Alternative to daily inhaler use may offer asthma sufferers a new option

People are so reluctant to take their inhaler medication for mild asthma on a daily basis that a pharmaceutical company has come up with a different approach.

Asthma is an inflammatory disease of the airways and lungs that can lead to wheezing, coughing, chest tightness and shortness of breath that can keep people up at night and lead them to miss school or work.

About 2.4 million, or eight per cent, of Canadians have been diagnosed with asthma. Most have a mild form and can go for weeks without symptoms.

The gold standard treatment for mild asthma is twice daily inhaled corticosteroid. But evidence from studies tracking people after they've filled their first prescription — in British Columbia, for instance — suggests that fewer than half fill the script a second time.

That means that over time, airways become swollen and inflamed. When asthma is not well controlled, it increases the risk of worsening or even life-threatening asthma attacks.

Doctors and pharmacists say it is human nature to want to avoid taking medications, especially in some chronic illnesses.   

There are many reasons why people with mild asthma rely on "rescue inhalers" alone instead of ones to treat the underlying problem of inflammation, said Dr. Paul O'Byrne, a respirologist and professor of medicine at McMaster University in Hamilton.

"It's a complex issue in my view, which involves a lot of patient psychology," said O'Byrne.

He said the reasons include:

• To take a medication every day, patients have to accept the view that they have a disease that needs to be treated. For some, that's not easy.
• After feeling well for weeks, some just forget the medications, because they aren't reminded by symptoms.
• Concerns about side-effects, driven in part by misunderstanding how inhaled steroids act differently from steroid pills.

Most people with mild asthma just use a fast-acting rescue inhaler when they have an asthma attack.

Now, however, researchers have tested an alternative that gives longer-acting, inhaled corticosteroid along with the rescue-inhaler medication when symptoms flare up.

That way, symptoms are quickly relieved and the patient benefits from the longer-term inflammation-fighting properties of the corticosteroid.

All of the medications in the study are sold by Astra Zeneca. The company funded the research.

O'Byrne was the lead investigator on a year-long trial of more than 3,800 people aged 12 and older in Canada, China, the United Kingdom, Australia, Brazil, South Africa and elsewhere.

In this week's issue of the New England Journal of Medicine, the researchers found that taking a maintenance inhaler twice a day remains the best option — if people will take it.

As a reliever medication, the combination inhaler with corticosteroid was better than a short-acting drug alone used to relieve asthma symptoms, O'Byrne said.

Months off inhaler

Patients have been doing this for years on their own, against medical advice, said Dr. Shawn Aaron. He treats people with asthma and is a professor of medicine at the University of Ottawa.  Aaron was not involved in the research.

"There are a lot of patients with mild asthma who I tell, 'Take your inhaler every day.' And I know they're not taking it every day. They even tell me that when they feel well, they'll spend months off the inhaler completely, and they'll start it again when they feel unwell. So in effect, what this trial doing is scientifically testing that approach," Aaron said. "They're listening to the patients."

Aaron called the trial interesting, but said it won't revolutionize care.

To reduce 'terrifying events'

"The safest, most effective way to treat mild asthma is with low dose, daily inhaled steroid. That's what this study has shown," Aaron said.

The inhaler medications all cost less than a dollar a day for maintenance puffs, O'Byrne said. Very occasional side-effects include hoarseness and oral fungal infection if taken with antibiotics.

Asthma attack rates in the two groups using a corticosteroid were similar, and were lower than the rate with just short-term reliever puffs.

"Reducing severe exacerbations is the objective I would like to see mostly impacted, because these are such terrifying events to patients," said O'Byrne. He vividly remembers the severity of his own asthma attacks as a child when no treatments existed, saying it drove him to want to minimize the risk for patients. 

Last month, the Canadian Institute for Health Information reported that hospitalizations for asthma among children and teens fell over the past 10 years, but it continues to be one of leading reasons for people under the age of 20 to be hospitalized.