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Know Your Medication

The best and most efficient pharmacy is within your own system. - Robert C. Peale

Although medication occupies a very important place in the treatment of asthma everyone with the condition, regardless of age or severity of symptoms, should at least try natural measures to alleviate asthma. All drugs have side effects and every opportunity should be seized to minimise the dosage required. Natural measures such as contained in this book have been proven to reduce the amount of asthma medication required and the very fact that you are reading this book indicates this is an approach you take seriously.

Medication for the treatment of asthma can be broadly divided into two groups namely reliever (bronchodilator) and preventer (steroid).

Reliever medication

Reliever medication is taken, as the name would imply, to obtain relief from symptoms. This is an important distinction from preventer medication taken to stop the symptoms from arising in the first place. The most popular form of reliever medication is the inhaler which will be familiar to most people; however it can also come in the form of a tablet or syrup. Reliever inhalers are easily recognisable by their blue, grey or green colour.

There are two types of reliever medication and they vary by how long the drug keeps the airways open. The most popular type of inhaler, which is known to everyone with asthma, is a short-acting reliever inhaler known as a beta2Agonist. This is taken only when needed and the effects last for three to four hours. Commonly prescribed short-acting relievers are Ventolin, Salamol and Bricanyl.

The second type of reliever inhaler is longer acting and keeps the airways open for about twelve hours. It is taken at regular times, usually in the morning and at night, and is marketed as Oxis, Serevent and Spireva. The drug and brand names of long-acting relievers are: Salmeterol, commonly known as Serevent, and Eformoterol, commonly known as Oxis and Foradil.

Short acting reliever guidelines

This medication should be taken on a need-only basis to overcome attacks.Try not to take reliever medication solely out of habit. Ensure that the inhaler is needed instead of instinctively reaching for it at the slightest hint of symptoms. If the symptoms are minor, try to stop the oncoming attack by using reduced breathing. If this does not stop the attack after five minutes, then take reliever medication. If the symptoms are severe, reliever medication should be taken immediately.

Try taking only one puff of the reliever inhaler each time. Professor Buteyko recommends taking one puff and waiting for the medication to take effect, which should happen within five minutes. If another puff is needed it should be taken at this stage. There is no point in taking two puffs of reliever medication when only one is needed. Steroids are different however and should be used according to the prescription and never altered without a doctor?s consent.

Long-acting bronchodilators (relievers)

These inhalers keep the airways open for several hours and are taken once every twelve hours. They are prescribed for use on a regular basis, two puffs at a time, but should NEVER be used for emergencies. People have been known to die from taking long-acting relievers for symptomatic relief.

One of the shortfalls of reliever medication (bronchodilators) is that it does not cure asthma. No matter what dose is taken today it will make no difference to what symptoms are experienced tomorrow.

Reliever medication also causes hyperventilation. It forces the airways open and because the underlying hyperventilation is not addressed, the body will mount an even greater defence to prevent a further loss of carbon dioxide. Tolerance develops and the amount of reliever medication required to maintain control increases as the person gets older.

The side effects of bronchodilators can include: hyperventilation, hyperactivity, muscle tremors (often felt as a shaking of the hands), restlessness, dizziness, headaches, palpitations or gastrointestinal upsets.

Preventer medication

Preventer medication is predominantly steroid based and must be taken all the time, according to a doctor?s instructions. Preventers come in red, brown or orange inhalers. Commonly used preventer medications are Flixotide, Becotide and Pulmicort.

Steroids (preventers) are the most effective anti-inflammatory drugs but they do not give immediate relief and their true worth only emerges with continuous use. A common mistake is to completely stop taking the preventer medication when fewer symptoms are experienced. In this case the asthma will slowly worsen over seven to twenty-one days, the need for a reliever will increase and this can result in a serious, uncontrolled asthma attack.

Steroids reduce inflammation which is the main component of asthma (2) but they do not cure the underlying disease.

It is important to note that preventative medication should never be stopped or reduced without consulting a doctor first.

The drug and brand names of oral steroids include: Prednisolone 1, 5 and 25 mg tablets that are commonly known as Deltacotril and Precortisyl Forte.

The side effects of steroids taken at high doses for prolonged periods (oral steroids) can include: high blood sugar/diabetes, hunger, cataracts, glaucoma, psychiatric disturbances, stomach ulcers, the increased likelihood of infection, depression, sleeplessness, aggravation of schizophrenia and epilepsy, suppression of the adrenal glands, thin bones (osteoporosis), roundness of the face, high blood pressure, retarded growth in children, thinning of the skin (looking like stretch marks), excessive hair growth especially for females or a general feeling of being unwell.

To help counter some of the side effects of steroids take a mineral supplement which is high in calcium and Vitamin D and exercise regularly.

Combination of reliever and preventer medication

A combination of drugs containing both reliever and preventer medication is becoming more commonly prescribed. Possible side effects from combination drugs are similar to those from long-acting and preventer medication taken together.

New developments with anti-inflammatory medication

A new class of preventer anti-inflammatory drugs commonly known as Singulair came on the market in the 1990s. The main action of these drugs is to inhibit the powerful effects of inflammatory mediators called Leukotrienes. They work differently to steroids and it will be some time before the true effects become known. History has been unfavourable to drugs for the treatment of asthma and often it is ten or twenty years before the side effects become known.

Singulair comes in five and ten mg tablets and the side effects can include: fever, respiratory infection, stomach upset, dry mouth, weakness, dizziness, severe allergic reaction, headache, sleeplessness and muscle or joint pain.

It is not advised that these tablets are taken by children under six years of age or by patients with Churg-Strauss syndrome.

