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 Pharmacologic Care for Asthma
Asthma is a disease characterized by ongoing inflammation of the airways, an overproduction of mucus, and airway constriction due to tightened muscles. The airway swelling in particular is thought to contribute to permanent structural changes in the lungs, a condition often called airway remodeling. In turn, these changes usually lead to accelerated declines in lung function, including irreversible decreases in airflow due to narrowed air passages.
Pharmacologic care for asthma generally relies upon two types of medications. "Controller" medications (primarily inhaled corticosteroids), taken on a daily, long-term basis, reduce airway swelling. These medications are preventive. Alternately, "rescue" medications (primarily short-acting beta2-agonists), taken as needed, quickly relieve the acute constriction of the muscles surrounding the airways that occurs during an asthma attack.
Not everyone who has asthma must be on both types of medicine. For people with mild intermittent asthma, a rescue medication as well as minimizing exposure to asthma triggers is the recommended regimen. The majority of people with asthma, however, fall into one of three categories of persistent asthma: mild, moderate or severe. No matter the severity, the best therapy for most people with persistent asthma includes daily use of a controller medication. There is also some evidence that early use of anti-inflammatory therapy might lead to disease modification and limit the progression of airway remodeling.
When controller medications are used appropriately, acute airflow obstruction and airway constriction should occur rarely, and short-acting beta2-agonists and other rescue medications should only be needed intermittently. Excessive beta2-agonist use is therefore a sign that a patient?s asthma is not well managed with controller medications. Thus frequent filling of prescriptions for rescue medications is a good marker for poorly controlled asthma, and ought to be monitored.
If asthma medications exist that prevent day-to-day symptoms, keep asthma under control in the long run and have few, if any, side effects, what keeps people with persistent asthma from taking them, as local data reveal? Well, that?s something we can?t answer definitively.
However, concerns about steroids may play a role. Some practitioners and patients worry about potential adverse effects of long-term use of inhaled corticosteroids, such as reduced linear growth or bone density loss. These fears continue, despite evidence that when taken at the recommended dosages, inhaled corticosteroids ICS) are well tolerated and safe. The potential, yet small, risks of adverse effects must be weighed against the risks of uncontrolled asthma.b
Another challenge is that even when clinicians prescribe controller medications appropriately, they don?t necessarily know if patients are filling their prescriptions, and how often. Other reasons for underuse of ICS may include the cost of the medication or lack of insurance coverage (beta2-agonists are less expensive than ICS), the ease of using rescue medications for the immediate abatement of symptoms versus the long-term commitment to taking daily inhaled corticosteroids, the perception that asthma is acute, not chronic, and denial of having the disease.
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