It is hoped that recent research into expanding the use of a targeted, expensive drug could bring financial relief to many who share symptoms with those covered by the drug’s current restrictive application.
At issue are serious symptoms caused by ACE-inhibitor-induced angioedema. The drug studied is Icatibant (brand name Firazyr), but its only approved application at present is for Hereditary Angioneurotic Edema, or HAE — a rare, but significant disease.
People with HAE suffer repeated bouts of swelling (angioedema) of different body parts, from lips and tongue to throat and even the intestines. The attacks can be severe and occasionally life-threatening when the airway is compromised. They are caused by the build-up and release of bradykinin, a powerful vasodilator. Icatibant works by blocking the tissue receptor where bradykinin exerts its mischief.
Not so rare is ACE-inhibitor-induced angioedema, which also occurs because of a build-up and release of bradykinin. Unlike HAE in which any part of the body is susceptible to swelling, ACE angioedema tends to occur primarily around the head and neck — lips, tongue, face, palate and throat.
Also unlike HAE which is caused by a genetic deficiency in an enzyme, ACE angioedema is caused in susceptible individuals by the medications called ACE-inhibitors, which are antihypertensives. At the current time the only FDA-approved use of Icatibant is in HAE; therefore, using it in ACE-angioedema would be an “off-label” use.
Which comes around to the crazy world of insurance. At this point insurance carriers will only cover the cost (roughly $8,000 per dose) for people with HAE. Hopefully, this research study will change things, as ACE-angioedema is a common reason for emergency room visits.
Dear Dr. K: I wheeze when I exercise. Does that mean I should stop aerobic activities?
The unequivocal answer to your question is “no” — and I’m sure Roger Bannister would second my answer.
Roger Bannister was the first runner to break the 4-minute mile. What many people don’t know is that he was a medical student when he performed that feat. (Pun intended.) In fact, in the 1950s when he broke four minutes the physicians at that time were mistakenly telling asthmatics not to exercise. Bannister actually changed that approach because of research he did in exercise physiology. He learned that exercise itself might stimulate wheezing with the activity but in the long run (pun intended), it helped lessen the asthma tendency.
Exercise can bring on wheezing for several reasons: airway cooling, airway dehydration and inhalation of allergens and pollutants. The latter is not surprising as the mouth breathing associated with aerobic exercise leads to inhalation of non-filtered air (bypassing the nose and sinuses).
Certain situations are more likely to elicit wheezing: running in cold/dry air, swimming in heavily chlorinated pools and biking along exhaust-laden roadways.
Sometimes exercise-induced asthma manifests as a cough rather than wheezing. This cough can happen during the activity or afterward (when it is known as “locker-room cough”).
The most important fact about exercise-related asthma is that improved aerobic conditioning lessens the asthmatic tendency and, in effect, “strengthens the lungs.”
General measures to manage the problem include identifying triggers such as high chlorine levels or pollutants, and avoiding them. Avoid exercising in extreme cold or dryness and engage in pre-exercise warm-up. For runners, if the asthma occurs while running fast, slowing the pace for a while can allow you to “run through” the asthma.
Finally, using an inhaled bronchodilator prior to exercise often eliminates the problem entirely.
Tough news reported in research results recently published in The Journal of the American Medical Association that persons with asthma were twice as likely to develop sleep apnea as non-asthmatics.
The study was done at the University of Wisconsin and involved thousands of people over a 25-year period. Sleep studies were done every four years in order to observe the frequency with which sleep apnea developed.
The striking outcome was compelling because asthma itself is a frequent cause of disturbed sleep. Hence, if the asthma gets blamed as the sole cause for nighttime wakening, the sleep apnea will go undetected and therefore, untreated.
The Wisconsin researchers suggested greater awareness of this possibility in asthmatics, their families and their doctors. If family members report snoring or apneic episodes, or if the patient has daytime somnolence, a sleep study should be considered.
The University of North Carolina recently completed a study of the use of Xolair (Omalizumab) in pregnancy.
Xolair is a monoclonal, anti-IgE antibody that is used as an add-on-therapy for moderate to severe asthmatics not adequately controlled with inhaled steroids.
Asthma is a common condition affecting roughly 10 percent of pregnant women. It is well known that poorly controlled asthma during pregnancy increases the risk for congenital anomalies, perinatal mortality, low birth weight and prematurity.
Xolair has been a welcome addition to the asthma treatment tool box, but up until now its safety in pregnancy was not known.
Although the study group was small — 191 women — the outcome indicated that Xolair does not appear to increase the risk for the fetus beyond that seen in the general asthmatic population.