteroids such as budesonide and beclomethasone are the best bet for treating moderate, persistent asthma in pregnant women, according to Dr. Scott Osur.

Studies have indicated that inhaled corticosteroids are rarely associated with congenital malformations. "Inhaled corticosteroids are extremely safe during pregnancy. This is a very important take-home message," Dr. Osur said at an international conference on allergy and clinical immunology sponsored by the State University of New York at Buffalo.

Of the inhaled corticosteroids, budesonide appears to be the best choice. It is the only inhaled corticosteroid in category B. "About a year and a half ago, the FDA changed the product labeling for budesonide from category C to B," said Dr. Osur of Albany (N.Y.) Medical Center. This change was based largely on the findings of a 1999 study of 2,014 records in the Swedish Medical Birth Registry, which showed no increased risk for congenital malformations, premature birth, low birth weight, C-section, stillbirth, or multiple births associated with the use of budesonide during pregnancy (Obstet. Gynecol. 93[3]:392-95, 1999).

Budesonide is an especially good choice for pregnant women who require high doses of inhaled steroids because it maximizes adherence, minimizes the need for systemic steroids, and has limited systemic effects.

Treating pregnant women who have asthma poses a challenge, and keeping the condition under control is key. "'There's really little evidence that if you have well-controlled asthma in pregnancy you will have any increase in maternal or fetal complications," said Dr. Osur.

He noted that, in addition to inhaled corticosteroids, there are several other medications that are safe and effective for treating pregnant asthmatics:

* Short-acting [beta]-agonists. Terbutaline has a slight edge given its category B classification, although it's hard to find. Albuterol or metaproterenol are safe alternatives given how long these drugs have been available.

* Long-acting [beta]-agonists. Salmeterol, which is in category C, has been available the longest and has the most extensive human data.

* Nebulized bronchodilators. Albuterol is generally considered the standard of care, although it is in category C. As an alternative, ipratropium is in category B.

* Mast-cell stabilizers. Although cromolyn and nedocromil are in category B, a Dutch metaanalysis of 24 studies on the effect of cromolyn on asthma in children concluded that there is insufficient evidence to support a beneficial effect of cromolyn (Thorax 55[11]:913-20, 2000). Dr. Osur said he does not find these agents very useful in the treatment of pregnant asthmatics.

* Leukotriene modifiers. It is generally thought that both montelukast and zafirlukast can be continued during pregnancy, if the patient has responded well to these before pregnancy.

Oral corticosteroids should be avoided given data suggesting that the risk of cleft palate increases by three- to sixfold when they are used, particularly in the first trimester. In addition, there is evidence suggesting that chronic use of these medications is associated with low birth weight and preeclampsia. "So if there's one message, it's the judicious use of oral corticosteroids, said Dr. Osur.

While not as serious a condition as asthma, rhinitis can be a problem for women during pregnancy. There are several antihistamines that can be used safely. Cetirizine and loratadine--second-generation Antihistamine--are good choices because of their category B ratings. Of the classic antihistamines, chlorpheniramine maleate or tripelennamine are generally recommended.

Oral decongestants are not safe in the first trimester because of an association with fetal gastroschisis of the abdominal wall, said Dr. Osur.

Good Asthma Control Improves Outcome

* Maximize nonpharmacologic interventions, such as environmental control.

* Avoid recently introduced asthma medications.

* Use the lowest dose of a medication that controls symptoms

* Make changes in the treatment regimen before conception, if possible.

* Keep blood levels of medications minimal by using inhaled routes.

* Continue immunotherapy at a stable dose, ff desired, but do not initiate during pregnancy

* Communicate regularly with the patient's allergist or asthma specialist during the pregnancy.

Source: Dr. Scott Osur
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Title Annotation:Women's Health
Author:Wachter, Kerri
Publication:Family Practice News
Geographic Code:1USA
Date:Feb 1, 2004
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