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From the Toronto Star, Special Supplement on Respiratory Illness

Tricks, truths and myths about asthma medications
Dual purpose inhalers promise to end drug juggling acts

Chris Atack
Special to the Star

Use the brown puffer, one puff twice a day to head off an asthma attack. Use the first blue puffer twice a day, one puff, in addition to the brown puffer for mild symptoms. For serious wheezing or shortness of breath, use the second blue puffer, not the first. Do not discontinue the brown puffer.

Huh?

The goods new: asthma drugs are very effective. The bad news: taking them can be very complicated. To keep symptoms under control, many patients juggle two or three different drugs, in different doses and combinations depending on how they"re feeling that day. Keeping track of what to take when can get more than a little tricky.

Tricky or not, drug therapy is vital to the health of asthma patients. Asthma is the most common long-term respiratory disease in Canadian children, accounting for one quarter of all school absences. When not controlled, it can deadly. In recent years it has killed about 20 Canadian children and 500 adults annually.

With an asthmatic child in the house, adjusting drugs and doses rapidly becomes second nature, according to Barbara Galen, whose daughter Alice was diagnosed at age two with asthma. In the eight years since then, Alice has been taking three different inhaled medications on and off, depending on how well controlled her asthma is at the time.

"At first it was a bit confusing," Galen admits. "The doctor gave me a bunch of pamphlets. I read them and combined the best of the advice. Today, we keep a chart. We note down morning and afternoon medications for all seven days of the week, because sometimes my husband does it, sometimes I do it, and it"s confusing. "Honey, did you give Alice her medications"" So we write it down. After a while it becomes routine, like washing your hair or making sure your kids have done their homework."

Asthma therapy is based on two categories of drug. Both are inhaled directly into the lungs, using inhalers, sometimes called puffers. To help patients keep their drugs straight, puffers are colour-coded. Medications to prevents asthma usually come in brown puffers. Those for relief of symptoms come in blue ones. The two drugs work in very different ways.

Inhaled steroids (the brown puffers) are usually the first choice for preventing asthma attacks. They make the lungs less sensitive to irritants like animal dander and dust. This reduces the lung inflammation which leads to asthma.

The second category of drugs, bronchodilators, usually come in blue inhalers. They deliver a healthy dose of the same sort of chemicals people produce when they come face-to-face with a hungry bear. These chemicals prepare the body for fight or flight, in the process opening up airways in the lungs.

Because they work fast, these are used to relieve wheezing, shortness of breath and other asthma symptoms.

"Inhaled steroids are the mainstay of preventive therapy," says Doctor Anthony D"Urso, Director of the Primary Care Lung Clinic, a Toronto respiratory center with over 2000 patients. "Even patients with very mild asthma and normal lung function benefit. Steroids definitely give the most bang for the buck."

Even so, many parents and children are leery of inhaled steroids. This is partly because they confuse them with anabolic steroids, a much more dangerous class of drug sometimes taken by athletes to improve performance. Some parents are also fearful that inhaled steroids will stunt children"s growth.

"I was concerned about steroids," admits Galen. "I mean, you hear about athletes and so on. But the doctor reassured me this really wasn"t the same thing at all. I did some reading because I was concerned about compromising growth, and I came to the conclusion it"s a balancing act. If a child is having asthma attacks and taking other medications, that can affect eating and overall health. That will compromise growth too, so it"s a trade off."

Like many urban myths, the notion that inhaled steroids interfere with growth contains a small grain of truth.

"The misconception arises from older studies showing a short-term decrease in growth in children taking inhaled steroids," says D"Urso. "But as we studied these children longer, we realized they caught up with other kids after the first year.

"At low doses, inhaled steroids are very, very safe. With low doses, children can generally use them for years and years without growth being affected, even if they start before puberty."

Steroids help control asthma, but they can"t totally prevent it. When an asthma attack occurs, patients reach for their blue puffers to open up air passages quickly. Bronchodilators are sometimes known as "asthma relievers" or "rescue medications" because they "rescue" patients from the unpleasant wheezing, coughing and breathlessness of an asthma attack.

"Many asthmatics have infrequent symptoms," says D"Urso. "They can get by reasonably well with just bronchodilators. There are many different ones on the market, for example Ventolin, Bricanyl and so on. They all work the same way."

Older versions are short-acting. Oxese, a newer drug, works for a longer time. Some patients use a short-acting bronchodilator to relieve symptoms but switch to a low dose of the longer-acting version when symptom-free, to help head off future attacks. Enter the second blue puffer.

Because the two main asthma drugs work in different ways, they are often combined for even better effect.

"Patients with mild asthma and normal lung function do better if they take a long-acting bronchodilator on top of a steroid," says D"Urso

Patients who need combination therapy can join the ranks of two-puffer users, or they can take one of the newer drugs containing both an inhaled steroid and a bronchodilator.

"A product called Symbicort has just been approved in Canada," says D"Urso. "The bronchodilator in the product is rapid-onset, so it can be used when a patient has an asthma attack. Also, it can be used more than twice a day, so it gives patients more flexibility."

While inhaled steroids may be the best thing to control asthma, some patients still refuse point blank to take them. One alternative for them is a class of drug known as leukotrienne receptor antagonists.

Taken by mouth rather than inhaled, these drugs have anti-inflammatory properties. "They are not as effective as inhaled steroids, so we only use them in patients who can"t or won"t use inhaled steroids," says D"Urso. "We don"t even used them as add-on therapy to inhaled steroids because studies show long-acting bronchodilators are better."

While puffers work wonders for asthma, sucking on them is anything but cool for image-conscious teenagers.

"With teens, there seems to be a stigma associated with inhaler therapy," says D"Urso. "Actually, it"s not just inhalers but any kind of medication. It seems to make them feel like they"re not part of the group, like they"re not well. Compliance becomes a big factor.

"I remind kids that at the Los Angeles Olympics, 10 per cent of the U.S. team was asthmatic. That includes top-level gold medal athletes. Being asthmatic doesn"t mean you"re a wimp at all.

"Some of them try and cruise along. They say "I can deal with it myself." This group finds it very difficult to buy in. Other groups are much more compliant. They tend to be athletic, they tend to be a bit more insightful and less vulnerable to peer pressure."

For Alice, peer pressure is no longer an issue. At age 10 she has adjusted well to her asthma.

"In kindergarten she would say, "Mom, I have asthma and no-one else does,"" recalls Galen. "I"d tell her "look, your uncle has it, some of my friends have it, and it"s actually not unusual."

"Now, if she"s playing outside after school she"ll take her puffer right out and use it. She doesn"t care and the other kids don"t mind either. I think it was worse back when asthma wasn"t controlled and kids had to sit out activities. Sometimes she has to miss gym, but not often. She does everything everyone else does. She"s in good health."

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