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Standard Asthma Treatments:

Depending on the severity and type of your asthma, your treatment will be geared to reduce inflammation and relieve symptoms.  The following is a list of treatments that are available in Western medicine:

Inhalers:

Inhalers were already invented for lung conditions in 1778 by an English doctor named John Mudge .  At that time opium was inhaled through a special pewter tank.  In the 20th century the inhaler for asthma was invented and revolutionised its treatment.

1.  PREVENTER INHALERS

 

A.  Corticosteroid inhalers:  if you have anything but mild asthma, corticosteroid inhalers are prescribed almost universally, and have made the treatment of asthma much more successful.  Corticosteroids are basically a synthetic form of the hormone cortisol which your adrenal glands naturally secrete in response to stress.  The reason cortisol is secreted in times of stress is to inhibit your immune system to help you deal with whatever stress you have without becoming ill with a cold for example.  This immune suppressing function is used in these inhalers to coat the inflamed tissue of your lungs thus preventing your own immune system from inflaming and damaging your pulmonary tissues.  These inhalers are taken daily to reduce inflammation in your lungs and are not used for acute asthma attacks.  Their regular use results in fewer asthma attacks, less mucus production, and fewer hospitalisations.  Most people respond well to this treatment.  The exception are people with neutrophilic asthma or people with very severe eosinophilic asthma, where these inhalers do not decrease inflammation enough.  For many asthmatics though this treatment is very effective at controlling most asthma symptoms.  If you have seasonal allergies or suffer more in the winter time, you may only need to use your corticosteroid inhaler during those times of year.  Corticosteroid inhalers come in several forms:

  • hydrofluoroalkane inhaler - these are aerosol inhalers, usually best used with an inhalation chamber (Foster, Flovent (Fluticasone), Alvesco (Ciclesonide)

  • dry powder inhaler - used directly into the mouth after activation.  They need to be inhaled with one deep inhalation.  Many asthmatics find the powder irritating to their lungs and they are also not easy to use when your chest is tight and symptomatic.

  • nebuliser solutions - used for severe asthma or during acute attacks where a nebuliser and breathing chamber are used, especially when breathing is difficult.

Many of the different corticosteroid medications come in the above mentioned forms, and some are combined with long acting bronchial dilators.  The main ones are:

  • Fluticasone (Flovent HFA)

  • Budesonide (Pulmicort Flexhaler)

  • Mometasone (Asmanex Twisthaler)

  • Beclomethasone (Qvar RediHaler, Clenil Modulite)

  • Ciclesonide (Alvesco)

Inhalers that contain both corticosteroids and a long acting bronchodilator are used when symptoms are not well controlled with the steroid inhaler alone.  Examples include:

  • Fluticasone and salmeterol (Advair Diskus, Seretide (UK))

  • Budesonide and formoterol (Symbicort)

  • Mometasone and formoterol (Dulera)

  • Fluticasone and vilanterol (Breo)

  • Beclometasone and formoterol  (Foster or Fostair)

  • Flluticasone with formoterol (Flutiform (UK))

Long acting bronchodilators are sometimes given separately to the corticosteroid inhalers, but these HAVE to be taken along with the corticosteroid inhaler.  If not they can be dangerous, and have caused fatal asthma attacks in the past.  Examples of long acting bronchodilators are:

Long acting beta agonists  (LABA)- are used to relieve airway constriction for at least 12 hours and reduce night time symptoms.   The most commonly used is Salmeterol (Serevent).

Long-acting muscarinic antagonists (LAMA) are usually used for COPD but can also help in asthmatics who produce a lot of mucus.  Tiotropium bromide (Spiriva Respimat) has an effect over 24 hours, hence only used once per day and always in combination with a corticosteroid inhaler.

For safety purposes preventer inhalers are usually brown, red or pink, as opposed to rescue inhalers which are blue.

B.  CROMOLYN SODIUM - this inhaler is considered a very safe option for some asthmatics, although it is not widely prescribed.  It is a mast cell stabiliser and thus reduces histamine and leukotrine responses to allergens, as well as inhibiting eosinophil chemotaxis (https://pubchem.ncbi.nlm.nih.gov/compound/Cromolyn-sodium).  It is a constituent of a plant used traditionally as a muscle relaxant by the Egyptians - Ammi visnaga​, and was discovered to have bronchiodilating effects by Dr. Roger Altounyan (1922–1987), an Anglo-armenian physician who himself was severely asthmatic. He eventually isolated the active compound, chromolyn sodium, after much trial and error (Source: Wikipedia). It has to be used 4 times daily and over the course of weeks to achieve any effectiveness, and does not add any additional benefit if you are already using a corticosteroid inhaler.  However, if you have just been diagnosed with atopic (allergic) asthma, it may be a good option to try if you do not wish to go on corticosteroid inhalers.  My personal experience is that most doctors do not know much about it, and it is not easily obtained.  Sanofi Pharmaceutical company in Europe manufactures it, selling it under the name of INTAL.   You can also get this medication as a nasal spray for prevention of allergic rhinitis. In tablet form it is used for mast cell activation syndrome, mastocytosis, dermatocraphic dermatitis and ulcerative colitis, It is usually replaced nowadays by other medications.

