Asthma in Women, Asthma in Pregnancy (cont.)

Although open windows can allow pollens and other triggers into the house, there may be a trigger in the house, such as smoke, that necessitates opening a window.

Pets with fur should be kept out of the bedroom. If pets are to be kept in the household, they should be bathed twice weekly to reduce the amount of allergens (substances with potential to cause asthma or allergy symptoms). An asthmatic may be allergic not only to the animal itself but also to danders or pollens that the pet carries in from the outside.

Following these recommendations down the last detail would be unrealistic, of course, but at least they are guidelines. Additionally, perhaps some of the chores that are associated with asthma triggers can be done when the person with asthma is out of the house.

Although these recommendations have not been proven to be totally effective (indeed some research finds these measures to not be helpful at all), they are inexpensive and without side effects compared to medications, and therefore are considered standard measures for consideration by every asthma. Physicians generally counsel all asthmatic patients regarding these measures, if they are found to be allergic by skin or blood testing.

Do Filters Help?

High-energy particulate absorption (HEPA) filters have recently gained in popularity. They are filters that remove many allergens from the air. There is not complete proof that these filters should be used by everyone with asthma.

Treatment With Medication: General Considerations

Key point: The risk of asthma that is not controlled in pregnancy is greater than the risk of using medication! The baby needs oxygen!

There are several kinds of asthma medications. Generally, they come in two categories: fast-acting medication (called rescue medication, used for immediate relief of symptoms) and medication (maintenance therapy) that is used regularly each day to prevent the need for the rescue medication. Preventive asthma medications are not addictive, even when used for years!

People who really know how to use their asthma medications and how to alter them with changes in their asthma symptoms not only feel better about their asthma, but research is also beginning to prove that they also have more healthy days than people who just visit the doctor at regular intervals.

Allergy shots (Immunotherapy) is effective for most people with hayfever. It clearly also helps some people with asthma as well. Those asthmatics likely to respond are children, highly allergic individuals and those with poorly controlled hayfever or sinusitis.

The latest treatment recommendations are based on the National Asthma Education and Prevention Program's Report of the Second Expert Panel on the Guidelines for the Diagnosis and Management of Asthma, published in 1997 (2). These treatment guidelines, sponsored by the National Heart, Lung, and Blood Institute, give more emphasis to the use of anti-inflammatory medications, and to possible prevention of asthma, than did prior guidelines. The plan is called a "step approach". This means that if one medication does not do the job, the dose or frequency of doses is raised and other medication is added, and then as the asthma is better controlled, the medications are decreased in a "step down". The 2 generally categories of medication are controller medications (maintenance medications) and reliever medications (rescue medications).

A. Rescue Medication: Inhaled for Quick Relief

For acute, meaning immediate, relief, medication that dilates (opens) the airways is used. These medications, b-agonists, are usually taken in inhaled forms, called metered dose inhalers (MDI's). Examples include albuterol and metaproterenol. There are few side effects of these inhaled bronchodilator medications. Some people may get palpitations, a sense of the heart beating fast, or a sense of feeling "jittery". Some people seem to be more sensitive to those side effects than others. Some people may notice this type of side effect only occur at high doses of the medications. This quick relief medicine should always be carried in case of unexpected need. Often people will be told to keep these medications scattered in easy-to-find locations, like purses or pockets, desk at work, or glove compartment.

B. Maintenance Therapy: Inhaled for Long-Term Control

Because asthma's underlying cause is thought to be inflammation (swelling in the airways), anti-inflammatory therapy is the basis for prevention of acute attacks (exacerbations). Daily preventive (maintenance) medication may be needed if people cough, wheeze, or have chest tightness more than once weekly, if night-time asthma wakes them up, if they have many asthma attacks, or if they are using asthma rescue medication daily.

Therapy consists of inhaled corticosteroids. Corticosteroids are drugs that if taken orally can have significant side effects over the long-term, although these are not the same drugs that became popular with body-builders. Therefore, inhaled forms of the corticosteroids were developed in the form of MDI's. Examples include fluticasone, beclomethasone, and budesonide. Although it is known which of these is the most potent compared to the others (fluticasone), studies actually comparing use of the medications are not very numerous. Steroids are anti-inflammatory, so that they decrease airway swelling, lessen mucus, and decrease the overly active "twitchy" problem in the airways.

