According to the Centers for Disease Control (CDC), the annual costs of asthma to the United States economy is approximately $80 billion. There are over 15 million Americans suffering from asthma. Costs per patient include work and school missed, scheduled and unscheduled visits to doctors' offices, urgent cares and emergency rooms, hospitalizations, and medications. Of the just over $3000 in annual costs per individual, close to $2000 is for prescription medications.
For almost three decades, international guidelines for patients suffering from mild asthma have included the use of steroid inhalers twice daily in order to minimize asthma-like symptoms such as wheezing, coughing or difficulty breathing. In the past, when patients would suffer from asthma attacks, the physician would often chalk this up to patient non-compliance, deeming that the flares were probably due to not using the medication as regularly as prescribed.
Well, as we say in reference to many issues in medical care, the patient's always right. At least in this case. A recent multi-institutional study, funded by the National Heart, Lung, and Blood Institute, questioned whether or not the issue of asthma attacks was or was not related to daily use of inhaled medications. The study was published in The New England Journal of Medicine.
The study looked at 295 people over age 12 years with mild asthma over a 42-week period. Subjects were tested for levels of eosinophils in their sputum. Eosinophils are a type of white blood cell seen in high numbers in patients with environmental allergies and asthma. High numbers of eosinophils in the sputum (obtained by having a patient receive a saline inhaler, loosening the secretions and enabling them to spit out some mucus/sputum into a cup) tend to be a marker for inflammatory types of asthma, which typically respond well to inhaled steroids. The concept is that steroid inhalers will lower the eosinophil count, and improve and/or prevent asthma symptoms.
But in the recent study, investigators found that nearly 75% of subjects had very low eosinophil counts. They also found that these individuals had no difference in response to long term inhaled steroids versus inhaled placebo (an inactive substance, but given in the same form and time interval as the active substance). Measures included asthma attacks and overall general daily asthma symptoms. The study was double-blind, meaning that neither the subjects nor the investigators knew whether or not they were being administered inhaled steroid or inhaled placebo.
While inhaled steroids are overall safe, they are not without risks, some of which include oral thrush, cataracts, bone loss, and in younger children, growth issues. And while the message of the study is not to stop inhaled steroids altogether, it does raise the important question of who these medications will best serve, and who would do just as well without.
