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LABA Research—Everything Old is New Again

By Dr. Larry Chiaramonte

The story in Reuters began: “One class of drugs used to prevent wheezing and shortness of breath in people with asthma may increase kids’ risk of being hospitalized for an asthma attack, according to a new analysis from the U.S. Food and Drug Administration.” The “new analysis” refers to a study in the November issue of Pediatrics that warns about the use of a class of asthma medication called Long-Acting Beta Agonists, or LABAs. Brand names include Foradil (generic formoterol) and Serevent (generic salmeterol). They are bronchoconstrictors, which relax tight airways.

What’s new about it? Okay—it singles out children between the ages of four and 11 who are 67% more likely to be hospitalized if they are receiving LABAs without an accompanying inhaled corticosteroid (ICS). In Advair and Symbicort the two are combined, which saves the trouble of taking two medications at a time. One of the researchers told Reuters, “Nobody is really prescribing a LABA on its own—that’s basically off the market.” If that’s true, that “nobody” is prescribing them, this study has about as much relevance as a study of auto emissions from the days before the catalytic convertor was required.

Well, they did use data from over 100 studies, and presumably most of them are old. But how old were they? Were any of the studies new? If so, who is prescribing these drugs?

Allergists have known about the problems for a long time. How long?

Before the original of our book was written back in 2003 research already showed enough about LABAs along these lines to indicate that they should never be used except as an adjunct to ICS, and we said so in that edition.

In the new book we wrote:

“In the final days before we ‘closed’ this manuscript prior to publication (June 2010), the U.S. Food and Drug Administration issued yet another warning for single-purpose long-acting bronchodilators:
“’Drugs in the class of long-acting beta agonists (LABAs) should never be used alone in the treatment of asthma in children or adults. Manufacturers will be required to include this warning in the product labels of these drugs, along with taking other steps to reduce the overall use of these medications.’”

Not to toot our own horn around here, but to me this only underscores my opinion that primary care physicians should refer all asthma cases to allergists or pulmonologists who keep up with the latest treatment information.

Why are LABAs so problematic? Here is how we explain it in Asthma Allergies Children: a parent’s guide:

“Bronchodilation relaxes muscles in the airways so that air can pass through. Inflamed adjacent tissues, however, are swollen and inflexible. Imagine filling a bicycle tire with air. The inner tube is flexible and expands. But what would happen if the tire itself were made of the same rubber that bowling balls once were made of instead of soft, flexible rubber? That flexible inner tube would wear out much more quickly.

“Bronchodilators are not complete treatment for the disease called asthma. They are there to help keep the airways open by relaxing the bronchial muscles. But the surrounding tissue is under a great deal of stress and it must be treated too.”

Inflammation is treated with ICS. That’s why you need both.

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