Great potential is on the horizon for asthma treatment, but nothing monumental in therapies has occurred this year. “There’s a surgery that might help some asthmatics. There’s better drugs coming out soon, but nothing definite yet on the market,” said Adina Knight, MD, an allergist at Alabama Allergy & Asthma Center and an assistant professor at UAB. “We definitely need more options. We all have asthma patients that, despite current drugs, we have trouble controlling their symptoms.” In the meantime, area specialists shared five pieces of information that can help doctors treat asthmatics, including a new perspective on allergic immunotherapy. 1. Allergic immunotherapy can halt the progression to asthma. New data show that in children even under five years old with allergic rhinitis, subcutaneous allergen immunotherapy can halt the progression to asthma, says Joe Larussa, MD, an allergist for 10 years at Pediatric and Adult Asthma and Allergy, PC. “We have learned that we need to treat the asthma earlier, so we can prevent any potential airway remodeling. The newer steroids are very safe, and it’s important to treat the inflammation and the lining of the lungs,” explained Larussa. He says it’s just like if your child has a rash — you’re quick to run to the drug store to treat that inflammation, and these new cortico-steroid inhalers do the same thing with the lining of the lungs. They prevent the inflammation. “It’s inflammation that causes the problem. Remodeling can be viewed more as a scar type of thing which is not reversible, whereas asthma is reversible if treated.” “Asthma is still the number-one reason for ER visits and hospitalization in children,” said Larussa. “By using the immunotherapy, it helps their bodies to battle the allergy versus using a lot of medicine. We get to treat the cause versus the symptoms, and that’s a more natural way to treat asthma.” 2. Never be afraid to refer. “Physicians don’t refer enough,” said Adina Knight, MD, an allergist at Alabama Allergy & Asthma Center and an assistant professor at UAB, “and that’s part of the new guidelines, that they refer to specialists more quickly than they have historically.” “Many primary physicians do a wonderful job of caring for asthmatics, but they don’t have the time to assess or monitor like specialists do,” she explained. Specialists, she says, can evaluate patients for triggers and can offer alternative therapies that might be newly available or options that require more monitoring. For example, she says, most physicians don’t have access to the allergy skin test. “Not very many primary doctors are set up for it, and it’s a better test that’s cheaper than the blood tests,” she said. With exact triggers identified, a patient who’s allergic to mold doesn’t need to invest in expensive dust mite covers or get rid of their beloved dog. Specialists can pinpoint and advise on which environmental control measures to take. She also points out that specialists tend to have an asthma educator nurse to explain how a patient can limit triggers, or when to call for help, or why and when to take their medications. “That kind of in-depth discussion makes it less likely they end up in the emergency room because they stopped taking medications,” said Knight. 3. Persistent cough, the only symptom? Pay attention to coughs, says pulmonologist Oksana Senyk, MD, PhD, FCCP and chief of the pulmonary division at Trinity Medical Center. “Persistent cough may be the only evidence of asthma,” she noted. “There may not be evidence of airflow obstruction by spirometry. With normal spirometry and long-term coughing for years, it should be referred for further assessment and a possible broncho-inhalation challenge (for example, a methacholine challenge),” she explained. “We have a rule of thumb that unexplained coughs should raise high suspicion for underlying asthma. A normal spirometry nor response to broncho-dilator doesn’t exclude asthma,” warned Senyk. 4. A patient’s ignorance can needlessly exacerbate the condition. “It’s fun to focus on the new stuff, the earth-shattering breakthroughs,” said Larussa. “But what is old can be what is most important.” He recommends teaching asthma patients to identify triggers and clearly understand what therapies to use, why to use them and when to use them, especially with families of children with asthma. A clear understanding of the consequences of not taking the medicines or avoiding or controlling the triggers can prevent needless ER visits and other complications. 5. Acid reflux or asthma? “Some interesting scenarios tie reflux to asthma,” said Senyk. “It can be very subtle.” For instance, a patient might gain a lot of weight and suddenly find that their asthma is worse. But weight gain can trigger reflux and that triggers the asthma. “We still see a lot of patients whose reflux has not been taken in-hand,” she continued. “It’s old hat for pulmonologists, but it’s worth focusing on. There’s a high prevalence of gastroesophageal reflux disease (GERD) in asthma patients.” Since acid reflux can trigger bronchospasms, many asthma patients benefit from anti-reflux medical therapy and may improve with a medication with a proton pump inhibitor (PPI), like metrovol or moprazole. “Some asthmatics don’t have classic heartburn, but they wake up choking and can’t breathe or start coughing after meals,” said Senyk. Nighttime choking especially may be caused by acid reflux, since it’s more likely to occur in the supine position. So, Senyk says, patients may benefit from a nighttime dose of a PPI or at least a trial, since so many patients are not recognizing the reflux symptoms and how it can affect their asthma by worsening the bronchospasms. April 2008