Question:
I have intermittent asthma. I'm 35 years old and have tried inhaled steroids
at least three times in my life. Each time I gave the steroids at three
months to kick in. And I have never noticed any perceptible improvement. I
am now on 4 puffs - twice a day (220 flovent). I am aware that steroids are
preventers (anti-inflamatory) and are not meant to provide instant relief
like albuterol.
My symtoms come and go. I have had long stretches symtom free. And long
stretches symtom-full. In both cases, steroids never seem to help. Also,
earlier this year I had a very bad few weeks with asthma and my doctor gave
a steroid pill. It had no effect. I HAVE had noticible improvements from long and short acting brinodilators
(serevent and albuterol) and Singulair seems to help. A few other things that seem to be contrary to the asthma norm: 1. I don't have alergies - I had scratch and shot tests and they all came
out negetive.
2. My symtoms are almost always between 3:00 PM and 11:00 PM. I never wake
up in the middle of the night from asthma.
3. Colds and flues seem to make myasthma better - not worse. So my question is: is there some small percentage of asthmatics that don't
respond to steroids? Do I maybe have something other than asthma?
Answer:
There is a small per cent of asthmatics who don't respond to steroids.
It's called steroid-resistant asthma.
This reaction to steroids, as well as your symptom history,
raises some doubt about your asthma diagnosis.
Asthma is diagnosed using spirometery; lung function
measured before and after adminstering a bronchodilator; a significant
improvement postbronchodilator, say 12%, tends to support an asthma
diagnosis. If in doubt a methacholine challenge test may be given.
Note that steroids, including steroid inhalers, should be used in
the minimum dose to control the problem, due to side effects. If they
don't help they shouldn't be used. Whether they help depends on
peak flow readings and symptom control.
You may want to seek a 2nd opinion from a teaching hospital with
a good pulmonary dept.
Links:
http://library.nationaljewish.org/MSU/13n2MSU_StRe_Asthma.html
Steroid-Resistant Asthma
Steroid-resistance
Inhaled glucocorticoids have become the mainstay of asthma therapy.
Treatment with oral glucocorticoids is the most potent therapy
available for acute asthma regimen for patients with severe
disease. Unfortunately, however, a small fraction of asthmatics
are steroid resistant and do not benefit from standard treatment.
Obviously it is critical to identify these patients as soon as
possible. Patients who do not respond to low steroid doses are
often placed on higher doses, which in steroid-resistant (SR)
asthmatics can cause significant adverse effects without
providing significant benefit. In addition, because steroids
patients is a challenging medical problem.
There are no definitive statistics on the prevalence of SR asthma,
but a rough estimate is that it occurs in less than 5% of the
asthmatic population.
The differential diagnosis includes sinusitis, gastroesophageal
reflux, congestive heart failure, an anatomic abnormality,
immunodeficiency, interstitial lung disease, and bronchopulmonary
dysplasia. Other conditions that could masquerade as SR asthma
include poor patient compliance with therapy, drug interactions
with glucocorticoids, abnormal glucocorticoid absorption or
elimination, food sensitivity, environmental factors,
and psychosocial factors."
