[Allergy & Asthma Corner]

Regular use of one of the inhalants on the left may reduce the need for one of the two on the right (oral steroid syrup or pills)

See the discussion below.

A Few Examples of Controller Agents That Contain Inhaled Steroid

Top five reasons daily puffs of inhaled steroids are important for control of persistent asthma (asthma symptoms more than 2x/week, or more than 2x/month in the middle of the night, as well as other criteria).

1) Inhaled steroids are the preferred anti-inflammatory medication for asthma control according to national and world health organizations.

2) Inhaled steroids work at the surface of the lungs and have limited systemic effect when inhaled at low to medium doses.

3) There are several decades of experience and research centered around inhaled steroids.

4) Inhaled steroids surpass all other controller agents (for example Cromolyn, Singulair, Nedocromil and Theophylline) in potential for reducing and controlling inflammation in the lungs of asthma patients.

5) One may in fact reduce their exposure to steroids in the long run, by taking daily doses of inhaled steroid at low to medium dose ranges.

Let’s delve into # five a little further.

We will compare a year’s cumulative dose of inhaled steroid to one oral steroid taper (short course of oral steroid gradually reduced over 7 days). An oral steroid taper is often prescribed when an adult or child has a moderate to severe asthma attack. Inhaled steroids (for example, Flovent, Pulmicort, Advair, Qvar, Asmanex, Azmacort etc) are commonly ordered to prevent and control asthma. Patients are encouraged to take inhaled doses for months to years, even when feeling well, in order to stay well. If inhalants are regularly and properly taken, asthma attacks may be avoided and therefore oral steroid courses may be avoided.

A 7 day standard taper of oral steroid, for an older child or adult, may include 40mg by mouth, daily for 3days, 30mg for 2 days and 20mg for 2days and 10mg for 2 days. The total dose adds up to 240mg.

One year of an inhaled steroid, medium daily dose of 440 micrograms (2 puffs twice daily of Flovent 110 for example) adds up to > 160,000 micrograms. It takes 1000 micrograms to make one milligram.

Thus the cumulative inhaled dose is 160 milligrams (the total for the year). Understand that the percentage of inhaled steroid that gets to the lung is at most, about 20% (of a properly inhaled dose). Not all of this 20% gets to the rest of the body. These reductions further decrease the amount inhaled over the course of a year from 160mg to 32mg, regarding systemic impact (the amount the body is exposed to, in addition to the lung).

All pill and syrup forms of steroids reach the body through the systemic circulation after being absorbed from the stomach. Injected or infused forms of steroids also circulate through the body. Such forms are routinely ordered in emergency departments and hospitals, as life saving measures.

So, we compare 32mg inhaled steroid exposure to the body over a course of a year to 240mg in one week, if a severe episode requires oral steroid.

Your body makes about 4mg of steroid daily for natural purposes (if you are an adult). Low to medium doses of inhaled steroid represent only a fraction of this number (remember, microgram quantities are a thousand fold less than milligrams, plus only a fraction of the inhalant dose gets into the system).

A similar relationship can be illustrated in children on inhaled steroids. Parental concerns about medications should be counter balanced by the risk of inadequate asthma treatment which may lead to the need for oral steroid (Prelone, Orapred, Prednisolone etc.). One or more oral steroid courses add up to over a year’s worth of inhaled steroid in most cases.

Concerns about growth and other developmental processes in children may occasionally lead to premature elimination of inhaled steroids by parents. This may put a child at risk for severe asthma (which may be life-threatening) as well as increase the chances of requiring oral steroid for a flare-up. Furthermore, growth and development may be severely impacted by poor asthma control. Controller medications are sometimes reduced or eliminated by the doctor if several months of good control have been established.

Current national guidelines recommend inhaled steroids for control of persistent asthma for people of all ages . Oral syrup and pill forms of steroids are recommended for treatment of severe asthma.

Medications should be adjusted upwards or downwards based on the doctor’s assessment of asthma control. Inhaled steroids are preferred for long term control and may spare a patient from needing oral or injected steroids by reducing asthma attacks and active chest symptoms.

Please discuss any concerns you have about medications with your doctor. Asthma is a highly treatable disease which remains grossly under treated in this country and worldwide.

Want more?

Check out these sites:

 www.sciencedaily.com/releases/2007/01/070123143233.htm 

and : www.asthma.ca/adults/treatment/steroids.php

Next Topic:

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The high efficiency air filter won't get to the dander before your nose, if it is already in the sheets.

Read about a recent study about asthma, cats and allergy triggers. Cats are wonderful and lovable creatures but if you are allergic..., sad news.  SEE BELOW.

Enclosure

Flo and Teddy

Will you be cuddling Teddy tonight? If you have allergy problems, maybe you shouldn't.

Flo, in the closet (If she can't be near you, how about your clothing?)

There are more than 20 million people that have asthma in the United States. A large percentage of households in America have cats and/or dogs. For years doctors have advised patients and parents to avoid bringing cats and dogs into the house in order to reduce exposure to potential allergy triggers.

I have wondered whether available allergy testing methods (skin testing or blood testing) although very sensitive, misses a number of people with asthma and hayfever that have cat or dog allergy. A number of times patients have had negative skin test results to cat but by history have breathing problems when in the presence of a cat.

If you have asthma, a cat in your house, and are allergic to dust mite, grass or mold, you may have more difficulty controlling your asthma because of the cat. Notice, I did not mention that you needed to be allergic to cat. Your skin test or blood test may be negative, suggesting no cat hypersensitivity. Yet, the presence of a cat in your home may worsen asthma control.

A recent study in the Journal of Respiratory and Critical Care Medicine, Vol. 176, pp 20-26, 2007, concluded that atopic people (allergic people) in general, may have greater lung hypersensitivity, whether allergic to cat or not, if a cat is in their home. The Study was conducted from 1998 to 2002 and involved over 1800 participants in 20 communities across Europe.

Blood tests were done to determine allergic sensitivity to house dust mite, grass, mold and cat. A special breathing test for measuring Bronchial Hyper-responsiveness (BHR) was performed on each patient. BHR reflects the level of twitchiness of the airways in the lung. People with asthma tend to have twitchy airways (more twitchy when the asthma flares up). Indoor triggers (cat and dust mite) were measured in the various households through scientific methods.

Expectations of the researchers were to confirm that people allergic to cat and dust mite (by blood test results) would have greater sensitivity (on breathing test measuring BHR) to these triggers when levels of these specific triggers were higher in their homes. The surprising findings were that people with negative cat allergy tests had more twitchy lungs (increased BHR) if they: 1) were allergic to one or more of the other three allergens (dust mite, grass or mold) and 2) had a cat in their home (especially when cat protein levels measured were moderate to high)

Bottom Line:

This is one study, which needs to have follow-up studies to confirm similar findings before major advisory based on the results is considered. Allergists have suspected their patients would be better off without cats and dogs in their homes, despite negative allergy test results, for decades. There were concerns about becoming allergic over time, and the impact on other family members (usually other members of a family are also allergic). This study provides an explanation for why some people with cats in their home may have trouble with their asthma even though they are not considered cat allergic.

We have to see what further research brings.