October 1, 2016: David Hodes, M.D., Palisades Pulmonary & Medical PC

If you continue to have asthma symptoms even though you are taking medication, talk to your doctor about finding a different treatment. There is, most often, little reason why anyone with asthma who is a nonsmoker and on appropriate treatment should not be fully controlled.

In many cases, I find patients with asthma who continue to have problems with symptoms – such as a cough, wheezing and shortness of breath that won’t go away – to have sinusitis. Often, they develop sinusitis (inflammation of the sinuses) a week or more after a cold. Their nasal passages harbor bacteria, which leads to sinusitis. Fortunately, people who are not allergic to penicillin can be treated with the antibiotic Augmentin (amoxicillin/clavulanate),which kills two types of bacteria found in nasal passages—aerobic (which require oxygen to stay alive) and anaerobic (which do not rely on oxygen). For people who are allergic to penicillin, two types of antibiotics (one for aerobes and the other for anaerobes) may be needed to treat both types of bacteria.

Other people who have trouble with asthma symptoms may have allergic asthma. These patients have high levels of antibodies called immunoglobulin E (IgE), which are produced by the immune system. If you have an allergy, your immune system overreacts to an allergen by producing high levels of IgE. There is a drug called omalizumab (Xolair), given by injection, that binds IgE and can be very helpful for people with allergic asthma. Some patients say once they have the treatment, it is almost as if they don’t have asthma anymore.

Many patients with persistent asthma can be well controlled with medication that combines inhaled corticosteroids and a long-acting beta agonist. These products include Advair, Symbicort, Dulera and Breo. Inhaled corticosteroids are anti-inflammatory medicines that reduce the swelling and mucus production inside the airways. When that inflammation is reduced, it is easier to breathe. Beta-agonists are medications that mainly affect the muscles that surround the small airways. When the lungs are irritated, bands of muscle around the airways tighten, making the airways narrower. This often results in breathlessness. Beta-agonists work by getting the muscles of the airways to relax, widening the airways. This results in easier breathing.

A third type of drug, called an anticholinergic, affects the muscles around the large airways. When the lungs are irritated, these bands of muscle can tighten, making these airways narrower. Anticholinergics, such as Spiriva, work by stopping the muscles from tightening. Some patients breathe easier when an anticholinergic drug is added to their regimen.

I have found that patients who are treated with inhaled corticosteroids alone often are not well controlled. But some doctors and patients are reluctant to use long-acting beta agonists because of studies that found that when these drugs were used alone, they might increase the risk of death. However, there is every reason for beta agonists to be considered safe when combined with inhaled corticosteroids.

The key to getting the right treatment is to find a physician who will consider all of the possible reasons your asthma isn’t well controlled. If your asthma may be triggered by allergens, your doctor should send you to an allergist. If your problems stem from sinusitis, you need to be treated for it. Your doctor should also make sure there are no other medical conditions that may be worsening your breathing. It is also important for your doctor’s office to have someone on staff who is available to immediately speak to you if you are having problems with your asthma. 

Not all asthma is the same. You should expect your doctor to do the legwork to go through all the possibilities, in order to match you up with the best treatment.