Why you should take your asthma medications more to eventually take them less!

With an overall 7% prevalence in US children, asthma affects over 5 million children. This prevalence increases to 13.5% in those children of Black non Hispanic ethnicity and 10.5% in those children living at or below the poverty line. Asthma is a very common childhood condition affecting a disproportionate number of minority children and children living at or below the poverty line. This disparity along with lack of education and understanding of the condition can greatly impact the quality of life of these children and their ability to breathe. In 2020, 4,145 individuals died of asthma , while 1.6 million emergency room visits were attributed to those with asthma showing that asthma poses significant risks of health and even death. As a pediatrician, I hear often from parents that they do not want their child on daily medications, that they would rather treat it “naturally” or even that asthma “runs in the family” and everyone has it so what’s the point of treatment. I understand how these viewpoints exist as well as the concerns of parents, but these statements highlight the need for increased education regarding asthma, the treatments and the risks.


What is asthma?

Asthma is reversible narrowing of the airway leading to inability to get air out due to inflammation.


How is asthma diagnosed?

Older children may be able to perform pulmonary function tests to diagnose asthma. Younger children may be diagnosed by observing a variety of factors, including a positive family history and or recurrent improvement of breathing with albuterol use. Asthma usually begins in childhood, in children with a positive family history and or with related medical conditions such as eczema or allergies. Symptoms can be triggered by environmental factors (dust, mold, etc…), viral illness, cold weather or even exercise. Symptoms include cough, wheezing and chest tightness.


What medications are used?

Medications for asthma are divided into two categories: daily (usually corticosteroids) and as needed medications (albuterol). The mainstay of treatment in asthma is albuterol. Albuterol is a medication that acts on the muscles of the airway relaxing them allowing more air flow (Ahrens & Smith, 1984).


Inhaled corticosteroids are usually taken twice per day for children whose symptoms persist or recur frequently. Medical providers take a stepwise approach to the management of asthma. For example, if you are over 12 years of age with daily symptoms of asthma, waking every night with a cough and limitations in your ability to play because of the symptoms, you would be classified as having severe persistent asthma. This would require two daily medications along with albuterol. If one adheres to taking these medications for at least 3 months and symptoms significantly improve, your doctor may consider “stepping down” therapy to step 2 (1 daily medication with albuterol) or even step 1 (no daily medication, only albuterol) (National Heart, Lung, and Blood Institute, 2012).


Many parents worry about the side effects of corticosteroid usage. These side effects include mood changes (Richards, 2008), immunosuppression (Coutinho & Chapman, 2011), and decreased adult height (Fuhlbrigge et al., 2012) among others when taken orally. The medications used for asthma are inhaled, precisely targeting the lungs, therefore reducing the incidence of these side effects.


How do you manage asthma?

The key to managing asthma is to understand the triggers and taking the medication or medications advised with the proper technique. Each visit with your health professional should include a review of known asthma triggers along with a discussion of strategies to avoid or mitigate these triggers. For example, if a trigger is dog dander, avoiding dogs should be discussed. In addition, medication administration techniques should be assessed. Small children are unable to time their breathing with inhalation, so often a mask and spacer device are prescribed to allow proper inhalation of the medications in small children. Along with these discussions, the provider should be given an asthma action plan. The asthma action plan is a written documentation of known triggers, the treatment plan and what to do when symptomatic.


When parents understand what asthma is, how to diagnose and the risk involved, they are better able to understand the need for treatment. Treatment of asthma is only optimal when parents and health care providers work collaboratively. First, healthcare providers should explain the diagnosis, discussing triggers, explaining medication dose and usage as well as giving written documentation. Secondly, parents have to adhere to the plan giving the child their best chance at “stepping down” from their medications in the future.


References

Ahrens, R. C., & Smith, G. D. (1984). Albuterol: an adrenergic agent for use in the treatment of asthma pharmacology, pharmacokinetics and clinical use. Pharmacotherapy, 4(3), 105–121. https://doi.org/10.1002/j.1875-9114.1984.tb03330.x


Coutinho, A. E., & Chapman, K. E. (2011). The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments and mechanistic insights. Molecular and cellular endocrinology, 335(1), 2–13. https://doi.org/10.1016/j.mce.2010.04.005


Fuhlbrigge, A. L., Williams, P., Zeiger, R. S., Raissy, H. H., Van Natta, M. L., Tonascia, J., Strunk, R. C., & CAMP Research Group (2012). Effect of inhaled glucocorticoids in childhood on adult height. The New England journal of medicine, 367(10), 904–912. https://doi.org/10.1056/NEJMoa1203229


National Heart, Lung, and Blood Institute. (2012). Asthma care quick reference: Diagnosing and managing asthma https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf


Richards RN. Side effects of short-term oral corticosteroids. J Cutan Med Surg. 2008 Mar-Apr;12(2):77-81. doi: 10.2310/7750.2008.07029. PMID: 18346404.

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