Corticosteroids require a doctor’s prescription. They can be used two ways: by spray inhalation or by mouth. Injectable forms are also available, but require prescription and the presence of a doctor or nurse to administer them. Injections of steroid medicines are usually given at the start of treatment in the doctor’s office, or they are given when the patient is seen in an emergency room or admitted to the hospital. Judicious early use of steroids by inhalation and by mouth will reduce inflammation in the mucous membranes of the respiratory tract and thereby prevent most hospital admissions.
There are several groups of steroids and several trade names in each group. Differences exist in the length of time the drugs continue to be effective. For the purpose of this discussion, two generic forms will be mentioned: prednisone and prednisolone. These are short-acting medicines whose effects last about 1 day. They are available only by prescription and come in 5-, 10-, or-20-mg sizes. There is a slight difference in the way the body uses these two drugs. Prednisone is converted to prednisolone in our bodies before it can work its magic.
For best results, the first dose of steroids is usually very high, about 60 mg of prednisolone or prednisone for an adult, less for children. That dose, twelve 5-mg tablets, can be taken all at once, as soon as the decision to use it is made. It is generally taken along with some food or water to protect against stomach irritation. Relief of signs and symptoms of asthma should begin within 4 to 8 hours.
Prednisolone suppresses the feedback mechanism between the pituitary and the adrenal glands, but even in large doses, it is changed by the body’s activity (metabolized) within 48 hours. So the second dose of steroid should be given about 2 days later, by which time the earlier dose has been metabolized. In an effort to get on an early morning schedule, the second dose is given at 8 am or earlier on the third day.
This schedule pertains only to prednisone and prednisolone. These medicines are closest in structure and function to hormones produced normally in the body. For modified steroids such as betamethasone, triamcinolone, and dexamethasone, the dosage will be very different, but the pattern of dosing will be the same.
If treatment is anticipated to last longer than 10 days, using an alternate-day dosing program offers less likelihood of side effects such as suppression of the pituitary-adrenal axis. In this situation, the starter dose of 60 mg can be tapered by 5 mg every other day. This will prolong the treatment period to more than 3 weeks. If a prolonged period of treatment is required, close consultation with the doctor is needed,
Steroid medicines are wonder drugs for suppression of inflammation and the signs and symptoms it causes. The downside to the use of steroids is the list of their side effects, including retention of water and salt, high blood pressure, high blood sugar, and increased susceptibility to infection, especially fungus infection, stomach ulcer, muscle aches and pains, glaucoma, and cataract formation.
Note again that the effect of cortiarids taken by mouth in tablet form is the same as when the medicine is used by inhalation, but there are some practical differences. The sprays cost much more than the medicines taken by mouth. In fact, there are no inexpensive steroids that come in spray form. On the other hand, the cost of steroid drugs for oral use is generally manageable for most patients. Prednisone and prednisolone tablets can be purchased at a retail pharmacy for $3 to $5 per hundred, modified steroids for ten times that price. In any case, if either oral or spray steroid medicine is used properly, there is no chance of overdose or serious side effects. So this book suggests use of steroid medicines by mouth whenever possible.
It is now 10 days into your most recent episode of asthma. You are free of signs and symptoms of asthma and feeling very upbeat. Some of the improvement in the way you feel is the result of improvement in your ability to breathe, but some improvement in your mood results horn a psychological lift (euphoria) that is another of the side effects of steroids. This psychological lift sometimes turns into a mild depression when the drug is stopped, another reason to taper the dosage as described above rather than withdrawing the medicine abruptly.
At this point, you have stopped the steroid but still are taking the spray and oral bronchodilator. The next effort is to stop those medicines, too. It should be easy to stop using the spray at this point. About a day later, stop the oral medication abruptly. Continue the breathing exercises and follow progress with twice-daily use of the peak flow meter. All should be well at this time.
But suppose it is not. Suppose, after this 10-day course of treatment, asthma returns as the medicines are withdrawn. The problem then should be recognized as a serious one. Some cause of asthma has been overlooked, some detail missed. The time has come to see your doctor for review of your problem. Unfortunately, there are a few patients for whom recurrence of asthma is a pattern that defies identification of its cause. While continuing to explore cause, the doctor may prescribe long-term, continuous use of an oral bronchodilator or a spray or oral steroid. This treatment is last resort and should not take the place of continuing the search for the cause of the asthma.
Peak flow determinations are a good guide to the state of the asthmatic process in every patient. They are very helpful for following the progress of long-term asthma and can be used to tell when dosages of a bronchodilator should be changed.
Breathing exercises are very important for the patient with a long-standing asthmatic episode. Stretch reflexes triggered by an over inflated lung may cause bronchial spasm, which, in turn, may cause more trapping of air. Any patient with continuing asthma should make special effort to learn breath control and use the breathing exercises to reduce stretching of the lungs.
What happens to the few patients who end up in the hospital? A battery of tests evaluates their condition. Blood tests tell about dehydration and the chemical composition of the body. Breathing tests indicate the severity of the lung problem. For a first admission, X rays, CAT scan, and other modalities look at the inner structure of the lung to make sure nothing has been overlooked.
In the hospital, the same medicines are used that have been used for episodes outside the hospital. There are no other useful medications. Under the close supervision available in the hospital, dosing can be pushed closer to the level that causes serious side effects; combinations can be used and varied. Oxygen is safer to use in a hospital setting and is more likely to be employed. Technicians are available who can assist in decompressing the lungs, often using the same type of breathing exercises described here. Using these techniques and drugs in the hospital, a total push toward recovery can be mounted.
What about the psychological condition of a patient with long-standing asthma? It is often not good. In a 1994 study, published in the European medical journal Pneumologie, it was recognized that one-third to two-thirds of asthma patients are assumed to have a psychological component to the disease. But that paper was not able to define a direct relationship between stress and onset of asthma.
Like other chronic diseases, asthma tends to be stressful and depressing. In addition, the effort of breathing is very tiring. The physical fatigue contributes to the depressed, unhappy psychological situation.
Some patients relate to their asthma by partially or completely denying that they have the recurrent, life-threatening disease. Adrienne Stewart was a young-looking grandmother who was very proud of her youthful appearance. When I told her she had asthma, her response was, “No way!”
There was simply no place in her self-image for a chronic disease. So she denied having asthma and refused treatment at first. With increasing frequency of asthmatic episodes, and a lot of pressure from her family, she finally opted for treatment. Even then, she referred to her disease as bronchitis.
Other patients may reject treatment for other reasons. Some will reject medical treatment in favor of “alternative” treatments . Others will learn to use their asthma to manipulate and control the rest of the family .For situations like these, psychological therapy is often helpful.
Do emotional and psychological problems cause asthma? Most professionals agree that they do not cause the physical disease. But there is little argument that moderate to severe asthma has an impact on life-style that may require special attention. This is the thesis of “holistic medicine,” treatment that considers the whole patient. Of course, psychological diagnosis and treatment are sometimes important. But they must always be associated with general medical treatment.
