Treating Asthma: Personalized Medicine

Are you getting care that's right for your body, your age, and your background?

From the WebMD Archives

A lot of people think that treating asthma is simple: when you start wheezing, just take a puff from a rescue inhaler.

But it's not so straightforward for most people. Every case of asthma is different and the disease can take many forms. So each person's treatment needs to be different too. The medicines that work for your relative or your friend or your neighbor may not work for you.

"Every person who has been diagnosed with asthma needs a treatment plan that's custom-tailored to his or her specific needs," says allergist Jonathan A. Bernstein, MD, associate professor of clinical medicine at the University of Cincinnati College of Medicine.

What's more, your asthma treatment may need to be adjusted regularly. Because the disease is constantly changing -- along with your life and related influences -- the treatment that once worked very well may no longer be the best choice.

"Your past experience of asthma isn't always predictive of what your asthma will be like in the future," says Hugh H. Windom, MD, associate clinical professor of immunology at the University of South Florida, Tampa. And as your symptoms change, your treatment needs to keep up.

So it's key that you and your doctor develop a personalized treatment program. When it comes to asthma treatment, one size does not fit all.

Misunderstanding Asthma

Many people with asthma only think about it when they are having an attack. But controlling asthma does not just mean treating flare-ups with a rescue inhaler. It's not like taking aspirin for the occasional headache.

"If you're just using a bronchodilator -- a rescue medicine -- you're not dealing with the real disease," Bernstein tells WebMD. "You're not treating the underlying inflammation in the airways."

Michael S. Blaiss, MD, past president of the American College of Allergy, Asthma & Immunology, says that some people don't really understand asthma.

"Many people -- and some doctors -- still don't realize that asthma is a chronic disease," he says. "It's still there even when you're feeling well."

In fact, the inflammation in the airways can worsen without causing any symptoms -- only lung function tests may detect it, says Bernstein. Even if you do have worsening symptoms, the changes may happen so slowly that you don't notice.

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"As with any chronic disease, people get used to their asthma," says Windom. "They think living with debilitating symptoms is normal."

Studies bear this out. According to the Asthma and Allergy Foundation, the majority of people with asthma (88%) said that their condition was "under control." But doctors would disagree. Of the patients polled, 50% said that asthma made them stop exercising, and 48% said that it woke them at night. If your asthma is under control, you should not be having these problems.

"I explain to my patients that asthma is really more like diabetes or hypertension," says Blaiss, who is also clinical professor of pediatrics and medicine at the University of Tennessee Health Science Center, Memphis. "We can't cure it, but we can control it with the right daily medication."

Asthma: A Changeable Disease

Asthma and asthma treatment can be affected by a number of things.

  • Age. "As children grow up, their asthma can change a great deal," says Bernstein. "For some, it goes away. For others, it gets worse." Children are also often exposed to more allergens while at camp or playing sports outdoors.

  • Environment. Your surroundings can have a huge effect on your asthma. Obviously, you'll be exposed to very different allergens if you move from the city to the country or vice versa. But much less dramatic changes can still have a tremendous impact. You may encounter all sorts of new triggers in a new house or at a new job. Even the most subtle change -- like a colleague using a new perfume -- can irritate your airways and make your asthma worsen dramatically.

  • Genes. We're still in the early stages of understanding the genetics of asthma, but researchers believe that genes play a big role. They may affect the course of your disease and how well a treatment will work.

    "Some people have a vigorous response to bronchodilators and some don't," Windom tells WebMD. "We now think that part of the difference between these people may be in their genes." Windom says that many are wrongly blamed for treatment failure and accused of not taking their medicine, when it fact it just doesn't work for them.

  • Other Health Conditions. Conditions like a sinus infection, lung disease, and acid reflux can all make your asthma worse. Other diseases can have an indirect -- but significant -- effect. For instance, some people with painful arthritis may have trouble using inhalers properly, says Windom. This can prevent them from getting as much medicine as they need.

  • Race. While the research isn't conclusive yet, there's a growing belief that African-Americans may be more prone to asthma than other groups. For example, according to the American Lung Association the rate of asthma among African-Americans in 2002 is higher than among whites. African-Americans may also be three times more likely to die from asthma than whites.

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"Socioeconomic factors, like limited access to good health care, probably also play a role," says Blaiss. "But I think that there is definitely a genetic component to why asthma is a more severe illness in the African-American community."

Genetic differences may also affect how well medications work in African-Americans. A 2006 article published in the journal Chest described one study of the long-acting bronchodilator Serevent. It turned out that African-Americans who took the drug were four times as likely to die or experience life-threatening events as those who did not. There were no significant differences between whites who did or didn't take the drug. The effects may be due to socioeconomic factors and not genetic ones, but more research needs to be done.

