Asthma Medicines

Gold Salts

Gold salts have been adminitered to asthmatic patients based on the benefit of this drug in patients with rheumatoid arthritis. Small numbers of patients have been treated with gold injections or an oral gold compound called auranofin, and individual patients have been reported to reduce their symptoms and steroid requirements. Studies of large numbers of patients are lacking and this approach is not without adverse effects, since gold may also cause pulmonary fibrosis. For these reasons, the use of gold salts in the treatment of asthma must be regarded as investigational.

Troleandomycin

Troleandomycin (TAO) , an antibiotic, has been administered to asthmatic patients who have been steroid dependent. It appears to simply slow the excretion of one of the oral corticosteroids, methylprednisolone. Selected patients receiving methylprednisolone who are given troleandomycin have been able to reduce their steroid dosage. A similar effect of TAO has been noted on theophylline breakdown. For this reason, blood levels of theophylline are required of patients maintained on this medication during TAO administration. TAO has no anti-inflammatory effect of its own and may cause liver damage. It must be concluded that TAO has little place in the routine treatment of bronchial asthma.

Antihistamines

Antihistamines have long been regarded as contraindicated in asthmatics. This prohibition has stemmed from the drying effect antihistamines have on lung secretions and the greater potential for “plugging”of the bronchial tubes in asthmatic attacks. This adverse effect has clearly been documented in many patients. On the other hand, studies of large dosages of antihistamines in asthmatic patients have occasionally demonstrated a beneficial effect. This is not surprising, since histamine is one of the irritating substances involved in provoking an asthmatic attack.

Azelastine

Azelastine is an antihistamine that has undergone trials in Japan and other countries in patients with bronchial asthma. Despite early positive results no significant benefit has been proven in large numbers of patients. One adverse effect is drowsiness. This drug is not available in the United States.

Ketotifen

Another antihistamine, Ketotifen, has been available for use in Europe for bronchial asthma. Tb date, studies do not demonstrate a significant beneficial effect. This agent may also cause drowsiness. Until further studies of additional agents are made available there can be no basis for the routine use of antihistamines for treatment of bronchial asthma. Antihistamines may be carefully administered for nasal or sinus disease if the patient is closely monitored by a physician.

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An asthmatic attack is one of the most striking medical emergencies. One of my first experiences with severe asthma was in the intensive care unit of Bellevue Hospital. I had been called to consult on a fifty-six-year-old woman who was having a severe asthmatic attack. As I entered the unit and approached the bedside, I noted several physicians already in attendance. The patient was sitting upright with labored breathing and I could hear her wheezing from several feet away. It was clear that she was not doing well despite continuous oxygen and medicated aerosol treatment. Unable to speak due to shortness of breath, her expression was one of fear and desperation. Several days later, greatly improved after vigorous treatment, I asked her to describe what she had been feeling during her attack. “It was like I was drowning.”

In the asthmatic attack there is constriction or tightening of the bronchial wall muscle, and secretion of mucus, often with “plugging” of small air tubes, as well as inflammation and swelling of the bronchial lining. The end result is blockage or obstruction of the bronchial tubes. The frequency, duration, and severity of the asthmatic attack varies markedly from patient to patient.

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The B-agonists were developed in the 1940s, with isoproterenol the first of the class. Like epinephrine (adrenaline) this agent has both beta-1 and beta-2 effects. Isoetharine was one of the first”selective”B2-adrenergic agonists introduced in the United States and it was followed by metaproterenol. With the development of selective B2-adrenergic agonists there is no place for the use of nonselective agents that have significant stimulatory effects on the heart and circulation. Further research has produced more potent and longer-acting selective agents.

For the Acute Asthmatic Attack: Short-Acting Agent

Several selective B2-adrenergic agonists are available for use. These agents are available as aerosol sprays delivered by metered-dose inhalers (MDIs), aerosol solution to be delivered by nebulization, dry powders for inhalation (DPI), short and long-acting tablets, and as syrups flavored for children. In the acute asthmatic attack the treatment of choice for prompt relief of symptoms is the administration of a short-acting B2-adrenergic agonist. B2-adrenergic agonists (albuterol, metaproterenol, pirbuterol, terbutaline, fenoterol, and bitolterol) have a rapid onset of action (within minutes) with a duration of action of four to six hours. The recommended dosage is two puffs every six hours as needed. These medications differ in potency as well as how fast they begin to work and when their peak effect is reached. There are also differences in how long the effect of the drug lasts. Fenoterol has never been made available in the United States. Its extremely rapid onset of action may have contributed to its overuse and it has been implicated in cases of fatal asthma in New Zealand. Table 1 lists the B2-agonists by generic and brand name as well as the types of preparations that are available.

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Although there are differences from patient to patient, the asthma attack is typically characterized by shortness of breath and wheezing. Cough and mucus production may be prominent symptoms. In some patients wheezing may not occur and a cough may be the dominant symptom. The patient demonstrates a rapid rate of breathing, often with heaving of the chest and use of neck muscles to assist each breath. During an attack the patient is totally disabled. Even speech may be impossible due to severe breathlessness. The patient may be totally consumed by the effort to breathe and unable to eat or dress. The patient is often restless and unable to lie flat. Severe attacks may end in exhaustion, with ominous slowing of the respiratory rate and arrest of breathing.

Depending on the severity of the patient’s disease the attack may be totally or partially reversible, allowing the patient to assume normal activities between episodes. Patients with severe asthma, however, may remain to some degree symptomatic at all times.

It should be noted that the degree of wheezing can be misleading. The severity of the asthmatic attack should never be judged on this basis alone. Some patients who are capable of moving large amounts of air may produce more turbulence and audible wheezing than others who are so severely obstructed that their breaths are shallow and incapable of producing much sound.

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