Sunday, October 9, 2016

1980s: Steroids for asthma

By the 1980s, steroids were ordered with increased frequency, although at low doses. (1) Inhaled steroids were also introduced to the market, and they were basically reformulations of the steroid molecules.

During this decade asthma continued to be treated as an acute disease. Again, this means that when you felt good you usually didn't take any medicine for it, and you only sought treatment when you felt symptoms.

If you were having moderate to severe symptoms and you went to the emergency room you would be given an intramuscular shot in your shoulder or butt of methylprednisolone, marketed as Solumedrol. This would probably go along with an albuterol breathing treatment, and possibly a shot of epinephrine or susphrine.

If you had a mild or moderate symptoms and you saw your physicians, you may be given a prescription for Methylprednisolone pills, marketed as Medrol. They were organized in packets by how many you were to take each day: seven in top row, five in the second row, four in the third row, three in the fourth row, two in the fifth row, and one in the sixth row.

This sequence made sure you obtained the a therapeutic dose on day one and then that you slowly weaned yourself off steroids so your adrenal medulla gradually started producing it's own cortisol again. The dose was relatively low to prevent side effects, although high enough to reduce inflammation and control asthma.

In the mid 1980s, the way asthma was approached started to come under question. Despite all the new and improved asthma medicines on the market, asthma death rates were on the rise. Between 1977 and and 1985, the asthma death rate rose from 0.7 per 100,000 to 0.8 per 100,000. Asthma prevalence rose 29% between 1980 and 1987, and hospitalization rates for children rose 4.5% annually during the 1980s. (2)

I have some more information about the suspected causes of the rise in asthma related deaths, and my own personal opinions. I also have my own story to tell. I will save those stories for another post. For now, I just want you to know that these concerns, these statistics, are what lead to researchers putting their heads together to figure out what could be done to lower asthma death rates, regardless as to the cause.

1980, I think, is one of the key years in our asthma history. This was the year that National Heart, Blood, and Lung Institute's (NHLBI) National Asthma Education Program coordinated efforts to get all the world's leading asthma and allergy experts together to review all the data and current wisdom regarding our disease and to formulate asthma guidelines.

The NHLBI asthma guidelines were published in 1989, and highlighted the following facts:
  • Asthma is often under-diagnosed
  • All asthmatics have some degree of chronic inflammation
  • A small amount of steroids in asthmatic lungs obtained from inhaled corticosteroids is often all that's needed to control this inflammation and prevent asthma symptoms.
  • The amount of steroid inhaled from an inhaler is very small compared to systemic steroids, and therefore side effects are rare and minimal at worse. For this reason, the benefits far outweighed the risks for asthmatics with uncontrolled asthma.
  • The emphasis for asthma treatment was changed from treating acute symptoms toward preventing asthma symptoms with daily use of asthma controller medicines to reduce underlying airway inflammation. This was thought to prevent asthma, or at least make asthma less severe when it did occur. 
  • Inhaled steroids should be used daily to prevent asthma, and rescue inhalers should always be available to treat acute asthma symptoms when they occur.
  • Inhaled steroids are safe to use for mild asthma to prevent airway remodeling that may cause asthma to become moderate to severe. 
These conclusions were significant to asthma management. Back in 1985, when my asthma became severe and uncontrolled, my regional doctor was unable to help me, and I had to spend six months at an asthma research hospital called National Jewish Hospital/ National Asthma Center (now National Jewish) to gain control of my disease. What they did was put me on a low dose of steroids to control my asthma, and then weaned me off them and onto an inhaled corticosteroid, which at the time was Azmacort.

The guidelines essentially made the wisdom that was available at research hospitals available to regional physicians. So, instead of being scared to use inhaled steroids, they were now noted to be safe and effective for controlling asthma. T'his was a significant point in asthma's history.  This fact cannot, and should not, go underestimated.

From this point on, regional physicians, an not just hospital physicians, began prescribing daily use of inhaled corticosteroids. Rather that tell patients to quit taking them when they felt good, asthmatics were encouraged to continue taking them, even when they felt good (especially when they felt good).

This, you might say, was the breakthrough that greatly improved asthma control, especially for the 75% of asthmatics with allergic asthma. At the time, asthma was essentially considered an allergic disease. It would be another 20 plus years before it was learned that some asthmatics have a subgroup of the disease that is not responsive to corticosteroids.

Still, the asthma guidelines caused an increase in corticosteroid inhaler prescriptions, and this lead to an inhaler boom in the 1990s.

References:
  1. Buer, Jonas Kure, "Origins and Impact of the Term "NSAIDs," inflammopharmacology," July, 2014, file:///home/chronos/u-48b0af7d8a6e832f841243beb1bf56db699d3e12/Downloads/NSAID%20accepted%20version%20for%20self-arch.pdf
  2. Mitmann, Gregg, "Breathing Space:  How allergies shape our lives and landscape, 2007, page 247

1 comment:

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