There Are New Medications For Asthma Prevention
Question: Our twelve-year-old son has asthma since he was an infant. It took us a long time to accept this. Over the years, his condition gradually improved after we made a number of changes to our home, like getting rid of carpets and teddy bears. Our younger daughter is three. Since she was born, we suspected she also has asthma. Her breathing is always noisy, and she seems to have colds throughout the winter. Our doctor recently told us that it is almost certain she also has asthma. We are kind of relieved, knowing that there could be something even worse. We want to know whether there are newer treatments available for her. Our son needs puffers when he gets a cold. Our daughter, on the other hand, seems to be sick all the time.
Answer:
You should be glad to hear that there are new medications available for asthma in the last few years. Our understanding of asthma has also improved because of on-going research around the world. Let me begin by briefly explaining about asthma and some of its triggers.
Asthma is one of the most common medical conditions in children and adults. Symptoms of asthma include chest congestion, coughing, wheezing, and shortness of breath. The bronchial tubes of these individuals are very sensitive to a number of triggers. When exposed to these triggers, the bronchial tubes become swollen and filled with mucus. The muscles around the bronchial tubes also tighten up, making it even harder to breath.
The most common triggers are present indoors in every home: house dust and mildew. House dust is present in pillows, mattresses, soft toys (like teddy bears), carpets, and curtains. Forced-air heating is problematic because it blows the dust around. Mildew is present especially in basements and bathrooms, around windows, and sometimes in the soil of houseplants.
Family pets, especially cats, can be troublesome for those children who are allergic to these animals. Cigarette smoke is a universal irritant that affects everyone with asthma. That is why it is most important that children (and adults) with asthma should avoid exposure to cigarette smoke. Strong chemicals like perfume, cologne, air fresheners, and scented candles can be troublesome also. Cleaning agents have been known to trigger asthma attacks.
The most important step in the management of asthma is improving the indoor environment, especially your home. I understand you have already removed some items that carry dust. You still need to look around some more to see whether there are additional things that may affect your daughter. If you have forced-air heating, you should hire someone to clean the ductwork. Just vacuuming at the vents is not effective.
If you have an air-exchange system, it needs regular service every few months to make sure it is clean. Any smoker should go outside, and there should be no smoking in the car either. Better yet, he/she should quit smoking altogether. Parents who smoke will set a bad example for their children.
If your daughter goes to daycare, you should also look at the environment there. Mildew in basement and dust in carpets can make her condition worse. I should mention here that viral infections (colds) can trigger asthma also. These viruses spread easily in daycare.
In my experience, improving environment is the most important step in the treatment of asthma. Very often, no amount of medicine can get a child’s asthma under control until one makes changes to the indoor environment.
From your description, your daughter appears to have daily problem with asthma. She would benefit greatly from using preventative medicine. The most effective one is inhaled steroid, which reduces inflammation in bronchial tubes and decreases mucus production. It is available in solution, which can be delivered through a maximist machine (also called nebuliser). This is very convenient especially for young children, although it is not too portable.
Inhaled steroids are also available in puffers. Children should use a spacer instead of squirting the medicine directly into the mouth. They also come in dry powder formulations for older children. These gadgets (turbuhalers and diskus) can deliver the medicine effectively into the lungs of these children.
There is very little side effect when you use low dose inhaled steroid to prevent asthma. The most common one is a mild yeast infection of the throat. This is due to overgrowth of yeast normally present in our environment. By simply rinsing the throat with water after inhalation will prevent this side effect.
In the last few years, a new class of preventative medicine called leukotriene-receptor antagonist (LRA) has become available in Canada. It works by blocking a key group of chemicals called leukotrienes in the bronchial tubes. These leukotrienes appear to be the main cause of inflammation in children with asthma. By using LRA to block leukotrienes, researchers were able to downgrade inflammation in the bronchial tubes and reduce severity of asthma.
In Canada, two LRAs have been approved for use in children and adults. Accolate was approved for children 12 years and over. It has to be taken twice a day on an empty stomach. This is a problem for children.
Singulair is more convenient, it is only once a day dose and can be taken with or without food. Recently it was approved for children as young as two years of age. Many parents can see an improvement after using the medicine for about one to two weeks. Side effects are extremely rare, the only significant ones that I have seen are headache and stomach ache.
Because this is a new medicine, most physicians are naturally cautious. However, experience over the last few years has proven that this is a very useful medicine for preventing asthma in children. Most often, physicians add Singulair to those who require higher doses of inhaled steroids for optimal control. After several weeks, most children would have less cough and are able to exercise more. As time progresses, many can reduce the dose of inhaled steroids, some can stop them altogether and use steroids only when they get sick.
I should mention here about another group of medicine that is available, although it is used more frequently in adults. You must be familiar with bronchodilators like Ventolin and Bricanyl. These are ‘short-acting’ bronchodilators that relax the muscles around bronchial tubes. When a child is sick, parents have to give these bronchodilators every two to four hours to control asthma symptoms.
Recently, there are ‘long-acting’ bronchodilators that work for about 12 hours. However, there is still very limited experience in using them in children, although they have been used safely and effectively in adults. They are usually added when other preventative medicines cannot provide adequate control of asthma symptoms.
Finally, I should mention briefly about what it means to have good control of asthma. All children get sick when they get colds, and their asthma will flare up with more coughing. In between these colds, children should be able to stay active, go to school, and participate in sports without coughing, wheezing, or tightness in the chest. There should be no cough at night or in the morning. These children should not require ‘short-acting’ bronchodilators more than 4 times a week.
It is very important for you to discuss with your doctor about the best choices of prevention medicine for your daughter. Again, I should emphasize that medicine alone may not control asthma, unless changes are made to the indoor environment. You should also work out an “action plan” with your doctor, so that you know exactly what to do when she gets sick. Even with the best prevention, she will get flare-ups and she needs more medicine.
[Note to Readers: In recent years, there are some reports of mood changes due to Singulair. Some children become more irritable or moody within days after starting this medicine. Please read another column published in May 2018.]