Management of Asthma and Chronic Airflow Limitation (Part 7)
The continued debate about which bronchodilator or bronchodilator combination is most effective for controlling chronic asthma begs the question of whether bronchodilators should ever be considered first-line therapy in these patients. Since the fundamental problem in asthma in virtually all patients is airway inflammation and bronchospasm is simply its most apparent manifestation, treating these patients with bronchodilators alone is inappropriate unless the symptoms of asthma are infrequent, predictable (eg, exercise-induced) and mild. Furthermore, in contrast with steroid aerosols, methylxanthines have no effect on airway inflammation as reflected in improvement of airway hyperresponsiveness. Hence, inhaled steroids are increasingly being chosen by chest physicians as drugs of choice for most patients with asthma. Aerosol betag agonists are added by these physicians for breakthrough symptoms of wheezing and breathlessness.
In patients treated with aerosol corticosteroids and betaa agonists, is it necessary to add a methylxanthine? One recent study addressed this issue. In this trial, patients receiving aminophylline reported less dyspnea and were observed to have improved baseline peak expiratory flow rates. However, the authors noted that these benefits occurred at the expense of excessive adverse side effects and cost. As well, the dose of aerosol corticosteroid employed in this study (0.10 mg beclomethasone dipropionate five times daily) was surely suboptimal in relation to current therapeutic concepts. Dose-optimized inhaled corticosteroids are now considered by many chest physicians to be the first-line drugs of choice in the treatment of chronic asthma — buy asthma inhalers. Some authors have recently suggested that this class of agents, by suppressing bronchial inflammation, may alter the natural history of the disease and prevent it from progressing to irreversible airflow obstruction.