There are no immediate side effects of steroid MDI's that a person would feel. Thrush, a whitish yeast infection on the tongue, can occur as a side effect, and is minimized by rinsing out the mouth with water after use and using a "spacer" device that attaches to the inhaler. Spacers are available by prescription and help the medication get into the lungs instead of depositing in the mouth. Based on the fact that use of oral steroids can put people at risk of osteoporosis (brittle bones), there is some concern that inhaled steroids might also decrease bone density, and as a consequence cause fractures later on. The research so far is regarding this possible side effect is controversial, but suggests that this possible side effect is greater with higher potency or higher doses of inhaled steroids. Hopefully the exact degree of risk with different preparations and doses will become clearer in the future. For the time being, consulting with a physician that adequate calcium intake, vitamin D intake, and exercise are being achieved for bone health is a wise idea.

The safest and most effective asthma treatment is inhaled medication, including corticosteroids

Salmeterol is a relatively new medication that is a longer-acting b-agonist. It is often used in people frequently needing b-agonists, in hopes of decreasing the need for short-acting rescue medications. It is also sometimes added to inhaled corticosteroids to improve asthma control or to reduce the dosage of these inhaled corticosteroids needed for asthma control. Some research has shown that asthma control in people already using steroid MDI's is improved moreso by addition of salmeterol than by raising the dose of the steroid MDI. Of course, this means using two inhalers instead of one inhaler. Salmeterol is sometimes used as a long-term medication to prevent exercise-induced asthma, but there is some research showing that its effectiveness when used for this specific reason may slightly decrease gradually with time.

Cromolyn is a medication that has been around for a long time. It is one of the safest medications of all available prescription medications, but it is not very potent. It is used sometimes as maintenance therapy to prevent acute asthma attacks, but it does not help during an acute attack.

C.Maintenance Therapy: Oral (by mouth) for Long-Term Control

Theophylline is an older asthma medication that is taken in pill-form. It acts as a bronchodilator and seems to be especially helpful for people with night-time decrease in lung function that commonly occurs in people with asthma. It's use at night has largely been replace by the long- acting bronchodilator salmeterol.

Use of theophylline requires blood tests to determine blood levels of the medication as part of its safety monitoring. It also has potential side effects, including nausea, increased heart rate (experienced as palpitations), irritability, and insomnia, among others. These side effects are similar to those of caffeine. It also has potential for many drug interactions, meaning it can affect the use of other medicines used at the same time for other conditions, and vice-versa. Acute illnesses can also alter its metabolism (how the drug acts in the body and is eliminated from the body). For these reasons it is infrequently used in asthma treatment. Newer medications particularly inhalers like salmeterol are more effective and have less side effects.

A new class of maintenance medicines has emerged in the last several years. In fact, they were the first new treatment to be approved in 20 years for chronic asthma They are pills that act to reduce the production of, or the action of, chemicals that the body itself makes during an asthma attack. These chemicals called leukotrienes are produced by the inflamed airway, and narrow the airways. These medications are called anti-leukotrienes. Depending on the medication, they either stop the production of the trouble-making leukotrienes, or else block the harmful action of the leukotrienes. It is hoped that they can reduce the need for, or possibly the dose of, other asthma medications. These medications include zafirlukast, montelukast, and zileuton. These antileukotriene drugs directly block bronchoconstriction but are also anti-inflammatory, whereas corticosteroids are only anti-inflammatory. These medications have not been compared to each other, so it is not known if one has any clear advantage over the others. Most of the benefit of these drugs is seen within 2-4 weeks of starting the medication (A), and they generally reduce the need for rescue therapy by 1/3rd (A). They help decrease nighttime asthma symptoms as well (A).

When compared head-to-head, the anti-leukotrienes and the inhaled steroids each help certain lung function tests, quality of life, night-time awakenings, numbers of asthma-control days, and asthma attacks. The two medications were each helpful as controller medications for chronic asthma. Both drugs were very well tolerated in terms of side effects. Other research has added anti-leukotrienes to high doses of inhaled steroids in chronic asthma patients. Patients who did have the anti-leukotriene added had a better chance of successfully reducing the inhaled steroid dose than those who did not add an anti-leukotriene to their inhaled corticosteroids. The anti-leukotrienes are not yet felt to be useful in severe asthma, and many people with milder asthma are already controlled and happy on either intermittent rescue medication or chronic inhaled corticosteroid MDI's with only occasional need for rescue medication.

