What hedgehogs can teach us about asthma management
I like stories and metaphors, and I use them both in life and in medicine. I was recently reminded of one of my favorites, the parable of the fox and the hedgehog, from recent studies about asthma and SMART therapy.
There once was a clever fox who wanted to eat the hedgehog. The fox had lots of tricks and schemes to get what he wanted. Every morning the fox would find some new way to launch a surprise attack on the hedgehog. One day he surprised him next to a stream, but the hedgehog reflexively curled up into a spiky ball that poked the fox’s nose when he tried to turn the hedgehog over. The next day the fox surprised the hedgehog on the path to the stream, but again the hedgehog curled into a spiky ball. The fox kept his nose clear of the spikes but hurt his paw trying to turn the hedgehog over. Day after day went on like this until the fox eventually gave up. The fox had lots of approaches, but the hedgehog knew one thing, did it very well and consistently, and avoided being eaten by the fox. What the hedgehog knew was so important he always stayed safe.
In life as in medicine, there is a lot to know and do. Sometimes, doing one important thing very well can be better than doing several less important things satisfactorily.
A better strategy for controlling asthma
It turns out that many asthma patients could benefit from acting a bit more like hedgehogs. While many patients have long used two inhalers with multiple medications to control moderate to severe persistent asthma, recent studies suggest that using one inhaler with a combined medicine can better control symptoms for some people with asthma.
An asthma attack happens when tiny muscles around airways constrict, narrowing airways and making it more difficult to move air in and, especially, out of the lungs. A patient with asthma can go into an attack when exposed to irritants or allergens that trigger a reaction in the airways. This could be smoke, dust, pollen, viral infections, bacterial infections, even foods or medicines.
The first medication healthcare providers usually recommend is a “rescue inhaler,” an inhaled beta agonist, medicine that causes those small muscles around the airways to relax. The most common one is albuterol. The medication takes effect quickly and tends to wear off within several hours.
Some patients’ asthma can be managed very well with albuterol used on an as-needed basis. Other patients have frequent or severe attacks that warrant medicine to prevent asthma attacks before they happen. These “maintenance” medications are taken on a regular basis even when patients are feeling fine.
In the 1990s, a large study was conducted to compare two types of medicine in preventing asthma attacks. It had seemed that if a short-acting beta agonist worked well to control acute asthma, a long-acting beta agonist (similar to albuterol but slower to take effect and longer lasting), would be the natural choice for maintenance medication. The results were surprising. It turned out that a different class of drugs, inhaled corticosteroids, did a better job at maintenance.
So, asthma recommendations became “start with one type of inhaled medicine as a way to reverse asthma attacks, and for frequent or severe symptoms ADD in a second inhaled medicine for regular use to prevent them.” Two inhalers, each for a different purpose.
The airways in patients with asthma show more changes than just spastic muscles. The membranes get thicker, more secretions are present, and cells and chemicals related to inflammation are present in lung tissue. The primary effect of inhaled corticosteroids is to reduce these inflammatory and allergic responses. In retrospect, it made sense that inhaled corticosteroids would outperform long-acting beta agonists when used as a maintenance therapy.
It seemed like we knew what there was to know, and many patients would be stuck with two inhalers for their asthma. But some researchers kept asking questions, including, “Is it possible to recommend one inhaler instead of two?” It is technically possible to put two medications into one pill, and it is also possible to put two medications into one inhaler.
SMART therapy
Single maintenance and reliever therapy (SMART) for asthma was created. SMART therapy uses a beta agonist with quick onset and long action, often Formoterol, combined with an inhaled corticosteroid into a single inhaler.
Why does it matter? By one estimate there are 26 million American with asthma. Many of them will have moderate or severe persistent disease. They lead busy, complicated lives. They may sometimes forget to bring both inhalers with them, or which is which, or run out of one before the other.
SMART follows the hedgehog’s strategy– do one thing that works well and do it consistently for better protection. Simplifying from separate inhalers for maintenance and symptom relief to a single inhaler for both can make medications a little bit simpler and could lead to better asthma management.
Recent studies show that it can lead to asthma control that is as good and sometimes better than the more traditional approach of two separate inhalers. In response, the National Heart Lung and Blood Institute (NHLBI) changed its asthma recommendations in 2020 to include SMART for patients 4 years old and older with moderate or severe persistent asthma.
It is important to note that you can’t just switch how you use your combination inhaler. Not all asthma medications have long-lasting effects and rapid onset, even if they are often combined with an inhaled corticosteroid and used as maintenance therapy like Salmeterol. Some patients with severe asthma should consider adding other inhaled medication, oral medication or injections for control of their asthma symptoms. Talk with your healthcare provider to determine what therapy makes the most sense for you.
Do a cost comparison
If you are thinking about requesting a change in medication, talk with your pharmacy to check costs and talk with your healthcare provider to determine the best therapy for you Depending on the details of someone’s health insurance, when a patient eligible for single maintenance and reliever therapy (SMART) switches from two inhalers to one, the cumulative co-pay could be higher or lower. Some combination products (including Symbicort and Dulera) can have higher costs. Fortunately, in the past year a generic version of Symbicort has been approved and costs about half as much as the branded product, which can defray possible added expense.
This simpler SMART regimen can be especially helpful for students, who by one estimate miss 13.8 million days of school because of asthma in a typical year. Students learn new things every day, and that’s of course good, but when it comes to maintaining an asthma routine, the hedgehog’s one trick could make managing their asthma just a little bit simpler and better.
As you send your students back to school (and fall arrives for all of us) be sure to update vaccines, particularly for influenza and COVID. Respiratory infections are a common cause for asthma exacerbations, but even patients without asthma can have significant impacts of respiratory infections, from missed school and work to hospitalizations.
Peter Barkett, MD, practices internal medicine at Kaiser Permanente Silverdale. He lives in Bremerton.
This article originally appeared on Kitsap Sun: What hedgehogs can teach us about asthma management
