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How do we choose the right medication for you?

By Dr. Paul Ehrlich

When I began practicing medicine, health-related television advertising was confined to over-the-counter medication and cigarettes. Clearly, some things have changed for the better. Good riddance to cigarettes. Allowing prescription meds to be advertised is a mixed blessing. It is good in the sense that it may prompt people to think about their health in more sophisticated ways. It is probably bad in that it may cause some people to self-diagnose conditions they don’t have and demand treatment in the form of a particular medication from family doctors who are too busy to get to the bottom of it.

Fortunately, the big-name prescription asthma medicines that fill the airways—that is the media airways—are good medicines. In this they are different from a non-prescription drug frequently used for asthma like Primatene. But I also think that it bears some discussion of how “we”, that is the doctor and the patient, as in “we chose such-and-such” make the decision to use one or another.

First of all, in the commercials and in the literature for these drugs, the idea of “control” is bandied about a great deal. For example, “prescribe …. only for patients not adequately controlled” and “[o]nce asthma control is achieved and maintained.” But what an allergist means by control may not be the same as what a family doctor means, or a patient means. To me, it means that inflammation is below a certain level so that it is unlikely that an asthma attack will be triggered. I can make that determination based on history, peak flow measurements, and in some cases measuring the exhaled breath for something called exhaled nitric oxide (eNO), which is a byproduct of asthmatic inflammation. To a patient or even a family doctor, it may imply only that the patient isn’t wheezing and coughing. So any decision about any asthma medication ideally should be made in consultation with a doctor who knows control.

In addition, a doctor who understands control also knows that the lungs—the lower airways—are affected by what’s happening in the sinuses—the upper airways. A “non-symptomatic” asthmatic with a stuffy nose is an attack waiting to happen. Allergens are trapped in the upper airways where they are inflaming the tissues. It’s just a matter of time before that inflammation heads south towards the lungs.

Second, the preferred medicines for controlling asthma are inhaled corticosteroids, or ICS, which, as we write in our book, suffer from guilt by association with anabolic steroids, although they aren’t related. But they really do work very well if properly used, so you shouldn’t be biased against them. As Dr. House said in an episode where a mother expressed reluctance to let her child use ICS, (and I only quote a TV doctor because very good doctors advise the show) “If you don’t believe in steroids, you don’t believe in doctors.”

If ICS doesn’t do the job, the commercials imply, “we” will choose a combination medicine that includes a long-acting beta agonist [LABA] to control bronchoconstriction as well as inflammation. As Dr. Larry wrote a few weeks ago, LABAs have had some unwarranted bad PR of their own, and the commercials that warn of it are still running even though the bad news has been discredited.

So, how do we decide?

(To be continued)

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2 Responses to “How do we choose the right medication for you?”

  1. I witnessed the varying notion of “control” via my mother’s adult history of asthma. Her G.P.’s was the antiquated notion that her asthma was in control until it wasn’t (i.e. unmedicated) at which point he advised her to take antihistamines, and often antibiotics. Eventually, after years, she went to a pulmonologist who controlled her asthma with daily inhaled medications — but only after significant damage had been done to her airways.

    As a result I appreciate the medicine you refer to as ICS as a means of preventing my mother from the downward falls into infection and ultimately into tissue damage, that people may not understand can be the other side of uncontrolled asthma.


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