For many years, the standard treatment for asthma was an inhaler with a medication called albuterol. Only if that wasn’t enough would additional medicines be added. If symptoms became especially bad, patients would receive oral steroids.
There are several problems with this approach. To start, it hasn’t been working well. Data from the Centers for Disease Control and Prevention in 2019 shows that more than 60 percent of asthmatic adults had uncontrolled asthma, frequently sending them to the emergency department or forcing them to miss work. Severe asthma can also be fatal; an average of 10 Americans die every day because of it, and in nearly every case, the death is preventable with the right treatment.
Albuterol also does not address the actual problem. Asthma is a chronic inflammatory disease of the lungs. During exacerbations, which can be triggered by external stimuli such as allergens or infections, airways become narrower, blocking air flow and causing difficulty breathing, wheezing and coughing. Albuterol relaxes the airways and relieves symptoms temporarily, but it does not resolve the underlying inflammation.
Here is where steroids come in. Oral steroids are extremely effective at decreasing inflammation, but they have a wide range of side effects, including bone loss, cataracts, weight gain, mood changes and immunosuppression, and therefore should be used only if necessary. Inhaled steroids, however, are much safer. The dose is many times lower, and the steroids go directly to the lungs, with very little ending up in the rest of the body. Multiple studies have shown that steroid inhalers prevent exacerbations and the need for oral steroids.
Thanks to emerging research, guidelines for asthma treatment have been shifting away from albuterol-only and toward steroid-containing inhalers. In 2022, the Global Initiative for Asthma (GINA) – a collaboration between the World Health Organization and the National Institutes of Health – issued landmark recommendations to change the paradigm of asthma care.
These new guidelines no longer endorse treating asthma with albuterol, a short-acting medication. Instead, they recommend that all adults, adolescents and most children with asthma receive inhalers containing steroids and a long-acting medicine to relax lung muscles. Patients with moderate-to-severe asthma should use the inhaler every day. Those with mild asthma should use it on an as-needed basis.
That means even people with an occasional need for an inhaler should switch from albuterol alone to a combination inhaler containing a steroid. This is not only better treatment but, as GINA explains, also helps patients avoid the “false sense of security” that can develop from the quick symptom relief albuterol brings. Albuterol does not treat patients’ underlying lung disease. In fact, using it regularly increases airway inflammation and is associated with a higher risk of severe exacerbations and even death.
Because the guideline change is relatively recent, many clinicians likely have not yet altered their practices. Many patients are not aware of the change or that other treatments exist. For instance, for patients with uncontrolled severe asthma, GINA recommends a class of medicines called muscarinic antagonists, which have been the mainstay of treatment for chronic obstructive pulmonary disease. Certain patients might also be candidates for immunological therapy with monoclonal antibodies.
With such a wealth of therapeutic options, people with asthma should not be experiencing impediments in their lives because of their disease. Neil S. Skolnik, a professor of family and community medicine at Thomas Jefferson University and an expert on primary-care treatment of respiratory illnesses, told me that non-asthma sufferers might not appreciate how much the condition impedes quality of life.
“Just imagine how it would feel if you were walking around having trouble getting air,” he said. A lot of people have symptoms every day, ranging from “a very annoying, embarrassing cough” to feeling out of breath doing basic chores.
Skolnik sees many patients who made lifestyles changes because they didn’t know about their treatment options. One of his patients, a lacrosse coach in her 30s, told him she stayed on the sidelines instead of on the field so that she wouldn’t get out of breath. She thought that was what she had to do to cope with her asthma.
“You don’t have to accommodate those limitations, because there are really good treatments available,” he said. He changed her therapy, and when he saw her six weeks later, she was back to coaching from the field.
Asthma is an incredibly common condition, affecting around 4.5 million children and 22 million adults in the United States. Each one of them should know that asthma doesn’t have to limit their lives.
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