For chronic asthma, theophylline, whose brand names include Theo-Dur, Uniphyl, Slo-bid and others, is now considered a third-line choice, but may be of benefit in nighttime asthma, due to its long duration of action. Adverse effects of theophylline involve many organ systems. They may be mild or severe and life threatening. Gastrointestinal symptoms include heartburn, nausea and vomiting. Central nervous system negative side effects include headaches, insomnia, tremor and seizures. And finally abnormal heart rhythms and deaths have been reported.

Some studies have shown that frequent over use of the bronchodilators may result in an overall worsening of the asthma condition. This effect and the adverse effects on the cardiovascular system may explain in part the increasing death rate from asthma during the past several years. In other words, increasing mortality from asthma may be partially iatrogenic, or in other words, doctor caused.

Anti-inflammatory Drugs
Control of inflammation is currently the primary focus in managing asthma. The most effective agents for this purpose are the corticosteroids. These medications interfere with the synthesis of inflammatory mediators and prevent migration and activation of inflammatory cells. Also, they improve responsiveness of airway beta receptors, which promotes relaxation of bronchial smooth muscle. Corticosteroids, produced naturally by the adrenal cortex, include hydrocortisone or cortisol, which can be prescribed by physicians.

However, conventional physicians usually prefer to use one of the synthetic corticosteroids. During an acute severe asthmatic attack requiring hospitalization, the patient is usually given methylprednisolone (brand name Solu-Medrol) as a 60 to 80 mg intravenous push every six to eight hours for the first 36 to 48 hours of hospitalization. The patient is then switched to high doses of oral prednisone or methyl prednisolone, which is rapidly tapered over the next 10 days to two weeks. Short-term adverse effects from oral or intravenous steroids include increased appetite, weight gain, elevated blood sugar, fluid retention, mood changes, and gastrointestinal upset. Most patients can avoid long-term (months or years) use of corticosteroids, which have additional adverse effects and risks. These include a suppressed immune system, adrenal suppression, osteoporosis, muscle weakness, cataracts, skin changes, and peptic ulcers.

I have just discussed the use of intravenous and oral corticosteroids in treating acute asthmatic attacks. However, the administration of corticosteroids by inhalation is being acclaimed by many clinicians as the greatest advance in asthma management in the last 20 years. Inhalation corticosteroids are being recommended by many physicians as the first-line maintenance therapy for the adult with daily or frequent asthma symptoms. However, inhaled steroids appear to be underutilized, as they constituted less than 15% of all asthma prescriptions in 1993, according to a pharmaceutical industry survey. Their dosage varies from 1 to 5 puffs, two to four times a day, depending on the preparation. Local adverse effects include hoarseness, cough, and oral candidiasis or thrush. Generally, chronic adverse side effects of steroids given orally are not seen to any extent with the inhaled form of steroids. The inhaled steroids should be given at the lowest possible dose, capable of controlling the asthma. Examples of inhaled steroid products are: Beclovent, Vanceril, Azmacort, and Aerobid.