What’s New in Asthma Management?
For the most severe cases, a non-drug procedure may help – not cure.
For some people with extremely severe asthma, using an inhaler and taking several medications is all part of the daily routine.
By Lisa EspositoSept. 4, 2014 | 2:27 p.m. EDT
It was a muggy 2011 Fourth of July in Illinois, and Kenny Beyer, 33, a severe asthmatic, opted for some exercise indoors. So he and his wife walked around the air-conditioned mall – until they were ambushed by the spraying ladies from the perfume shop across the aisle. Although 50 feet of benches and potted plants separated them, that didn't matter – it only took one whiff to bring on an asthma attack. Beyer immediately pulled out his inhaler and finally felt well enough to walk to the exit. A few hours later, though, he landed in the intensive care unit at his local hospital.
If you have asthma, you have lots of company – nearly 19 million U.S. adults. Maybe you just have episodic asthma, like exercise-induced asthma when you run, and all you need is an albuterol inhaler puff for quick relief. But if asthma is part of your daily life, you’re probably taking routine daily medications.
Some people have chronic persistent asthma that's mild enough to be controlled by a single medication – an inhaled corticosteroid (Aerospan, Alvesco, Flovent, Pulmicort, Qvar) – which is considered the gold standard of asthma treatment. But "with severe and very severe asthma, you must treat those patients with combination therapy," says Michael Foggs, president of the American College of Allergy & Asthma Immunology.
Treatment can include two, three or more medications, with one or more doses of each a day. Some asthma inhalers (Advair, Dulera and Symbicort) combine a steroid with a bronchodilator to open the airways. In addition to inhalers, patients may also take pills known as leukotriene receptor antagonists (Accolate and Singulair). A relatively new drug class called monoclonal antibodies (Xolair) can reduce the body's response to allergic triggers in some allergic asthmatic patients. Doctors work closely with patients to choose the right medications based on age, symptoms, asthma severity and medication side effects. Asthma can change over time, and doctors may adjust medication types and dosages so patients continue to get the best response.
For people with extremely severe asthma, you almost need a spreadsheet to keep track of routine medicines, not to mention rescue treatments as needed during the day or night. In Beyer's case, four nebulizer (mist) treatments with several medications made up part of the daily mix, along with inhalers and oral medicines including prednisone, which is notorious for its complications, including weight gain, osteoporosis, high blood pressure and diabetes, all of which he developed.
[See: How to Cope With Asthma.]
Allergens, Irritants Lying in Wait
About 80 percent of adults with asthma have coexisting environmental allergies, says Foggs, who is also chief of allergy and immunology with the Advocate Medical Group in Chicago. "Allergy looms large with most asthmatics," he says, "and they have environmental triggers that just set off the asthma."
Environmental triggers include allergens such as dust mites, mold, pollen, tobacco smoke and pet dander, as well as chemical irritants (like the perfume that triggered Beyer's severe attack). Infections can trigger asthma, so your doctor will probably recommend a pneumonia vaccine and a yearly flu shot. Dust mites are a common trigger, and allergen-proof, zippered covers are available to help eliminate them from pillows, mattresses and box springs. If your home has carpets and you’re the one vacuuming, make sure you wear a mask. The list goes on, and asthma triggers and how to avoid them vary with each person. All patients should have an asthma action plan to help them track their medications and breathing function, and note steps to take during an asthma attack. You can pick the format – whether it's a Word document or interactive tool – that works best for you.
With the intricacies of immunotherapy for allergies, and all the possible medication permutations, there's no one size fits all for asthmatics, Foggs says, and it's essential they be under the care of a board-certified asthma and allergy specialist.
Different Kind of Treatment
In Beyer’s case, despite doing all the right things – adhering to his drug regimen, seeing a specialist, doing his best to avoid asthma triggers – his asthma and overall health kept getting worse. “My life was scheduled around my breathing treatment," he says. He was spending more and more time in the hospital, and he lived with the fear of respiratory failure. "It was getting to the point of, will my next attack be my last time on Earth?" he says.
In September 2011, Beyer’s local allergist referred him to the University of Chicago Medical Center, where pulmonary specialists were performing a new procedure approved by the Food and Drug Administration in 2010. Called bronchial thermoplasty, it involves inserting a catheter into the lungs and using radiofrequency to generate heat to destroy or neutralize smooth muscle. It’s only meant for adult patients with severe asthma who do not respond to standard medication.
Smooth muscle of the lungs is one type of muscle you don't want to build. Increased smooth muscle has two harmful effects: It can block the airways, making it harder to breathe, and when stimulated by allergy triggers, smooth muscle can react and constrict the lungs further.
"Thermoplasty works because an asthmatic has breathing tubes that are wrapped around with muscles that are like a tight rubber band, ready to constrict," says D. Kyle Hogarth, an associate professor of medicine and director of bronchoscopy at The University of Chicago Medicine. By inserting a catheter into the lungs and using radiofrequency to generate heat, he says, "thermoplasty gets rid of those rubber bands so the tubes can’t constrict as easily."
Thermoplasty is done in three separate stages, each performed at least three weeks apart under sedation. Some patients have asthma flares after the procedure and require hospitalization for treatment and observation.
Bronchial thermoplasty isn't a cure and it's not for everyone, Hogarth emphasizes. For the average asthma patient, he says, inhalers control their disease “really well.” But then there are others: “No matter what we do … they’re still having frequent attacks. They still need their rescue inhalers a lot; they still need steroids – oral steroids, which is a miserable thing,” Hogarth says. “They’re still in the hospital; they’re still in the ER, they’re in your clinic. It’s all a nightmare, and that’s the group we target."
Since FDA approval, about 3,000 U.S. patients have had bronchial thermoplasty. In March, a Cochrane Review of studies calculated that of 100 patients treated with thermoplasty, six would require an additional hospitalization over the treatment period, but it concluded the procedure "has a reasonable safety profile after completion of the bronchoscopies." It also found a "modest clinical benefit" in quality of life and lower rates of asthma flare-ups, but did not find a significant difference in asthma control scores.
Some insurers cover the procedure, while others still consider it investigational – they’re waiting for additional clinical studies. Depending of the patient’s insurer, the procedure costs about $30,000, which Hogarth says pales in comparison to the cost of frequent hospitalizations for patients whose asthma can’t be controlled.
Improvement, Not Cure
"If you have asthma that’s difficult to control, probably the most important thing you can do in the world is accurately establishing the diagnosis of asthma," Hogarth says. That means seeing a pulmonologist or allergist to make sure you don’t have an alternative diagnosis, including a genetic disorder called alpha-1 antitrypsin deficiency, which can mimic asthma but is treated completely differently.
In September 2011, Beyer underwent a diagnostic workup to determine that he was a good candidate for bronchial thermoplasty. His first procedure took place that October. Hogarth performed the three-stage procedure, during which he found “real thick muscle wrapping around [Beyer’s] airway,” which was gone after thermoplasty.
Eventually, Beyer was able to taper off prednisone and get his diabetes under control – and was able to lead a more normal life. "I didn’t cure him, just got him to the stage where his meds actually helped him," Hogarth says.
About 3.5 years later, Beyer is doing a lot better. He's off daily prednisone and has whittled his asthma medications down to three. His FEV1 (a measure of lung function) – has increased by over 25 percent, he reports. "Now I'm in the hospital maybe twice a year," he says. "So the quality of life is a lot better." He's happy to mow the lawn without wheezing and walk around the mall with his wife without fear.