Customizing Your Asthma Treatment

Because asthma is such a changeable disease, with so many different triggers and symptoms, finding the best treatment can be tricky. Even the most basic medical needs -- like the frequency of checkups -- can vary a great deal from person to person.

"It's really difficult to standardize how often a person with asthma should schedule appointments," says Bernstein. "A person with mild intermittent asthma may only need an appointment once a year. Someone with very severe asthma may need to go in once every two weeks." It all depends on your particular condition.

Asthma medicines are not interchangeable. "Some treatments work well for certain subgroups and some don't," says Windom. "But right now we don't have ways of testing beforehand what will work best." The foundation of asthma treatment is the use of prevention medications, which are used daily to keep symptoms from worsening. Inhaled corticosteroids -- such as Advair (a corticosteroid combined with a long-acting bronchodilator) and Flovent -- are examples of inhaled steroids. A newer class of long-acting drugs is leukotriene modifiers, such as Accolate, Singulair, and Zyflo.

As effective as these medicines are at controlling asthma, they essentially treat the symptoms of asthma or block the effects of specific allergens. One type of treatment stops the underlying cause of asthma symptoms. The only drug of this class available, Xolair, blocks the effects of IgE, a molecule that can trigger asthma symptoms. IgE is overproduced when the body is exposed to allergens.

As researchers learn more about the antibodies that trigger the symptoms of asthma, Windom predicts that drug companies will develop more medications to block their effects. So rather than having one "wonder drug" that controls everyone's asthma, we could have several different ones designed to help different groups of people.

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Becoming a Proactive Asthma Patient

Keep in mind that getting a personalized treatment plan for your asthma isn't just your doctor's responsibility. You have an important role to play too. "People really need to be proactive patients," says Bernstein.

Blaiss agrees. "Patients have to partner up with their doctors if they want to get the best care," he tells WebMD.

Being a partner in your health care requires some work on your part. Most important, you have to be sure to give your doctor all of the relevant information. A lot of people forget -- or don't bother -- to mention to their doctor that they had changes in their asthma symptoms.

"If the doctor doesn't know that your symptoms have changed, he might just keep refilling the old prescriptions, even if they're not helping," says Blaiss.

So before your next appointment -- prepare. Take a hard, objective look at your health. Since your recollection may not be totally accurate, you might want to start keeping a journal of your symptoms.

Keep track of any asthma attacks and any potential triggers that you are aware of. And also write down how often you're having attacks during the night or while exercising. If you have nighttime symptoms more than twice a month you may need a change in your treatment.

Also, monitor how often you use your inhalers. If you're using your quick relief inhalers more than two days per week, you may need different medication.

While you must get enough medication to control your symptoms, don't assume that more is better. Every medicine you add increases the risk of interactions and side effects.

"A lot of people wind up on five different medicines over time," says Windom. "They may have their symptoms under control, but two or three of those medicines may not really be doing anything." So he says that, together with your doctor, you need to make sure you are not taking any unnecessary medicines.

"Once you and your doctor agree on a treatment plan, you need to stick to it," says Bernstein. He also says that people need to be careful to practice environmental control at home -- like keeping pets out of the bedroom, wrapping the mattress and box spring in vinyl to keep out dust mites, and using a dehumidifier. You shouldn't expect your doctor to resolve your asthma entirely through prescription medications.

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Finally, don't give up.

"Like other chronic illnesses, dealing with asthma can be exhausting," says Windom. It's easy to get discouraged, especially if treatment hasn't been helping.

But don't surrender to your symptoms. If your asthma treatment hasn't been working, maybe it just needs to be adjusted or changed. You might find that a good partnership with your doctor and a personalized treatment plan could make all the difference.

WebMD Feature Reviewed by Brunilda Nazario, MD on September 22, 2008

Sources

SOURCES: American Academy of Allergy, Asthma and Immunology web site, "AAAAI Allergy & Asthma Medication Guide: Asthma Medications." American Academy of Allergy, Asthma and Immunology web site, "AAAAI Fast Facts about Asthma." American College of Allergy, Asthma & Immunology web site. "Taking Control: A Guide for People with Asthma." American Lung Association web site, "Lung Disease Data in Culturally Diverse Communities: 2005." Asthma and Allergy Foundation of America web site, "Asthma Overview." Jonathan A. Bernstein, MD, allergist, associate professor of clinical medicine, University of Cincinnati College of Medicine; fellow of the American College of Allergy, Asthma and Immunology. Michael S. Blaiss, MD, chair of the American College of Allergy, Asthma and Immunology (ACAAI) Asthma and Respiratory Disease Committee; past president of the ACAAI; clinical professor, pediatrics and medicine, University of Tennessee Health Science Center, Memphis. Nelson, H.S., Chest, January 2006; vol 126: pp 15-26. Hugh H. Windom, MD, associate clinical professor of immunology, University of South Florida, Tampa.

© 2006 WebMD, Inc. All rights reserved.

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