An Overview Of Common Long Term Asthma Control Medicines

All medicines have side effects and need precautions. Yet for a patient of asthma, there is no respite from them. She must use them for years. That is why it becomes so important to understand the challenges of using long term medicines for asthma, and the way they are taken. Each of the small things can make a difference. Next to medical advice, awareness is the most important medicine for an asthmatic.
An Overview of Common Long Term Asthma Control Medicines
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Asthma requires long term treatment, making it essential for the treatment options to be viable in the long run. Medicines that lead to cumulative toxicity or increasing adverse effects may not be fit for the long term treatment even if they provide expedient relief to the patients, whereas some less medicines that provide slower relief may actually be preferable.


Asthma: The Challenges of Long Term Treatment

Asthma often requires long term treatment to prevent the asthmatic attacks. The medicines used for long term asthma control differ from those used for the control for an attack of asthma, and both the kind of

medicines can only be used for the purpose for which it is prescribed. It means that medicines used for long term asthma control used for preventing attacks are not effective if the attack has already started. In such cases, one should opt for short term treatment, or preferably, contact the physician first.

Asthma involves chemical triggers, which attract more chemicals and ultimately lead to secretion of mucus and contraction of airways thereby leading to breathlessness and cough, the primary symptoms of asthma. The common long term asthma control medicines prevent this process by acting on one of the crucial ingredients of its flare-up, and thereby control and prevent asthma attacks. Like other medicines, these too have their own side effects, but most of them are temporary and not serious.

Medicines for Long Term Asthma Treatments

The long term asthma control medicines can be grouped in four categories:

1. INHALED CORTICOSTEROIDS – These are the mainstay of long term asthma control and perhaps the most effective medicines for this purpose. Common medicines falling in this category are Fluticasone (Flovent), Budesonide (Pulmicort), Triamcinolone (Azmacort) and Flunisolide (AeroBid), though this category also include older medicines like Beclomethasone (Beclovent, Vanceril) and Dexamethasone (Decadron). One of the latest medicine added by FDA in this category is Mometasone furoate (Asmanex) which was added in 2005.

Inhaled corticosteroids are the most effective medicines for long term control. Usually they are prescribed as a single daily dose, but some recent studies like IMPACT (Improving Asthma Control Trial) suggested that occasional doses on need basis can take care of mild asthma. Inhaled corticosteroids can be taken alone or in combination with other medicines.

The side effects of inhaled steroids are few and not so serious as those of oral or injectable steroids. They can sometimes cause sore throat, hoarseness, dry mouth or fungus infection in mouth and throat, which can be avoided by rinsing or gargles after the dose, or in case of younger children or old debilitated patients, by using a spacer which improves coordination with inhalation. Other side effects include rashes, facial edema, a higher risk of cataract of the eye and osteoporosis. Thus, those on long term medication must undergo complete check up from time to time to ensure that any side effect is timely diagnosed and managed.

2. INHALED LONG ACTING BETA-2 AGONISTS – These include Salmeterol (Serevent) or Formoterol (Foradil). They are not used alone as they are considered inferior to inhaled steroids. Their importance is when used in combination with Steroids, which is currently the most effective form of inhalation treatment for long term control. Salmeterol is totally ineffective in sudden attacks, while formoterol has some effect. Now devices for delivering both with the same device are available in United States (Advair) as well as Europe (Seretide, Symbicort).

FDA recommends that these medicines should be used (along with steroids) only for those whose asthma is not controlled with steroids alone. While using them, it is important to note that they are not effective in sudden flare-up of asthma, which requires a different set of treatment. Lastly, these medicines should never be changed or their doses modified by the patients on their own, so always consultant your physician before stopping or starting them.

3. ANTI-MAST CELL DRUGS – This category includes Cromolyn Sodium (Intal) and Nedocromil (Tilade). They prevent exacerbation and are reasonably effective, especially in preventing allergic asthma in children and exercise induced asthma in all. They are also safe for using in case

of pregnant women. Their side effects are uncommon and mild, including sneezing, nasal congestion, nose bleed, nausea and headache.

4. LEUKOTRIENE ANTAGONISTS – Medicines under this category include Zafirlukast (Accolate), Montelukast (Singulair), Zileuton (Ziflo), and Pranlukast (Ultair). They are also preferred in combination with steroids. Their use is hence another option for those whose asthma is not controlled by steroids alone. Their side effects include gastro-intestinal distress, though rarely they can cause more serious problems like Churg Straws Syndrome (a flue like disease with sinusitis, rash and numbness in hands and feet) and liver disease, when taken in very high doses.

5. THEOPHYLLINE – Sustainable release Theophylline tablets taken orally are another option for long term control. Important things to remember while taking Theophylline is that it should be taken strictly as per prescription since overdosage can occur easily. Also it should be taken carefully by smokers, or those taking other medicines as it can interact and create complications.

6. NEW MEDICINES – Efforts for newer medicines for providing long term asthma control are on, and in this series one new option is Omalizumab (Zolair), which is a mono-clonal antibody that prevents the immunoglobulin E from exacerbating asthma attacks. It can be given only to those aged 12 years or more. It is still costly, and is given by injection every three to four weeks. More work on its use is still going on.

Types of Asthma Inhalers

Most common form of long term treatment involves inhalers. There are four major types of inhalers.

(i) Pressurised M.D.I.s (Metered Dose Inhalers) - These deliver a fix dose to the mouth when pressed, which has to be then inhaled. Their major advantages are that they are simple to operate, small, cheap and easy to handle or carry. However, their use is optimised only when the pressing of its top for delivery is fully coordinated with the inhalation process. If this coordination is faulty, the full dose will not reach the airways. So, it may not be ideal for younger children or very debilitated patients.

(ii) Breath-activated M.D.I.s (Auto-inhalers)- These are slightly bigger in size. They do not require pressing of top of inhaler. Breathing triggers the delivery of medicine, and so it results in better coordination between delivery of medicine and inhalation.

(iii) Inhalers with spacer devices - These inhalers have a spacer or reservoir in between the cannister and the mouth, so that when the inhaler is pressed, it releases the medicines in the spacer, from where it is sucked in during the process of inhalation. It also results in better coordination, but is larger and hence less convenient to carry. But this may be the best inhaler for small children or very weak patients.

(iv) Dry powder inhalers - These involve a dose of dry medicine being sucked in when we breathe, but requires greater effort to suck the medicine in. They come in many designs and sizes, and can be used by most people except children and very sick patients.

Finally, one should always remember that medicines used for long term control act by preventing attacks and are not effective for treating acute attacks of asthma. In case of attack, the patient should either opt for the medicines specifically prescribed for that purpose, or immediately consult a physician.

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