Study: Mild asthmatics can cut back on albuterol
Study: Mild asthmatics can cut back on albuterol
Daily use of bronchodilators questioned
There’s an asthma epidemic raging in America or is there? Opinions differ about the extent of America’s asthma problem, but one thing is certain: Many patients, especially children, are placed on bronchodilating drugs at the first sign of a wheeze.
The question isn’t so much whether the drugs work, but how they should be used in the long run. Is it better, for example, to have patients use bronchodilators like albuterol on a regular, daily basis, or should the potent drug be reserved for emergency situations?
That depends on what kind of an asthmatic you’re dealing with, suggests a study published in The New England Journal of Medicine (NEJM) last September. It concluded that mild asthmatics derived little clinical benefit from regular use of albuterol inhalers, and recommends these patients use the drug only as needed.
Robyn Levy, MD, an allergist in Atlanta, thinks all asthmatic patients need to be taught not to misuse bronchodilators. "Albuterol is a rescue medicine. It does not address the underlying inflammation of the bronchioles," she says, but only relieves a symptom. "If you have a headache you take a Tylenol. If you have a migraine you don’t take tons of Tylenol."
Levy says some asthma specialists changed their thinking on albuterol use after published accounts of deaths from frequent use of the drug. "We began to tell patients to use anti-inflammatory drugs on a regular basis and the rescue drug [albuterol] as needed. But if you need it a lot, something’s wrong," Levy says. "We began to use bronchodilator overuse as a marker for patients not doing well."
Jeffrey M. Drazen, MD, of Brigham and Women’s Hospital in Boston, says it’s controversial whether albuterol should be treated only as a "rescue" drug. Drazen, who took part in the NEJM study, says it’s acceptable for patients with reasonably normal lung function to use albuterol three or four times a day. Drazen calls "reasonable" use of the drug no more than one 200-puff canister a month equivalent to about 10 doses a day.
"There are a lot of people out there who think two puffs a day [of albuterol] is habitual," Drazen says. "Then there are people like me who think eight puffs a day is OK. We know from our study that 10 puffs a day is OK."
Drazen also falls into the camp of anti- inflammatory skeptics at least when it comes to long-term efficacy of the drugs when compared with bronchodilators. "When I’ve looked at the data, I’m not convinced [the nonsteroidal anti-inflammatories] provide any better long-term effects," he says.
Watch for albuterol prescribing in children
One prescribing trend with albuterol especially albuterol syrup is in children who have respiratory infections. Pharmacists working in hospital asthma clinics should keep an eye out for excessive albuterol syrup use in children. Drazen suggests the automatic prescribing of albuterol for children with colds may be an example of overusing a good thing. No more than one out of six should need the drug, he says, because that’s how many patients with colds actually experience wheezing.
Still, Drazen says current evidence suggests health care management organizations are not overprescribing albuterol. "We’ve gone to a database from health care management organizations and looked at the frequency of albuterol prescriptions and it parallels what we expect the frequency of asthma to be," he says. "It varies between 7% and 10%."
Who gets asthma?
Meanwhile, another recent study suggests that social factors may play a role in who is diagnosed with asthma. According to the report, a diagnosis of asthma is more likely in children who live in the inner city and who don’t regularly see a doctor.
In Philadelphia, researchers found that black and white patients between 9 and 11 years old had equivalent rates of wheezing. But more black children than white children were eventually diagnosed with asthma 72%, compared to 57%.
Episodic, inadequate care may be the reason for the more frequent diagnoses of asthma in inner-city black children, the researchers suggest. If a physician doesn’t know a patient, and the patient shows up in the emergency room wheezing, one logical conclusion might be that the patient has asthma.
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