It might be that these medications if used regularly for many weeks, are good at preventing exercise-induced asthma, as is being shown in recent research, and that they may help a certain type of asthma called aspirin-sensitive asthma. However, there are many issues that have come up regarding these medications; people may find using MDI's more convenient that taking these pills, MDI's in low doses have minimal absorption compared to pills thus possibly less potential for side effects, and long-term studies of these pills are not available yet. Also, zileuton has potential to cause abnormal liver function test in the blood, so that all people taking this medication will need liver test monitoring via blood tests at intervals, especially in the first 3 months of use. Therefore their precise role is still being determined, especially in the long-term. Specifically, we need long-term safety and effectiveness data, and need to clearly establish what specific group of asthmatics will benefit most from them. Probably for the time being, in real daily practice while we await research, their use is considered in the following mild to moderate asthmatics: those with less than optimal benefit from inhaled steroid, those with aspirin-sensitive asthma, and those needing high doses of inhaled or oral steroids.

In summary, then, these anti-leukotrienes are a good choice for people with aspirin-induced asthma, and they can improve lung function in those with chronic asthma by decreasing: need for rescue medications, asthma symptoms, frequency of attacks needing oral steroid pills, and dose of inhaled steroids needed for long-term control. They are also useful for exercise-induced asthma.

In very severe asthma, daily oral corticosteroids (or steroids) may be necessary. These have many potential side effects, so that physicians generally explore every single other reasonable alternative before starting oral corticosteroids. They also try to use other medications to reduce the necessary dose of these steroid pills. These oral steroids are not the same medications used (abused) by body builders. They can be life-saving drugs for people with severe asthma, and they are used in the lowest dose possible in order to reduce possible side effects. When people are admitted to the hospital having an acute asthma attack that cannot be terminated with inhaled medications, they are often given corticosteroids in intravenous form (into the veins in their arms) for a short time to bring the attack under control, after which the medication is converted back to oral and inhaled forms. The most frequent use for oral steroids is a short course (5-10 days). This is the most effective way to control acute asthma attacks or poorly controlled chronic asthma which are not responding to inhaled medications.

The Office of Women's Health of the Federal Drug Administration has a section called Women's Health: Take Time to Care (7), the aim of which is to make women aware of safe medication use. Women are the principal users of medications and who often have to administer medication to family members.

D. Use of Medications: Optimizing Their Effects and Safety

Frequent review of the technique of using inhaled medications is very helpful. First, the cap should be removed. The inhaler should be shaken before use. Inhalation of the medication should be done with the head tilted back, with the mouth about 1 inch away from the inhaler. Before inhaling the medication, patients should exhale (breathe out) completely. The medication is inhaled slowly, over 3 to 5 seconds. Then breath should be held for 10 seconds so the medication will get to and stay in the lungs. When prescribed two puffs at one time, a few seconds should go by between puffs. People having difficulty using the inhaler with a spacer (see below) should discuss the problem with their physician. The inhaler and its cap should be cleaned in warm water each day. The mouthpiece should also be washed occasionally with mild dishwashing detergent and water. After being washed each time, the parts should be allowed to dry before storage.

Spacers are devices used to increase the amount of medicine actually reaching the lungs. They also help to avoid the thrush (see above) that can happen as a side effect of the inhaled corticosteroids. Rinsing out the mouth after each use of inhaled corticosteroids will also help minimize thrush. The spacer can minimize the amount of medication that just stays on the tongue, so that the medicine will go where it belongs, in the lungs. The spacer holds the medicine so it can be inhaled slowly, and helps to minimize cough that results occasionally from using an MDI.

If a woman uses her quick-relief (rescue) medication more than 3 times weekly, chances are she should be on a daily long-term therapy medication to decrease inflammation over the long-term. Using inhaled steroids early in asthma's course may not only control asthma better but also make lung function normal.

People who use both inhaled steroids and rescue inhaled bronchodilators should first use the bronchodilator to open the airways, to better allow the corticosteroid that they use next to reach the lungs.

All women with asthma need to have education regarding what to expect from their asthma as well as what to expect from their asthma medications. Education is critical, and every woman's plan is individualized so that a woman should be able to do her usual activities. Women should expect or request a written plan from a treating physician which includes expected length of treatment with each medication, when to expect each medication's effect to be felt, and what to do if a dose is missed.

To see how much medication is left in an MDI canister can be difficult. However, putting it in a sink full of water can give an idea of how empty the canister is. A canister floated in this way will float completely to the top when it is empty and sink all the way to the bottom when full. It will be floating vertically when half full, and sink vertically when mostly full.

The older form of the inhaled asthma medications is slowly being phased out. This is because the older MDI's have chlorofluorocarbons (CFC's). These CFC's decrease the amount of ozone in the ozone layer around the earth and are therefore thought to have a harmful effect on the environment. Therefore, the medications are gradually being put into forms that do not contain CFC's. Some of these forms are already available. New formulas, such as dry powder inhalers, are being substituted for the older CFC MDI medications, with the goal of one day having only non-CFC-containing inhalers.

