Asthma: A Closer Look

Closely linked to allergies, asthma is a chronic inflammatory disease that makes a person’s airways (bronchial tubes) particularly sensitive to irritants. During an asthma episode, an individual might experience a tightening in the chest or a cough, shortness of breath or wheezing. It is often difficult for the asthma sufferer to move air in and out of the lungs.

Asthma triggers may be allergens but may also be other environmental factors such as pollution, strong odors or weather changes. Stress or illness may also trigger an asthma episode. What actually triggers an asthma flare up can vary greatly from person to person.

Asthma affects people of all ages. However, it is the leading chronic illness of children in the United States and the leading cause of absenteeism due to chronic illness.

Asthma affects people of all races. However, African Americans are more likely than Caucasians to be hospitalized for asthma attacks and to die from asthma.

Pregnancy and Asthma

A trusted adage in management of pregnancy is to take as few medications as possible. This paradigm developed after the thalidomide disaster in the early 1960s that resulted in many horrifying birth defects. In managing diseases like asthma during pregnancy today, however, one can expect fewer birth defects by using appropriately selected medications. While there are still too few data assessing the actual risk of medications to unborn children, the past twenty years have shown how important it is to reduce swelling and inflammation in the lungs. Many studies have compared benefits of taking inhaled steroids versus not using preventative medication. Results consistently show better outcomes for both mother and baby by emphasizing this paradigm: "Keep mom free of asthma attacks and lessen the chance of dangerously low oxygen levels for the fetus." In other words, the danger of untreated asthma far outweighs the potential danger of the medication.

A few asthma medications, including Pulmicort and Singulair, are FDA Pregnancy Category B. The FDA Pregnancy Categories were established to aid physicians in selecting medications with the least risk for pregnancy. Although the categories are useful, "the letters imply a gradation of risk that doesn't necessarily exist," says Dr. Sandra Kweder, the FDA's deputy director of the office of new drugs. I don't know anything that is Pregnancy Category A except pre-natal vitamins. Category B may imply better safety than Category C or D, so we often consider using them first. Nonetheless, allergists are comforted by the consistently good safety results of Pulmicort. Does that mean every woman with asthma should change to Pulmicort before attempting pregnancy? No, that's a decision best left to the doctor and patient. So the take home message is, "Breathing for two can be made easier with appropriate use of medications."

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

Asthma Inhalers

Inhaling asthma medicines lets them go straight to the lung. As opposed to pills, they work faster and have fewer side effects. Asthma inhalers are basically divided into those that treat your symptoms, and those that prevent your symptoms. Treatment (rescue) inhalers include ProAir HFA, Xopenex HFA, Proventil HFA, and Ventolin HFA. Prevention (maintenance) inhalers include Advair, Symbicort, Dulera, Asmanex, Pulmicort, Flovent, Alvesco and some others.

Until 2009, generic albuterol was a popular rescue medicine. It was taken off the market because the propellant contained chlorofluorocarbons (CFCs). CFC inhalers have been replaced with hydrofluoroalkane (HFA) inhalers. The HFA propellant does not damage the ozone layer like CFC's do. Further, the HFA is a better propellant for asthma. The medicine comes out at 40 mph instead of 70 mph. It’s easier to make that sharp right turn to go into the lungs at 40 than 70. Additionally, HFA places albuterol into solution, rather than suspension like CFC's. Think of how tiny the salt particles are when dissolved in water (solution), and compare that to mixing sand with water (suspension). The sand particles are small, but they eventually settle out at the bottom.

Better dissolved, the albuterol HFA can penetrate into deeper, thinner parts of the lung, allowing for better dilatation of the breathing tubes. Old albuterol cost about $20.00 for 200 puffs, whereas HFA albuterol can cost $50.00 for 200 puffs. However, they sometimes have co-pay discounts at their websites. Right now, WalMart has the best bargain with a smaller size of Ventolin HFA called Ventolin ReliOn. It only has 60 puffs per inhaler, but only costs $9.00. Another downside of HFA’s is you have to rinse out your HFA device with running water every few weeks or it may clog up.

Some patients really prefer the old CFC inhalers. For them, we recommend asking their doctors to consider changing them to Maxair Autohaler. Unlike albuterol, this asthma rescue medication was not affected by the December, 2008 deadline. According to the March 29, 2007 issue of New England Journal of Medicine, it is "subject to withdrawal in the future". Per Maxair’s website, it will remain available in the USA through December, 2013.

Xopenex HFA is a newer form of albuterol, called levalbuterol. For many patients, it has fewer side effects than albuterol.

No matter which asthma rescue drug you use, if you're using it more than once a week, ask your doctor if you would benefit from an asthma controller inhaler. These inhalers prevent the swelling and inflammation that causes asthma in the first place.

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.

Vitamin of the Decade – Vitamin D

Vitamin D deficiency has recently been linked with an increased risk of cancer, heart disease and rheumatoid arthritis. We are also seeing a connection between Vitamin D deficiency and poorly-controlled asthma. An increase in cases of Vitamin D deficiency over the past several decades is thought to be one of the reasons that the prevalence of allergies and asthma has been increasing. What is different now than 50 years ago? We spend much less time outdoors, decreasing the Vitamin D made in our skin. We eat more processed foods, getting less Vitamin D through our diets. In addition, more asthma and allergies are being seen especially in industrialized countries far from the equator where there is less opportunity for sun exposure.

There are at least two reasons why a lack of Vitamin D would make asthma worse. In Vitamin D-deficient asthmatics,steroids do not work as well. Thus, the medications Advair,Symbiotic and Flovent provide less benefit. Second, Vitamin D helps the body fight off viral infections, one of the main causes of asthma attacks.

Vitamin D deficiency is not only associated with asthma but with severe, difficult-to-treat asthma. Mothers who are Vitamin D-deficient during their pregnancies are more likely to have children with allergies or asthma. Prenatal Vitamin D deficiency may affect the development of the lungs and the immune system.

What we have not proven is that supplementing low Vitamin D levels improves the control of asthma. Those studies are just now being performed. In addition, Vitamin D can be harmful if you get too much, so replacing it without a doctor tracking your blood levels may present its own challenges. We have long wondered why certain patients with severe asthma do not benefit from inhaled steroids. Hopefully, we are on our way to providing some relief to those who suffer the most from asthma.

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.