Buteyko Breathing and medication

While it is not known exactly how steroids work, it is accepted that they treat inflammation which is the underlying airway obstruction. Professor Buteyko regards steroids as the treatment of choice. His belief is that steroids work by reducing breathing and this occurs as quickly as one hour after being taken. By reducing the breathing, airways are opened without a further loss of carbon dioxide. Professor Buteyko believes that taking the correct dosage of steroids is fundamental to maintaining safe control but unfortunately many people do not take the correct dose. Some people take too low a dose with the result that the asthma is uncontrolled and the risk of a severe attack remains present.

Alternatively, some people start with a too-high dose that is not tapered downwards in accordance with the improvement in their condition. The British Guidelines on Asthma Management (7) advocates that ?there is evidence that all of the inhaled steroids are absorbed to some extent from the lung and hence will have some systemic activity. It is prudent therefore, as with all treatment, to give the lowest dose of inhaled steroid compatible with asthma control?. It is also advised to step down the dosage of steroids once the asthma is under control, although the Guidelines recognises that this ?is often not implemented?. Any reduction in steroid intake should be slow and only in conjunction with your doctor because patients respond at different rates when their doses are tapered. Other patients rely too heavily on reliever medication and are fearful of steroid medication.

Patients who rely predominantly on large doses of reliever medication for many years will have continuous symptoms and feel debilitated. Reliever medication can also pose a risk to a person?s health and life. The management of asthma has changed over the years and people no longer need to rely on large amounts of reliever medication for their treatment.

History of medication

In 1949, a scientist called Hench and his team developed synthetic cortisone, which mimics the body?s own naturally produced steroid. They were later awarded the Nobel Prize for Medicine for their achievements. Although steroids were introduced in the 1950s, there was very little known about what the correct dosage should be. As a result, large doses were prescribed resulting in many side effects. As soon as patients came off steroids, they suffered relapses and so required long- term treatment for control of asthma.

The serious side effects caused medical professionals to switch to bronchodilator reliever drugs as the favoured treatment for asthma. Reliever medication has a very powerful, quick acting effect, relaxing muscles to force the airways open. One puff of a short-acting reliever, such as Ventolin, will bring relief for three to four hours. The premise was that by taking a reliever on a regular basis, control could be maintained over the long term. However, over time, it was realised that this too may not be the best approach.

The relationship between an increase in the death rate and the increased use of reliever medication has been well documented. For example, deaths in Britain rose from 1,500 a year to 2,000 a year while prescriptions for reliever medication increased from eight million to 15 million.9 In New Zealand an epidemic of asthma deaths occurred during the ?70s and ?80s believed to be caused by the reliever drug Fenoterol. Studies concluded that patients who used Fenoterol had a far greater chance of suffering a fatal asthma attack than those who didn?t. While this drug has been banned in New Zealand, it is still prescribed in Britain.(10, 11, 12, 13)

Overuse can be classified as taking more than three puffs of Ventolin per day. If this is the case then reduced breathing should be applied intensively. If it is not proving possible to reduce the need for reliever medication to three puffs within a short time, then preventer medication is necessary for a short period.

Taking a large quantity of reliever inhaler every day leads to increased tolerance to the medication.(14) There is a great risk with this, as the reliever eventually may not work in an emergency situation.(15, 16) Overuse of reliever medication has been described as putting paint on rust; the symptoms are suppressed while the underlying condition gets progressively worse. The body fights back because the protective mechanism is removed by the reliever. This results in greater difficulty maintaining control and increases the risk of a serious attack.

Regular use of short-acting reliever inhalers leads to increased exercise induced bronchoconstriction.17 This is not particularly well known among many sports coaches who always recommend taking reliever medication before exercise. The continuous use of reliever medication will in the long term exacerbate exercise-induced asthma. If reliever medication is required before exercise it begins to cause chronic hyperventilation and therefore the likelihood of having an attack during exercise is high. It would be far safer to refrain from competitive sport until the control pause is high and it is possible to participate in exercise without the need to take the inhaler beforehand. Alternatively an exercise such as walking that does not require advance reliever medication should be chosen. See the section on sport for how to prevent an asthma attack during exercise.

Since the 1990s there has been a decrease in the death rate directly as a result of introducing steroid inhalers. Steroids can cause side effects when taken in large quantities and over a long period of time. However, the quantities involved in inhaled steroids are too low to generate concern.

The human body produces natural steroids in the adrenal cortex located on the outer surface of the adrenal gland. Without this natural steroid, the body would cease to function. It is believed by Professor Buteyko that hyperventilation causes the adrenals to produce fewer steroid than what is required by the body. As a result there is a need to supplement the difference between what the body produces and what is required with synthetic steroids. While the direct relationship between hyperventilation and inflammation may never be proven, scientific trials have demonstrated a reduction in the need for steroids when hyperventilation is reduced. For example, the volume of breath per minute of the Buteyko group at the trials at the Mater Hospital, Brisbane, was 14.1 litres. After three months, this had reduced to an average of 9.6 litres and the need for steroids had reduced by forty-nine percent.

Since the mid 1990s long-acting bronchodilators and combination inhalers containing this medication have become very popular. Common long-acting bronchodilators are traded under the brand names of Serevent, Oxis, Spireva and Foradil. On January 23rd, 2003 the Food and Drug Administration (FDA) in the US announced: ?The drug [Serevent] may be associated with an increased risk of life-threatening asthma episodes or asthma related deaths, particularly in some patients.?(18) Then, on August 14th, 2003 the Reuters newsagency headline read: ?New warnings added to Glaxo Asthma Drugs? and the report declared that ?Serevent and Advair will carry new warnings about a higher, though small, risk of life-threatening asthma attacks and deaths, U.S. regulators said.