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    Monday, January 27, 2003

    Breath Deep: A pulmonary physician had this to say about asthma control medications, especially cromolyn sodium:


    No, no, NO! We do NOT want people using cromolyn. Cromolyn is a trade name for "placebo." It doesn't control asthma in adults. Its effects are minor, and no good pulmonary doc or allergist I know of would use it as a first-line controller.

    Singulair: not as a first-line controller, though many FPs and pediatricians use it that way. It simply does not have the anti-inflammatory suppressive effect that corticosteroids have, and
    patients switched to leukotriene receptor antagonists may lose their asthma control. Singulair (or Accolate) is appropriate when a patient won't/can't use an inhaled steroid, but
    shouldn't be a first controller. It's a very useful second controller, and good data from the IMPACT trial shows that it can be about as useful as Serevent. The Glaxo people disagree, of course, and have funded a number of studies to dispute this (too many to attach!!).

    Singulair gets used in the pediatric world because pediatricians are still afraid of inhaled steroids, though the CAMP study showed that inhaled steroids are indeed safe in children. And better than nedocromil, another trade name for "placebo." Mothers of asthmatics are very afraid of inhaled steroids.

    Personal story: I teach, talk and treat asthma. My 10-year old has asthma, and it was really interfering with her life. I'm an asthma doc. I really, really know these drugs. It only took me EIGHTEEN months to convince my wife that an inhaled steroid would be okay.

    Back to the drugs. Serevent should not be used as a first controller in any circumstance. It has no significant anti-inflammatory effect except (perhaps) on airway edema. It might actually worsen the numbers of eosinophils in asthmatic airways. It's a great bronchodilator, and combined with an inhaled steroid makes a very useful contribution. But multiple studies have shown that asthma control worsens with Serevent alone.

    My bottom line: inhaled corticosteroids should be the first controller used in asthma, adults and children alike. Leukotriene blockers are okay as a second controller or when one can't/won't take steroids. Serevent should ONLY be used as a second controller, where
    it can make a substantial contribution. For my severe asthmatics, I use all three.

    Whew. Let me clarify. I didn’t mean to imply that these other controller medications should be first line therapy, only that they are still considered appropriate alternatives according to current guidelines on asthma therapy. And lets face it, surveys of therapy like the one GlaxoSmithKline did don’t take into account the nuances of patient preferences and fears. It’s far better to put someone fearful of steroids on the Cromolyn or Singulair than to do nothing at all, or to bully them into accepting a steroid inhaler only to have them go home and put the prescription or the medicine away in a drawer never to use. And none of this changes the fact that GlaxoSmithKline issued their statement based on findings that weren’t statistically significant.

    posted by Sydney on 1/27/2003 07:23:00 AM 0 comments


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