Last updated: Aug 01, 2009
“There are more hazards with undertreating asthma, such as losing days of school or even death, than there are side effects of asthma medications,” says William Lunn, MD, the director of the interventional pulmonary service at Baylor College of Medicine, in Houston. “As a doctor, I would hate for parents to get scared by reports and decide that their kids should not be treated with asthma medications.”
Here is a closer look at some of the major issues and controversies surrounding common asthma medications as well as some practical pointers for parents and patients of all ages.
What you may have heard:
Oral steroids suppress growth in children
Corticosteroids are powerful anti-inflammatory drugs that do a great job of suppressing the underlying inflammation that can lead to asthma attacks. They can either be inhaled or swallowed as a liquid, and include the drugs prednisone, prednisolone (an oral version of prednisone), Flovent, and Pulmicort. Although people often refer to them as steroids, they are not in the same class of drug as the muscle builders sometimes abused by athletes. You also may have heard that oral steroids can stunt a childs growth. “Parents might be concerned about growth suppression in younger kids who take inhaled steroids for asthma,” says William J. Calhoun, MD, a professor of medicine and the vice chair of the department of medicine at the University of Texas Medical Branch, in Galveston.
What the experts say: This is a legitimate concern, but unlikely, says Dr. Calhoun. In general, the much stronger oral steroids are given to children for only brief periods of time to combat the most severe asthma symptomsespecially those that might require hospitalizations. Inhaled steroids, on the other hand, may be taken by children daily on an ongoing basis. Because these are inhaled directly into the lungs (rather than swallowed and circulated throughout the body), experts believe they are much less likely to affect a childs growth and do so to a much smaller degree. “The magnitude of growth suppression with properly managed asthma therapy is a quarter to one-half an inch in final adult height,” says Dr. Calhoun. He serves as the chairman of the Food and Drug Administrations Pulmonary-Allergy Drugs Advisory Committee, but the views he is expressing are solely his own, and do not reflect those of the committee, he notes.
Some of the older inhaled corticosteroids may affect bone growth, but the newer inhaled steroids do not appear to affect growth to the same degree, he says. Why? Newer inhaled steroids are more effective than the older counterparts, and as a result, doctors can use smaller doses. Whats more, “the older steroids activated cellular pathways that caused slowing down of bone growth and the newer steroids dont have that property,” Dr. Calhoun says.
The bottom line: The growth suppression issue is not a reason to avoid these effective medications. “Uncontrolled asthma in childhood can also cause growth suppression because when asthma is not controlled, the child is sick all the time and growth can be compromised,” Dr. Calhoun stresses.
What you may have heard:
Inhaled steroids suppress the immune system
Another concern is that steroids can cause suppression of the immune system, making a person more prone to infections. “Steroids can and do suppress local immunity,” Dr. Calhoun explains. That said, “when physicians treat patients with asthma with inhaled steroids, we view this in terms of risk and benefit,” Dr. Calhoun notes.
What the experts say: In fact, oral steroids are more likely to suppress the immune system, and this is much less likely to happen with inhaled steroids. Oral steroids are used sparingly and for short periods of time to treat the very worst, potentially life-threatening asthma attacks; inhaled steroids can be safely used on a daily basis. The benefits far outweigh the risks when it comes to using inhaled steroids to treat asthma. “There is a small increase in pneumonia risk if you have asthma and are taking an inhaled steroid, but this a small risk in comparison to the profound benefit that we get from managing asthma with these medications,” he says.
The bottom line: “The positive news about asthma is that we have multiple very good and very safe medication choices available,” Dr. Calhoun says. ”They are powerful medications and they need to be, because asthma is a serious disease.” As such, they can have side effects that need to be evaluated and monitored at the physician level, he explains. If you have concerns, talk to your doctor. In addition, children who take inhaled steroids should rinse their mouth out after using the inhaler to reduce their risk of thrush, an easily treatable yeast infection of the throat.
What you may have heard:
Long-acting bronchodilators may increase the risk of asthma-related death
Long-acting beta2-agonists, a type of bronchodilator, open the airways in the lungs by relaxing the muscles that line the airways. These drugswhich include Advair (fluticasone and salmeterol) and Symbicort (budesonide and formoterol)help prevent asthma attacks, but they do not stop an episode that has already started. Questions about their safety have mounted in recent years, ever since the FDA issued an alert in 2005 that the drugs had been associated with an increased risk of asthma-related death.
What the experts say: In 2006, the FDA required that all long-acting beta2-agonists update their labeling to include more information about the risk of death, and the agency continues to assess the safety of the drugs. (In December 2008, an FDA advisory panel voted unanimously to ban the use of two long-acting beta2-agonists, Serevent and Foradil, in children.) Current guidelines for asthma discourage the use of this class of drug by itself, rather than as a supplement to other asthma medications. “These medications dont treat inflammation at all, so if an asthma patient uses a long-acting bronchodilator without inhaled steroids or a tablet to control inflammation, their airway inflammation can get worse because the long-acting bronchodilator can mask the symptoms,” says Dr. Lunn. “People get such bad inflammation, have a bad attack, and cant open themselves up.”
The bottom line: As a rule, long-acting bronchodilators should always be paired with an inhaled corticosteroid that also controls inflammation. “There is no role for long-acting bronchodilators in asthma management unless they are delivered in conjunction with an inhaled steroid,” says Dr. Calhoun. Although the safety of this treatment strategy has not been definitively proven, the combination of the two drugs has not been shown to pose a measurable risk of death.
What you may have heard:
Singulair is linked to a risk of suicide
Singulair (montelukast) is a leukotriene inhibitor that is taken in a once-a-day pill form. This drug works by blocking action of leukotrienes, body chemicals that contribute to allergy and asthma symptoms. The FDA has cited reports of people taking Singulair for asthma who have exhibited suicidal thoughts and behavior (including suicide), as well as other neuropsychiatric symptoms such as agitation, depression, and hallucinations. (The FDA has investigated two other asthma drugs, Zyflo and Accolate, in addition to Singulair, but most of the reports are associated with Singulair, which is far more widely used.)
What the experts say: Though the FDA did not conclude definitively that the events reported were induced by the drugs, the agency in June 2009 requested that the manufacturers of these drugs include a precaution about neuropsychiatric events in their prescribing information and labeling. “[Right now] it is unclear is whether suicidal thoughts and actions are strictly a consequence of the drug, some underlying effect of asthma, or a result of the impact that asthma has on ones sense of self worth and quality of life,” Dr. Calhoun says.
The bottom line: Being forewarned is being forearmed, according to Dr. Calhoun. “If mood changes develop, talk to your physician or your childs physician,” he says. “Singulair can be very effective at managing asthma, and we dont want patients or parents of patients to stop this drug without first talking to their doctor.”
Overall, if you hear something alarming about your asthma medication, “the first step is to talk to your doctor and say ‘I am concerned, or ‘I heard this on radio. What is the real scoop?” Dr. Lunn suggests. “Dont jump to conclusions. Let the doctor educate you.”