By Dr. Larry Chiaramonte
One of the persistent discussions in treating asthma is whether to start with smaller, milder dosages of medication and “step up” if they prove ineffective, or start with heavier dosages and “step down.”
In the South Bronx, New York where I practice, and indeed with most asthmatics, patients want to get the condition under control immediately, even if it means taking more medication, as they should. After inflammation is under control, we can take the steps to ratchet down the reliance on high dosages, using peak flows, measuring exhaled nitric oxide, and other means to fine-tune our choice of medications and their dosages.
In this initial treatment, we have three primary weapons:
1.Long-acting beta agonist [LABA]to relax the spasm in the bronchial muscles;
2. Montelukast, a leukotriene-receptor antagonist (LTRA], since leukotrienes are an important cause of allergy.
3. Inhaled corticosteroids [ICS] to thin thick mucous and reduce inflammation.
We try to avoid systemic steroids such as prednisone because they affect the larger immune system instead of just the lungs. (That’s not to say they aren’t effective with asthma. In the days before inhaled steroids, bragging rights went to the doctor who used the least amount of systemic steroids. One of my teachers said at a national meeting he never used steroids to treat
asthma. This was technically true, he transferred from his care all the severe asthmatics to others on his staff, who then used steroids.)
Unfortunately, inhaled corticosteroids still have a vestige of the old stigma attached to them, although it is largely unwarranted. They are central to our NIH asthma guidelines. The NIH states that ICS are safe, necessary for reducing airway inflammation, and prevent the damage of airway remodeling. Add to the historic mistrust of corticosteroids the confusion with testosterone-derived steroids that athletes use and the result is great reluctance to use, or even on the part of primary care doctors to prescribe, these most effective asthma drugs, even after twenty years of safe usage.
While I prefer to step down from aggressive treatment, I don’t have anything against stepping up strategy, unless, as frequently happens, it means avoiding ICS unless nothing else works. Patients suffer in the meantime.
[Note: A different take on this issue “Step-up Therapy for Children with Uncontrolled Asthma” by Robert F. Lemanske, Jr., M.D. appears in the March 18, 2010 issue of the New England Journal of Medicine. There is also a related editorial by Erika von Mutius, M.D., and Jeffrey M. Drazen, M.D.