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'Reliever' Inhalers Tied to Asthma Deaths

Excessive use of short-term beta agonists could increase risk

FRIDAY, Aug. 2, 2002 (HealthDayNews) -- Asthma patients who use their so-called "reliever" inhalers excessively are at increased risk of death from asthma, a new study shows.

Stephan Lanes, an epidemiologist at Boehringer Ingelheim Pharmaceuticals in Ridgefield, Conn., led the study, which evaluated the relative risk of dying from asthma for someone taking a specific asthma drug -- either short-acting beta agonist inhalers designed for emergency or relief use, or inhaled steroids, longer-acting medicines designed to keep the condition under control.

Lanes and his colleagues examined the records of more than 96,000 asthmatics, ages 10 to 79, whose treatment details had been entered into the General Practice Research database in the United Kingdom between the years 1994 and 1998.

During that time, 43 people died specifically as a result of their asthma, most of whom were over the age of 50.

When the researchers looked more closely at how many times each patient used which drugs -- and factored in age, sex, weight, number of doctor visits and smoking -- they found that those who used the beta agonists the most had the highest risk of asthma death.

Specifically, those who had used seven to 12 prescriptions of beta agonist inhaler medications the previous year had a 16-fold increased risk of death. If they used at least 13 relief-inhaler prescriptions the previous year, the risk of death rose 50-fold.

The risk is an adjusted relative one, computed by comparing the use of medications by asthma patients who died with the overall use of asthma medications by control patients who had asthma but survived. For each patient who died, 20 control patients were selected and their medication use was compared with the medication use of the patients who died.

But of the 43 people who died of asthma, the researchers found, 39 had used seven or more prescriptions a year of the short-acting beta agonists.

Seven prescriptions of beta agonist inhalers a year would represent excessive use of the reliever inhalers, most asthma experts would agree. Seven prescriptions a year, according to one asthma expert, would translate to a patient using the reliever inhaler twice a day, two puffs each time.

In recent years, the standard of treatment for asthma care is to prescribe long-acting steroid inhalers for prevention and the beta agonist inhalers for emergency or relief use perhaps several times a week but not daily.

The findings, reported in the August issue of the journal Thorax, mirror those of several other recent studies, Lanes says.

In the United States, 17 million people suffer from asthma, the chronic lung disease marked by inflamed air passages and difficult breathing, according to estimates from the Asthma and Allergy Foundation of America.

Some experts say the latest findings beg the question: Is it the increased medication use that boosts the death risk or is it the condition of the patient? That is, do the patients who use the reliever inhalers most often have uncontrolled asthma or are in worse shape?

Dr. Harold Nelson, a fellow of the American Academy of Allergy, Asthma and Immunology (AAAAI) and a physician at the National Jewish Medical and Research Center, wonders if people who were sicker simply used more reliever inhalers.

"It's not the medicine perhaps, but the asthma," he says. There may indeed be an association between higher beta agonist reliever inhaler use and asthma death, he adds. "But it may not be cause and effect."

"That, of course, is the $64 million question," Lanes says. "People are going to debate this. There's no such thing as a definitive study."

But in this study, he says, "we were able to look at inhaled steroids and beta agonists."

And the findings showed, he adds, that as the use of inhaled steroids increased, the risk of asthma death decreased. And as the use of beta agonist reliever inhalers increased, the death risk increased.

In addition, they found that patients who had been prescribed more than one reliever inhaler prescription a month cut their risk of death by 60 percent if they regularly used a long-acting inhaled steroid.

Exactly how the increased use of reliever inhalers boosts death risk is beyond the scope of the study, Lanes says.

"I'm not saying it is a hard-and-shut case, although there are data in the paper that might suggest that," Lane says.

Dr. Stanley Szefler, also an AAAAI fellow, says the study is "another in a series ... that have made the same point."

Increased use of the reliever inhalers is a sign that asthma is not well-controlled, he says.

"If a patient is using a canister or more a month of quick-reliever inhalers, the doctor should review the treatment plan. The major message is that a high dependence on quick-reliever medication is a sign that asthma is not well-controlled," Szefler, a physician at the National Jewish Medical and Research Center in Denver, adds.

Ideally, Szefler says, reliever inhalers should not be used more than several times a week (perhaps more if used as a preventive for exercise-induced asthma).

What To Do

For information on asthma treatments, visit the American Academy of Allergy, Asthma and Immunology. For information on controlling asthma, check out the National Heart, Lung and Blood Institute.

SOURCES: Stephan Lanes, Ph.D., epidemiologist, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Conn.; Harold Nelson, M.D., National Jewish Medical and Research Center, Denver; Stanley Szefler, M.D., National Jewish Medical Center; August 2002 Thorax
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