Further information on how to use inhalers probably and regarding monitoring and treatment of asthma are available from the NHLBI (2).

E. Treatment & Monitoring Based on the Type of Asthma

Doctors usually give out a written set of instructions that describes the individual treatment plan. The partner in the treatment plan, the woman with asthma is expected to keep an accurate diary of her symptoms. She needs to go the doctor at least a few times a year, even if she feels okay and thinks her asthma is doing fine.

Also, if she has moderate or severe persistent asthma, or if she ever develops severe asthma attacks regardless of the type of asthma she has, she should monitor her peak expiratory flow, sometimes called simply peak flow. The highest of 3 trials using a peak flow meter is the person's peak flow. Peak flow monitoring helps both the woman and the physician know how her asthma is really doing, and may help the woman be more aware of how her symptoms relate to her lung function at any given time. The NIH has information on performing peak flow monitoring. (2)

Technically speaking, asthma is no longer defined as mild, moderate, or severe. Instead, more specific categories are now used, and doctors base their treatments on them. Asthma classification categories are now mild intermittent, mild persistent, moderate persistent, and severe persistent. Within each one of these categories, attacks can be mild, moderate, or severe.

Summary of Treatment Issues Specific to Asthma and Pregnancy

Asthma course can get better, worsen, or stay the same during pregnancy, in unpredictable fashion. Risk of using asthma medications during pregnancy is much lower than the risk of bad outcomes due to uncontrolled asthma. Oxygen supply for the fetus relies on proper control of a pregnant woman's asthma. Asthma is to be treated as aggressively in pregnant as in nonpregnant women, with both rescue and preventive medications. Although women are understandably worried about using any medications during pregnancy, use of asthma medications during pregnancy clearly bring about less in the way of bad outcomes than does leaving asthma uncontrolled during pregnancy.

References, and for further information or help, Government initiatives and national organizations devoted to asthma.

(1) The Global Initiative for Asthma is a project of the National Heart, Lung, and Blood Institute, National Institutes of Health, and the World Health Organization. Its purpose is to increase public awareness of asthma, support asthma research, decrease its harmful toll on the U.S., and improve its management. Information is at www.ginasthma.com/home/home.html

(2) National Heart, Lung, and Blood Institute is at www.nhlbi.nih.gov, and their specific asthma information for the public is at www.nhlbi.nih.gov/health/public/lung/index.htm, 1-301-251-1222

(3) The National Institute of Allergy and Infectious Diseases of the National Institutes of Health www.niaid.nih.gov

(4) The U.S. Environmental Protection Agency is at 800-438-4318, www.epa.gov

(5) The National Institute for Occupational Safety and Health (NIOSH) is at www.cdc.gov/niosh/homepage.html

(6) The American Lung Association is at 1-800-LUNG-USA, www.lungusa.org

(7) The American Academy of Allergy Asthma & Immunology is at www.aaaai.org, 1-800-822-2762

(8) The Office of Women's Health of the Federal Drug Administration has a section called Women's Health: Take Time to Care, at www.fda.gov/womens/tttc.html

(9) En espanol (in Spanish): www.aaaai.org/public/publicedmat/tips/default.stm

www.lungusa.org/diseases/espanol/espanol.html

www.nhlbisupport.com/asthma/patedu.html

(10) The Asthma and Allergy Foundation of America is at www.aafa.org/home.html, 1-800-727-8642

(11) The National Jewish Medical and Research Center is at www.njc.org, and its information service is at 1-800-222-LUNG

(12) The American Thoracic Society is at www.thoracic.org

(13) The American College of Chest Physicians is at www.chestnet.org

(14) The Allergy, Asthma & Immunology Online (from American College of Allergy, Asthma & Immunology) is at allergy.mcg.edu

(15) The Mayo Clinic Health Oasis Allergy & Asthma Center is at www.mayohealth.org/mayo/common/htm/allergy.htm

(16) The National Asthma Education and Prevention Program (NAEPP) is at www.nhlbi.nih.gov/about /naepp/naep_pd.htm, 1-301-251-1222

(17) The American College of Allergy, Asthma, and Immunology 1-800-842-7777

OTHER REFERENCES

(A) Drazen et al, Treatment of asthma with drugs modifying the leukotriene pathway, NEJM, 340(3):197-206.


Last Editorial Review: 4/5/2002