March 19, 2010
Dear Mayo Clinic:
I am an active 84-year-old man and was diagnosed with asthma and COPD a few years ago. My pulmonologist prescribed two medications — Advair and Spiriva — that seem to do the same thing. Why would I need both medications and are there other options?
The medications you mention include three drugs because Advair contains two different medications. Spiriva is approved for treating chronic obstructive pulmonary disease (COPD). Advair is approved for both asthma and COPD. For people with moderate to severe COPD, research has shown a number of benefits with triple therapy like yours.
COPD is a lung disease that blocks airflow and makes breathing difficult. In most cases, the lung damage that leads to COPD is caused by cigarette smoking. But other irritants can cause COPD, too, including cigar or pipe smoke, air pollution and certain occupational exposures. In some cases, COPD results from a genetic disorder that causes low levels of a protective protein called alpha-1-antitrypsin.
Asthma occurs when the airways in the lungs (bronchial tubes) become inflamed and constricted. This may be triggered by allergies or viral infections. During an asthma attack, the airways thicken due to inflammation, the muscles of the bronchial walls tighten, and the airways produce extra mucus that increases obstruction.
A number of medications help control symptoms of COPD and asthma. Bronchodilators relax the muscles around your airways to make breathing easier and relieve coughing and shortness of breath. It may seem odd to take two drugs that do almost the same thing. But, there are two classes of bronchodilators: beta-agonists and anti-muscarinics. They work using different mechanisms to open up airways. Examples of short-acting bronchodilators are albuterol and ipratropium. Long-acting bronchodilators include tiotropium (Spiriva, an anti-muscarinic) and salmeterol and formoterol (Serevent and Foradil, both beta-agonists). Salmeterol is the long-acting bronchodilator in Advair. Several studies have found that using the two types of bronchodilators that you're taking, along with an inhaled corticosteroid, results in better control of COPD symptoms, better exercise tolerance and better pulmonary function.
Inhaled corticosteroid medications (such as the fluticasone in Advair) are essential to the treatment of asthma in all but the mildest cases. They are also used to treat people with COPD who have frequent "exacerbations" — temporary worsening of symptoms, often brought on by infections or exposure to irritants. These drugs work by reducing airway inflammation, which helps you breathe more easily.
If you develop side effects that seem to be caused by a medication, talk to your doctor. Alternative drugs may be effective. One alternative for treating asthma is a leukotriene blocker, such as montelukast (Singulair). Theophylline is an alternative for both asthma and COPD. Recent studies have shown substantial benefit using theophylline in doses lower than employed in the past.
You did not say if you are a smoker, but for those who smoke and have COPD, the most essential step in any treatment plan is to stop all smoking. It's the only thing proven to slow the progression of COPD and to improve survival with COPD. Smokers who need help quitting should talk to their doctor about strategies for quitting, including medications that might help. Annual influenza immunization is also very important for those with asthma and COPD.
Some pessimists assert that asthma and COPD are not curable. While that is true of most chronic illnesses, in fact, many cases of mild asthma go into remission or show few symptoms with effective therapy. Most cases of COPD are mild and require little treatment beyond smoking cessation, immunizations and occasional bronchodilator use. For more severe cases of both asthma and COPD, symptom control and quality of life can be greatly improved with effective use of medications and pulmonary rehabilitation. Prompt, aggressive treatment of exacerbations is a high priority for those with moderate to severe asthma or COPD. Chronic oxygen therapy is needed only for the most severe cases. Surgery, including lung transplantation and lung volume reduction, are beneficial for a limited subset of persons with very severe COPD.
— Paul D. Scanlon, M.D., Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minn.