2.  RESCUE INHALERS - rescue inhalers should be carried by any person with asthma at all times to relieve acute asthma attacks.  These beta-adrenergic inhalers act quickly (within 5 to 20 minutes) to open your airways, and can be life saving if you are having an acute attack.  These work in a similar way to adrenalin, another hormone secreted by your adrenal glands in response to acute stress - helping you to run for your life in situations of danger by opening your airways, increasing your heart rate and brining extra blood flow and tension into your muscles.  It is because of these actions that inhalers like Ventolin, Salbutamol and Albuterol act as short term bronchial dilators - the effects last about 4 to 6 hours.  However, just like adrenalin, they may have some unwanted side effects that can be dangerous if they are taken too often or in too high a dosage.  These include increased blood pressure and tachycardia (rapid heart rate).  They may also make you feel shaky and cause muscle cramping.  As such they should not be abused, and used only when necessary.  Please note that learning the Buteyko Method will probably relieve you of having to use these inhalers very often, as you will be able to control most of your own symptoms.

Atrovent (Atroaldo), is another rescue inhaler that acts in a different way to Ventolin and has a milder, but longer lasting effect.  It is an anticholinergic drug which blocks the cholinergic receptors in the muscles surrounding the airways which usually bind Acetylcholine (a neurotransmitter) causing a bronchospasm.  This medication is sometimes prescribed together with Ventolin to extend its bronchodilating effects, or in cases where the treatments are not working as well as expected.

ORAL TREATMENTS:

Among oral treatments that you may encounter for your asthma are mast-cell stabilisers (cromolyn sodium), anti-histamines, leukotrine inhibitors, antibiotics and oral steroids.

Leukotriene Inhibitors - Montelukast & Zafirlukast- some asthmatics may benefit from this type medication which block inflammatory molecules called Leukotrienes. Leukotrienes are a type of eicosanoid inflammatory mediator that are secreted by leukocytes (a white blood cell  whose primary function is to protect you against foreign invaders) in response to allergens.  They induce an inflammatory response in the airways which may result in bronchial constriction, and increased mucus secretion.  Four different types are known, and one of these is also known to play a crucial role in anaphylaxis.  These drugs can have quite severe side effects affecting your mood (anxiety, aggression, to the point of causing hallucinations or sleepwalking.  Other side effects may include neuropathy (tingling, numbness, shooting pains or weakness).

Source: (https://en.wikipedia.org/wiki/Leukotriene)

Oral (or injected) Corticosteroids - prednisone, prednisolone, deflazacort etc.. During severe flare ups of asthma, which may result from viral infections such as a cold, emotional or physical stress, allergen or airborne particle exposure, you may be prescribed a course of oral steroids.  Usually they are tapered down from a high initial dosage over the course of a week to 10 days.  This is a synthetic form of the hormone cortisol, and just as in the preventer inhalers, their function is to reduce inflammation by suppressing the immune system.  Most people can get off these medications and truly can be life saving.  The caveat is that over time they act as though your stress hormones are too high, which may result in bone loss (osteoporosis), muscle wasting, weight gain, type two diabetes, hypertension, kidney function decline and other undesirable problems.  Because of this they are given a bad rep, and when patients with very severe asthma become dependent on them, efforts are taken to try other, often expensive therapies, in an attempt to wean them off these medications.  In contrast, inhaled corticosteroids found in preventer medications have primarily a local effect, and their dosage is minuscule in comparison to the oral version. Perhaps I should mention here that there is some evidence that asthmatics have inherently low cortisol reserves.  As such replacing low cortisol with bio-identical hormone (hydrocortisone or Cortef) may be very useful in some cases, and may help keep asthma symptoms well controlled.  For more details on how to test for this and how to use cortisol safely you should read "Safe uses of Cortisol" by William Mc Jeffries.  Doctor Jeffries spent 50 years in clinical practice giving bio-identical cortisol where needed and never saw any adverse results when done properly.  If you are steroid dependent this book may put your mind at ease and help you devise some strategies together with your doctor for you to stay healthy in spite of needing these medications.

Monoclonal Antibodies:

For patients with severe or persistent asthma a new type of therapy has become available which, for many, has increased quality of life significantly.  Monoclonal antibodies are basically antibodies that are produced in a laboratory (made in cells) that are specific to short circuit the inflammatory response by binding to molecules (cytokines) that induce airway inflammation. They are given by injection (or intravenously) on a bi-weekly or monthly basis, and are mostly well tolerated.  The draw back ist their cost, which makes them unavailable to some patients.  However, considering how miserable life can be for a person with severe asthma, they can be life savers.  The main monoclonal antibodies used for asthmatics are: 

 

Omalizumab (Xolair) - antibodies block IgE on the surface of mast cells and basophils.  Useful in IgE predominant asthma.

Meoplizumab (Nucala) - antibodies against IL-5 which lower eosinophil counts.  Particularly for patients with high serum or tissue eosinophils. It is also used to treat EGPA (eosinophilic granulomatosis with polyangiitis, i.e. Churg Strauss syndrome)

Reslizumab (Cinqair) - IL-5 antagonists, for similar indications as Mepolizumab.

 

Benralizumab (Fasenra) - antibody binding up the IL-5 alpha subunit on basophils and eosinophils.aIt is also used for eosinophilic type asthma.

Dupilumab (Dupixient) - inhibits IL-4 alpha subunit and reduces cytokine inflammation from IL-4 and IL-13.  It is used for patients with an eosinophilic phenotype or patients who are dependant on oral corticosteroids for their asthma control.