Breath of Fresh Air: Feature Articles

Montelukast (Singulair®) is a leukotriene receptor antagonist, blocking the effects of leukotriene chemicals after they have been made in the body. Its action is like that of zafirlukast (Accolate®), a previously available anti-leukotriene. It is to be taken as a tablet once daily in the evening.

In January, the Food and Drug Administration decided to remove terfenadine (brand names: Seldane® and Seldane D®) from sale in the United States. This popular antihistamine was found to cause very rare episodes of serious irregular heart rhythms. Alternative antihistamines that, like Seldane®, do not cause sleepiness are currently available and free of the risk of heart arrhythmias. These non-sedating antihistamines are sold under the brand names: Allegra®, Claritin®, Hismanal®, and Zyrtec®.

You may have seen a recent article in the Boston Globe regarding asthma that seemed to pit the Kennedys against environmentalists. The environmentalists favored proceeding with a plan that would eliminate by the year 2000 use of chlorofluorocarbon propellants (known as CFCs) in all pressurized asthma canisters for inhaled medications. The Kennedys, having experienced asthma first-hand in their own family, argue that medical use of these CFC propellants should be allowed to continue, despite their harmful effect on the ozone layer of the atmosphere, until alternative methods to deliver medications by inhalation are developed.

This Spring, Glaxo Wellcome has made one of its inhaled medications available without CFC propellants, in the form of a dry-powder inhaler. Like the Turbuhaler® in which Pulmicort® is sold, Serevent® is now available as a dry-powder inhaler. The Serevent® Diskus® delivers the equivalent of two puffs of medication from the conventional Serevent® pressurized canister. The Diskus® has the added advantage of a built-in dose counter that indicates the exact number of doses remaining in the inhaler device.

The Doser® is designed to fit on top of the metal canister of most metered-dose inhalers. With it in place, to actuate the inhaler, you press down on the Doser®. A small computer chip within the Doser® keeps track of how many times it has been pressed. Thus, you can record how many "puffs" of medicine are left in your inhaler. Also, you have a record of how many inhalations of medication you took on each day for the preceding month. Each Doser® can be used on only one inhaler at a time. Its retail cost is approximatley $30.

Another electronic device that keeps track of the number of inhalations used from your metered-dose inhaler is called Smart Mist®. It has a number of other functions as well. With the Smart Mist® device, your metered-dose inhaler fits within the Smart Mist® holder. It actuates a puff of medicine from the metered-dose inhaler when you take a breath in from the mouthpiece, but only if the inhalation is a slow and steady one. Thus, it trains proper inhalational technique with the inhaler. Smart Mist® can be programed to record data from several different inhalers used concurrently. It also has a built-in lung function monitoring device. Your peak flow can be measured, recorded, and later printed out as a graphic display of your lung function over time. The entire device is no bigger than a portable tape recorder. Its cost is several hundred dollars.

A new therapy has become available that can be used to treat thinning of the bones (osteoporosis). Osteoporosis is a particular concern for persons with asthma who have needed to take corticosteroids in tablet form (for example, prednisone) for prolonged periods. It is also a concern of most women after the menopause, because lack of the hormone, estrogen, leads to excessive calcium loss from bone. Until now, the most common treatments for prevention or reversal of osteoporosis were estrogen replacement therapy (tablets or transdermal patch) for women, alendronate (Fosamax®), or calcitonin by injection or nasal spray. A major disadvantage to estrogen hormone replacement therapy is the possibility of unpleasant and potentially dangerous side effects from stimulation of breast and uterine tissue, including breast swelling, vaginal bleeding, and an increased risk of uterine cancer (cancer of the womb).

A new derivative of estrogen, called raloxifene (Evista®), has been approved for use in post-menopausal women. It helps to treat and prevent osteoporosis but has no effect on breast and uterine tissues. Although it appears not to be quite as strong as estrogen hormone in strengthening bones, its safety and lack of side effects may make it an appealing alternative for many women.

Albuterol (brand names: Proventil® and Ventolin®) is the bronchodilator most widely used for nebulization in the United States. On chemical analysis, the currently available albuterol medication contains a mixture of two forms of the molecule, a "left-handed" molecule and a "right-handed" molecule. Techniques are now available to isolate and study the effects of the separate molecular forms of albuterol. Such studies suggest that the bronchodilator effect resides predominantly in one of the forms; the other form is relatively inert and may contribute to some of the negative effects of albuterol.

A pharmaceutical company based in Massachusetts, Sepracor, has discovered a chemical process that allows them to produce only the favorable right-handed form of albuterol. Their product, levalbuterol (brand name: Xopenex®), will soon be made available for purchase in this country in the form of a nebulizer solution. It is said to be more effective than albuterol as a bronchodilator, or if given in doses that achieve the same amount of bronchodilation, to have fewer unpleasant side effects.

In October the Food and Drug Administration gave approval for the inhaled corticosteroid, budesonide (Pulmicort®), to be given on a once-daily schedule for the control of asthma. Persons who find that their asthma is well controlled on the usual twice daily regimen can reduce to once daily (same total daily dose) without loss of benefit. The primary advantage is convenience, the ease of having to use your inhaled steroid only once a day. It is likely that other inhaled steroids will also be effective when used in the same way. Remember: your asthma should be under good control before considering — with your doctor — switching to a once-daily program for your medication.

The results of a recent controlled study, published in the medical journal, The New England Journal of Medicine, concluded that chiropractic care is not useful for treating childhood asthma.

Chiropractic care involves the manipulation of muscles and bones with the belief that skeletal malalignment is a cause of many common disease states. In addition to their conventional anti-asthmatic medical treatments, 83 children with mild to moderate asthma were treated with either real or simulated chiropractic manipulations for 16 weeks.

This study could find no benefit from the real chiropractic treatments. Children receiving these spinal manipulations felt no better, had no improvement in their lung function, and no change in the frequency with which they needed to use their bronchodilator inhalers for relief of symptoms. In brief, the study found that chiropractic care is not useful for treating asthma.