For Asthma .. There is No one Treatment That Fits All

A new set of rules recognizes the complexity of the interaction between a patient's genetics and the environment in which they live when it comes to asthma (Genetically L / The New York Times).
A new set of rules recognizes the complexity of the interaction between a patient’s genetics and the environment in which they live when it comes to asthma (Genetically L / The New York Times).

Asthma may be a disease with one name, but experts say it is not known to most people with it that it is not just one disease, nor that “there is no one-size-fits-all” treatment for it.

But rather, as it has been detailed in a set of new 54-page guidelines developed by a panel of experts, in the past 13 years since the last guidelines were issued, tremendous progress has been made in understanding the organic causes and effects of different types of asthma, and the various approaches needed to treat it, and reduce attacks. In children and adults. The guidelines were published last December in the Journal of Allergy and Clinical Immunology.

“In recent years we have realized that asthma is slightly different, with different underlying mechanisms, and that its treatment paradigm has completely changed,” said Dr. Michael Wischler, an asthma specialist at the National Jewish Health Hospital in Denver.

Asthma is now known to be a much more complex condition than experts realized in 1991 when the first comprehensive guidelines were issued. It is now considered a pathological syndrome with many different characteristics or phenotypes that result from the interaction between a person’s genetics and the environment.

Also, although it has not been discussed in detail in recent guidelines, the latest treatment of what is known as biological medicine heralds new forms of treatment for severe asthma patients that are not well controlled by other treatments, albeit cheaper. Biologics are made from modified molecules of living organisms’ cells designed to target specific disease pathways that accumulate to produce asthma symptoms.

“The past 13 years have seen an explosion of new strategies and new concepts, new understanding of the mechanism, new drugs and new treatments. In the past five years alone, 5 new asthma drugs have been approved,” said Dr. Wischler in an interview.

The new guidelines could be especially helpful for people treating asthma, whether mild or severe, that is not adequately controlled. More than half of all asthma patients are treated by primary care physicians, with referrals to specialists such as pulmonologists or allergists when their conditions are severe or not when they are not, said Dr. Michael M. Clotter, professor emeritus of the University of Connecticut School of Medicine who chaired the expert panel. It responds well to treatment.

Asthma affects about 25 million people in the United States, including 5.5 million children. It is not an infection, although the body reacts as if an enemy has attacked it. Rather, asthma is a chronic respiratory disease that affects people whose airways become inflamed in response to various stimulating substances or behaviors. The airways become inflamed, swell, and the surrounding muscles narrow, causing a bronchospasm. Unless bronchospasm is quickly reversed, breathing can become very difficult and lead to hospitalization or death.

Although people with asthma always have some degree of bronchitis, they are especially sensitive to certain factors that can worsen the inflammation and lead to difficulty breathing. Thus, some people with asthma suffer from environmental allergies, for example, to pollen, animal dander, dust mites, rodents, or cockroaches, which, when met, can trigger an asthma attack. Others are sensitive to irritants in the air, such as tobacco smoke, air pollutants, or substances with strong odors.

For example, “What is used even for cleaning can be an irritant to a person with asthma,” said Wischler.

For some people with asthma, a viral infection, such as influenza or the common cold, or the use of a medication such as aspirin, non-steroidal anti-inflammatory drugs, or high blood pressure relievers, can increase inflammation in the airways and lead to difficulty breathing. Some people still experience narrowing of the airways when exercising, especially in cold weather.

Even strong emotions such as fear, anger, excitement, laughter and sudden changes in the weather are problems for some asthmatics.

Wecheler said that although many of the asthmatics I knew were afraid that they were more likely to contract the Coronavirus and get very sick, the evidence did not show an increased risk of either contracting the Coronavirus or of developing a worse infection if that happened. “In fact, treating asthma may prevent Corona disease,” he added.

Researchers now realize that the event causing an asthma attack can have different manifestations within the airways, and thus respond better to different treatments. In asthma caused by allergies, inflammatory cells called nitric oxide collect partial exhalation in the airways, but when a viral infection causes inflammation, cells called neutrophils are released, which calls for different treatment.

The new guidelines highlight the value of a measurement called fractional exhalation nitric oxide, a biomarker touted as useful in the correct diagnosis and appropriate treatment of asthma in different patients. For children 5 years of age and older, nitric oxide measurement can help confirm an asthma diagnosis and evaluate treatment effectiveness.

Although the guidelines do not provide hard and fast rules, they offer valuable treatment suggestions when the treatments currently in use do not lead to the best possible treatment. For example, the committee stated unequivocally that wrapping mattresses and pillows in allergy-protective covers is not in itself an appropriate treatment for someone with an allergy to dust mites.

The committee wrote that “single-component interventions often do not work” in efforts to control indoor allergens. Among the proposed approaches are the use of pesticides against household dust mites on carpets, mattresses, and furniture, and air filtration and purification systems, including those containing high-potency nano-particles filters; And remove mats and carpets that cover the floors completely, at least in the allergic person’s bedroom; And loosen mold.

The report also warned against relying on a negative result in an allergy test if a person reported worsening symptoms when exposed to the allergens tested. On the other hand, some patients who have tested positive for sensitivity may not react to this substance in real life. Some may have developed a tolerance to the allergen that can be reversed when trying to reduce a patient’s exposure to them.

 © The New York Times Foundation 2021

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