The National Institutes of Health (NIH) just finished a study on poorly controlled asthmatics. Asthma by its very nature is a condition that tends to wax and wane. When asthma worsens the standard medical approach is called step therapy; that is, whatever the current therapy is, additional steps are taken to regain control. These steps involve the addition of extra controller medicines.
Over the past few years a common step that’s been taken is to add a long-acting bronchodilator (LABA) to the use of an inhaled steroid. For example, someone on Flovent inhaler would step up to Advair (Flovent plus the LABA Salmeterol), or someone on Pulmicort inhaler would step up to Symbicort (Pulmicort plus the LABA Fomoterol).
Another approach is to double the inhaled steroid. If someone is on two puffs of an inhaled steroid twice a day, he or she is told to increase to four puffs twice a day, or a different, stronger inhaled steroid is used.
The NIH study compared these two standard options to a novel one, which is the addition of Tio tropium bromide to an inhaled steroid. Tio tropium is an anti-cholinergic medicine that has been used for years to help people with Chronic Obstructive Pulmonary Disease (COPD). The cholinergic nerves that innervate the lungs cause broncho constriction (airway narrowing) and excess mucus production. Blocking these nerves through an anti-cholinergic dilates airways and reduces excess mucus.
The NIH compared the three different steph in terms of regaining asthma control. All three steps worked. The mildest benefit came from doubling the steroid dose. The best effect came from adding a LABA or Tio tropium, with the latter being the more effective step.
The reason this study was done is that although LABA therapy has been extremely effective over the years, some people have not tolerated the medicine due to side effects such as tremor, anxiety, and rapid heart rate. Also, doubling the inhaled steroid works, but there is greater likelihood of systemic steroid effect from using higher doses.
As of now, the Food and Drug Administration has not approved Tio tropium for asthma, but experts expect this approval to be forthcoming.