Inhaled Steroids And Singulair Can Prevent Asthma
Question: Our daughter is nine years old. She has had bronchitis since she was two. We thought that she didn’t like activities. When she plays with her friends, she always sits down after running for a short time. We recently saw a paediatrician who told us that our daughter has asthma, and the lack of energy is a sign of asthma. This doctor recommended us to give her inhaled steroid twice a day as prevention. We are concerned about using steroids every day, although she has used it many times before. We have heard that there is a pill which can prevent asthma. What would you suggest?
From your short description, it looks like that your daughter has asthma since early childhood. It is not uncommon for doctors to diagnose asthma as bronchitis in young children. When asthma is not under control, oxygen cannot get through the swollen bronchial tubes as easily. As a result, children can get short of breath after exercise, and have to sit down or rest sooner than other children who don’t have asthma.
There are two large groups of medicine to treat asthma, relievers and controllers. Relievers are bronchodilators that relax muscles around tight bronchial tubes, therefore allow more air to get into the lungs. As a result, those with asthma feel that the symptoms of cough, shortness of breath, and wheezing, improve after taking bronchodilators. However, the effect of these medications does not last very long, and they are not effective against the inflammation in the bronchial tubes present in everyone with asthma.
The second group of medicine, the controllers, is anti-inflammatory medications that fight inflammation in the bronchial tubes. Children with asthma have very sensitive bronchial tubes that react to certain triggers and germs. When bronchial tubes are stimulated, they develop an inflammatory response with swelling of the bronchial wall, and mucus pour from glands into the lumen of these bronchial tubes. The end result is narrowing of the lumen, so that it is harder for air to get through.
Steroids are the most effective anti-inflammatory medications for asthma. Oral steroids (prednisone is the most common one) are used for acute asthma attacks, and start to work within 24 hours. Most of the time, oral steroids are used for a short time only to get asthma under control. Occasionally, intravenous steroids are necessary in very severe attacks.
Inhaled steroids, on the contrary, can be used for both short-term and long-term. For those who have asthma problem several times a year, if the attacks are not severe and can be controlled easily, inhaled steroids can be used for several weeks and then stopped. However, for those who tend to have rather severe asthma attacks, or if their asthma symptoms are present much of the time, then inhaled steroids can be used every day for a longer time to prevent asthma.
Long-term use of inhaled steroids has been studied by scientists and specialists. If the dose of inhaled steroids that is used is not too high, the chance of side effect generally is low. Of course, one has to balance the severity of asthma and the amount of inhaled steroids being used. It is always a good policy to use the lowest dose of inhaled steroids to keep asthma under good control.
You may ask: What do you mean by good asthma control? It means children should be able to go through everyday activities without cough, shortness of breath, or wheezing, while awake and at night. Children should be able to exercise, like running and biking, without getting tired easily. Those involved in strenuous activities and certain sports may require more prevention medicine like inhaled steroids to maintain their lungs in a healthy state.
Side effects of inhaled steroids include yeast infection in the mouth (also called thrush) and hoarseness of voice. If the dose of inhaled steroid is very high, some of the medicine can be absorbed into the body and affect the adrenal glands, and may slow down the child’s growth.
You can reduce these side effects by a few simple strategies. If your daughter uses a puffer (also called MDI or metered-dose-inhaler), adding a “spacer” between the puffer and the mouth can reduce the amount of steroids deposited in the mouth and back of the throat. Rinsing the mouth and throat after inhalation can also help. For those who get thrush often, I have also suggested brushing of the tongue and palate when they brush their teeth.
The new group of prevention medicine is called leukotriene-receptor antagonists (LRA). Scientists found that when bronchial tubes are stimulated by triggers, there is a series of chemical reactions leading to the final stage of swelling, mucus, and tightening of muscle around the bronchial tubes. The most important chemical in this process is called leukotriene. When they block leukotriene from attaching to cells in bronchial tubes, they can stop the inflammation. This finding leads to the development of LRA.
There are two medications in this group approved in Canada: Accolate and Singulair. Accolate can be used for children 12 years and over, one pill twice a day. To ensure absorption, it has to be given on an empty stomach. Side effects are few, the most common one is headache.
Singulair comes in 5 and 10 mg pills. Children 6 to 14 years of age should take 5 mg, while older children and adults can use 10 mg pills. The dose is once a day, and can be taken with food. The manufacturer recommends taking it at night to control nighttime symptoms.
Not everyone will benefit from LRA. In general, it takes several days to weeks before one can tell whether the medicine helps. Since this is a totally new group of medicine, there is very little known about the long-term side effects.
At the present time, I recommend LRA to children who require fairly high doses of inhaled steroids to prevent asthma. The hope is that if LRA works, we can reduce the amount of inhaled steroids needed to keep asthma under good control. The important thing is not to stop inhaled steroids when we start LRA. Many children likely will need a combination of LRA and inhaled steroids.
Because LRA is not a steroid, a few parents have decided to use it for prevention instead of inhaled steroids. This is purely a personal choice for them. At the present time, with limited information that we have on LRA, I find it difficult to make this recommendation to everyone.
Finally, I want to point out the importance of reducing triggers around your child in order to reduce the severity of her asthma. Common triggers include dust, mildew, cigarette smoke, animals, as well as indoor chemicals. By reducing triggers, you may also reduce the amount of inhaled steroids that she will need to keep her healthy all the time.
[Note to Readers: We have gained a lot more experience in the use of Singulair in the past twenty years. It is fairly effective in reducing the severity of asthma in children, and sometimes can be used as the only prevention medicine for asthma. It can affect the mood of some children; please refer to a more recent column on side effects of Singulair. A new inhaled steroid called Alvesco (ciclesonide) is a pro-drug, will not cause hoarseness of voice, and has much less side effects than other inhaled steroids.]