PURITAN NEWS WEEKLY
SOME THOUGHTS ON ASTHMA –
PART 3
By Parnell McCarter
There are at least
four reasons in my
opinion to immediately start oral steroids on occasions when
an inhaled steroid is not working to
address a severe asthma bout of an asthmatic, while simply using bronchodilators as a stop-gap until the oral steroid fully kicks in
and is controlling the asthma:
#1. Oral steroid is a more effective way
to stop a bout of severe asthma than bronchodilators.
As it says at http://www.asthma.partners.org/NewFiles/OralSteroids.html
: “Many asthmatic patients have said that when you need them, oral steroids
"work like a miracle." If needed to treat severe asthma, oral
steroids should not be avoided; they should be taken promptly. Their risk comes
only with overuse or prolonged continuous use; and long-term oral steroid use
is not necessary for the vast majority of persons with asthma because other
effective treatment strategies are readily available.”
#2. There is less **relative** risk than
prolonged days of use of bronchodilators.
"We compared blood 
-agonist
levels in patients dying from asthma with those in controls, and
estimated the risks associated with specific classes of medication
and patterns of management. We identified 89 asthma deaths and
recruited 322 patients presenting to hospitals with acute
asthma...The use of oral steroids for an attack of asthma reduced
the risk of death by 90%." - http://ajrccm.atsjournals.org/cgi/content/abstract/163/1/12 from American Journal of Respiratory and
Critical Care Medicine, 2001
"It is of concern that in response to increased asthma symptoms only 20%
of asthma death and NFA cases were reported to have increased use of oral
corticosteroid medication in the prior 12 months, whilst over 80% of cases in
both groups had increased the use of beta-agonists." - from "A comparison
of asthma deaths and near-fatal asthma attacks in South Australia" in the
European Respiratory Journal at http://erj.ersjournals.com/cgi/content/abstract/7/3/490
, 1994
"The use of long-acting ß-agonists could be associated with a clinically
significant number of unnecessary hospitalizations, intensive care unit
admissions, and deaths each year. Black box warnings on the labeling for these
agents clearly outline the increased risk for asthma-related deaths associated
with their use, but these warnings have not changed prescribing practices of
physicians (25). This information could be used to reassess whether these
agents should be withdrawn from the market." - “Meta-Analysis: Effect of
Long-Acting ß-Agonists on Severe Asthma Exacerbations and Asthma-Related
Deaths” at http://www.annals.org/cgi/content/full/144/12/904?linkType=FULL&journalCode=annintmed&resid=144/12/904
from the
"Specific Warning on Salmeterol and Formoterol. In 2003 a "black box"
warning was added to product packaging for drugs that contain salmeterol, including Serevent Diskus, and Advair Diskus. Serevent and Advair are approved for patients
age 12 years and older. The warning was based on a study that demonstrated more
serious and even fatal asthma episodes in patients who used the drug than in
patients who used a placebo." - http://health.nytimes.com/health/guides/disease/pediatric-asthma/long-term-relief-medications.html
All the data I have seen shows that the relative risk of oral steroid use in
treating bouts of severe asthma is less than use of bronchodilators.
#3. It allows one to live a more normal
life than the alternative route of prolonged days of use of bronchodilators.
Because it is more quickly effective, one can more quickly resume normal life,
including things like exercise which help one deal with the next illness.
#4. It is better for long term condition
of the lungs than prolonged days of use of bronchodilators.
Whereas bronchodilators hurt the lungs, oral steroids help heal them, reducing
inflammation and slowing down breathing.
Their use in bouts of severe asthma only can be one piece of addressing asthma,
along with:
a. Exercise, to the extent one can do it without any mouth breathing
b. Chin-up strips, to curb mouth breathing during sleep
c. Buteyko technique for which there is good
evidence. eg: Journal of New Zealand Medical
Association (http://www.nzma.org.nz/journal/116-1187/710/) -
"This study broadly replicates the findings of Bowler et al.5 BBT as taught by a member of BIBH was observed to
produce a large clinically significant reduction in β2-agonist and inhaled
steroid use without negative impact on measures of lung function and with no
apparent adverse effects. The study by Bowler et al demonstrated inhaled
steroid reduction of 49% for the BBT group and 0% for the control group at
three months.5 The
current study exhibited inhaled steroid reduction of 50% in the BBT group and a
1% increase for the control group at six months. With regards β2-agonist use, Bowler et
al demonstrated a 95% reduction in the BBT group and a 7% reduction in the
control group at three months. Our study showed a reduction of 85% in the BBT
group and a reduction of 37% in the control group at six months. The magnitude
of effect in both studies was remarkably similar."
etc.