Unfortunately, patients failing to take their maintenance medication is an all-too-common scenario.

By Amanda Gardner
Updated February 29, 2016
Got wheezing? It’ll most likely get better for a day or two around ovulation, according to a 2012 Norwegian study. When researchers charted symptoms of nearly 4,000 women over the course of their menstrual cycles, they found that while wheezing and shortness of breath were higher during the middle two weeks of the month (when estrogen levels are naturally high), both symptoms dipped right around the time of ovulation (days 14 to 16). “We see this anecdotally, too, so it makes sense that a woman should talk to her allergist about individualizing her asthma treatments to her menstrual cycle,” says Bryan Martin, DO, president of the American College of Allergy, Asthma, and Immunology.
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Carolyn M. Kercsmar, MD, the director of the asthma center at Cincinnati Childrens Hospital Medical Center, recently had a 10-year-old patient who decided, on his own, to stop taking his asthma medicine—crucial maintenance steroids he was supposed to take regularly.

His reasoning: He felt fine and hadnt had any asthma attacks for a while, so why bother? Dr. Kercsmar performed a series of tests, and it was clear his lung function was compromised, even though he didnt have any coughing, wheezing, shortness of breath, or other signs of asthma. She made sure he knew that he needed to start his asthma medication again.

"We were to come into pollen season, which could have triggered his asthma symptoms, possibly leading to an emergency room visit or hospitalization,” she says.

Generally, asthma can be categorized into two classes: intermittent asthma, in which symptoms occur less than three times a week, and chronic asthma.

People with intermittent asthma can often get by using only a short-acting or “rescue” inhaler when symptoms develop. Those with more chronic asthma and more frequent flare-ups (like Dr. Kercsmars 10-year-old patient) need to take a maintenance medication to reduce inflammation between attacks. “The goal of asthma treatment is to prevent, prevent, prevent,” Dr. Kercsmar says.

Unfortunately, patients failing to take their maintenance medication is an all-too-common scenario. People may take medication incorrectly, in an erratic stop-and-start fashion, or just flat out skip it. Its not that people with asthma are trying to dupe their doc. Asthma can be a sneaky foe. Most people feel perfectly fine, until they very quickly don't. All it takes is a rise in pollen counts, a common cold, a chance encounter with a cat, a change in temperature, or a bout of exercise to send a patient into the danger zone. The problem? Its hard to predict when that will happen.

“It can be hours, days, weeks, or months, so its pretty easy for patients to be lulled into a false sense of security,” says Dr. Kercsmar. “Its an incredibly variable disease that can be punctuated by flare-ups, but the time between flare-ups can be variable.”

Why you may be on a symptom roller coaster

Even patients with the best of intentions may have a hard time taking medications day in and day out, sometimes several times a day, when they feel just dandy. The temptation is to think, “Why not just skip it today since I feel fine?"

“This is a chronic problem that I encounter with many asthmatics,” says Len Horovitz, MD, a pulmonary specialist with Lenox Hill Hospital, in New York City. “Once patients are well controlled on medications, a part of their psyche thinks they've been cured and they no longer need medication.”

As a result, patients end up on a “roller coaster,” says Mark H. Moss, MD, an associate professor of medicine and pediatrics at the University of Wisconsin School of Medicine and Public Health. “They have very few symptoms when they take their medicine, but then the symptoms reemerge when they stop taking it.”

But skipping medications, even when you dont have any symptoms, could mean more flare-ups and worsened asthma down the line.

“Its important to continue to use anti-inflammatory maintenance medications because theres an inflammation process thats occurring within your lungs,” says Amber Watts, PharmD, an assistant professor of pharmacy practice at Texas A&M Health Science Center Rangel College of Pharmacy, in Kingsville. “The steroids in these medications help prevent that inflammation and reduce the chances of an exacerbation. Its not going to completely prevent an exacerbation, but it does decrease the risk.”

What's a steroid?

Asthma is a chronic condition that is thought to be driven by inflammation in the airways. That inflammation is pretty much always there, only producing symptoms when a certain threshold is reached; that threshold, as well as individual triggers, is different for each person.

“Its like having a charcoal fire burning all the time and more fuel comes along, like wind or oxygen, then you have a raging inferno and get symptomatic,” Dr. Kercsmar says.

Anti-inflammatory medications such as corticosteroids (commonly called steroids, but in a different class of drug from anabolic steroids, which are sometimes abused by athletes), leukotriene pathway modifier drugs, and IgE blockers dampen down this ever-burning “charcoal fire.”

When a person has an asthma attack, the lining of the airway swells, secretes more mucus, and, most dramatically, constricts the muscles in the airways. This calls for a different treatment: A person uses a rescue inhaler or nebulizer to administer bronchodilator drugs (such as albuterol) to open the tight airways.

“That works primarily to relax the muscles. It essentially has no effect on inflammation,” says Dr. Kercsmar. And it acts within minutes to provide relief. Even without maintenance medications, some patients will go weeks or even months without a problem. But doctors cant always tell which patients fall into this category.

Skipping a child's medication now may mean stronger drugs later

It is especially important for children and teens to take medicine as directed. “Through childhood, asthma may periodically become more severe or improve, and that does complicate things because parents may perceive that a childs asthma is ‘cured,” says Dr. Moss. “They could continue for months or potentially even years like this only to have the asthma worsen as they get older.”

Often a remission occurs during adolescence, but there is no cure for asthma, and the condition will likely reappear in adulthood, only more chronic, explains Dr. Moss.

Sometimes medications can be stopped or the dose lowered, but a doctor needs to make that decision, Dr. Moss says.

Unexpected triggers such as a cold, allergy, chemical irritant, or air pollution can quickly bring the asthma from the back burner to the front burner, Dr. Horovitz says.

“Not taking maintenance medications makes patients vulnerable,” he says.

Parents can be scared off by the fact that maintenance drugs have a steroid component, thinking it will affect their childs development, Watts says. But since patients are inhaling the steroids—rather than swallowing them in a liquid—its much less likely. While corticosteroids can stunt growth slightly, its unlikely with inhaled steroids. But if your childs asthma is so bad that he or she is at risk for hospitalization, doctors may have no choice but to put him or her on the much stronger oral corticosteroids—at least temporarily—to get the asthma under control. (You can read more about asthma drug safety here.)

Patients should also remember to rinse their mouth after taking inhaled corticosteroids, so as to avoid developing thrush, a yeast infection of the throat, Watts warns.

“Whether you have a child with asthma or have it as an adult, you shouldnt skip your maintenance medications. You should always take them as prescribed every day and, if you notice more symptoms or a difference in breathing, then you should definitely call a physician so that he or she can adjust your medication,” Watts says.