Inhaled corticosteroids are still considered the most important medications for treating persistent asthma. They have a long track record, and they are the only class of drugs that is proved to prevent death from asthma.
Recently, some experts have become more comfortable with the leukotriene modifiers. But the evidence suggests that leukotriene modifiers will work only in some cases of asthma. Many patients maintained on a corticosteroid and a leukotriene modifier will have clinically significant loss of control if the corticosteroid is stopped (and so this should be done gradually). The exact role of these drugs continues to evolve.
Most patients with mild to moderate, persistent asthma can be maintained with an inhaled corticosteroid alone. The recommendation is to start with a high dose to get inflammation under control and then step down the dose. If there are too many acute episodes or there is an inadequate peak flow rate, a possible first-line add-on drug is a long-acting, inhaled [[beta].sub.2]-adrenergic agonist. Leukotriene modifiers may be increasingly popular as the first-line add-on, but patients with nighttime episodes while on an inhaled corticosteroid can also be treated with an inhaled corticosteroid plus salmeterol. In addition, evidence suggests that a long-acting, inhaled [[beta].sub.2]-adrenergic agonist is more effective for overall asthma control than is a leukotriene modifier.
For the rare patients who don't respond to these drugs, options are limited, Cromolyn and nedocromil are usually used only in children. Theophylline is not a good option because of its side effects. A systemic corticosteroid is usually regarded as a final step, but in severe, acute asthma it can be life saving. (Theophylline, cromolyn, nedocromil, and systemic corticosteroids are not included in the chart below because of space limitations.)
In pregnancy, the consequences of uncontrolled asthma outweigh the risk from most medications. Zileuton and zafirlukast should be avoided during pregnancy because they are teratogenic or fetotoxic in animals. Short-acting [beta]-adrenergic agonists at high doses have been shown to be teratogenic in animals, but there is no evidence that animal data translate to human risk. Theophylline is teratogenic in animals but does not appear to be associated with fetal risk in humans. It can cross the placenta and cause tachycardia and vomiting in newborn infants. Clinical data indicate a possible association between use of oral corticosteroids in the first trimester and some birth defects and toxicity; therefore avoid these drugs during the first trimester, if possible.
COPYRIGHT 2002 International Medical News Group
COPYRIGHT 2002 Gale Group
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