- OTC Drugs
- Side Effects
Asthma is a disease in which there is a brief, temporary narrowing of the airways in the lungs, referred to as bronchospasm. This is only part of the picture. The main problem in asthma involves inflammation and swelling of the airways. It is important to understand that the lungs have a series of tubes akin to branches of tree leading to each of the air sacs of the lungs. When these tubes become inflamed, the walls thicken and the opening of the tube narrows. This causes increased resistance for air flow. In addition, these changes make it easier for bronchospasm to occur. Both bronchospasm and thickened airway walls prevent air from moving in and out of the lungs easily. As a result, a patient with asthma has episodic difficulty breathing. An asthmatic episode can resolve spontaneously or may require treatment.
It is crucial to understand that over time the airway inflammation associated with asthma can result in permanent remodeling/scarring of the airways. When this occurs and lung function no longer returns normal when not having an attack, Asthma moves into the category of disease known as chronic obstructive pulmonary disease (COPD). Therefore, if persistent symptoms of chest tightness, cough, wheezing, shortness of breath occur, it is imperative to be evaluated by a physician. Even mild symptoms, if long lasting, can reflect chronic inflammation and progress to COPD. The available over-the-counter (OTC) medications treat bronchospasm primarily and have little, if any, effect on airway inflammation. It is not advisable to use over-the-counter asthma medication unless instructed by a physician knowledgeable in the treatment of asthma. Airway inflammation is treated by prescription medications such as montelukast (Singulair), zafirlukast (Accolate), and inhaled corticosteroids (steroids).
Asthmatic patients and their physicians may select from a wide variety of prescription medications. This is not true for OTC medicines, which are limited to epinephrine (adrenaline) and ephedrine. In addition, many asthmatic patients should not use epinephrine or ephedrine because of their relatively weak effectiveness or side effects.
To decide whether an OTC epinephrine or ephedrine product may be useful, patients should understand:
- the abnormal conditions that exist in the airways of asthmatics;
- the effects of epinephrine and ephedrine;
- the specific factors that should be considered when choosing and using epinephrine and ephedrine; and
- the side effects of these drugs.
The advantages of using OTC medications for asthma include their affordability and accessibility (lack of need for a prescription and/or health insurance approval). Unfortunately, these medications are less effective at controlling asthma and sometimes can be more dangerous.
Recently, the FDA published safety concerns about the new medication Asthmanefrin and the EZ Breathe atomizer. They report complications such as chest pain, nausea and vomiting, increased blood pressure, increased heart rate, and coughing up blood. Even more disconcerting, they have reports of a choking hazard from a washer dislodged during atomizer use.
Most pulmonary and allergy specialists would discourage the use of these OTC medications unless asthma symptoms are extremely mild and infrequent.
What is asthma?
The cause of asthma is unknown. Physicians know more about the abnormal conditions that occur in asthma. These conditions include:
- hyper-responsiveness (contraction) of the muscles of the breathing airways in response to many stimuli such as exercise or allergies (for example, drugs, food additives, dust mites, animal fur, and mold);
- inflammation of the airways;
- shedding of the tissue lining the airways;
- increased secretion of mucus in the airways; and
- swelling of the airways with fluid.
Each of these conditions narrow the airways and make breathing difficult. Asthma symptoms include wheezing (the hallmark of asthma), coughing, difficulty breathing, and tightness of the chest. Health care professionals diagnose asthma by the presence of wheezing, though wheezing can occur with other diseases, such as airway narrowing from other diseases, or excess fluid from congestive heart failure. Other common symptoms, such as cough and shortness of breath, help determine if asthma is present. Breathing tests (spirometry) that evaluate the movement of air into and out of the lungs can be very helpful in making the diagnosis. Normally, one can exhale 70% of the air from the lungs in one second with a forced exhalation. In asthma, this number is often reduced when a patient is having symptoms. When they are better, the volume of air exhaled in that first second (referred to as FEV1, forced expired volume in one second) often is normal. This reversibility also helps confirm the diagnosis. Often a bronchodilator is administered after initial testing to determine if the airways dilate, another confirmatory test. Some have a type of asthma referred to as cough variant asthma. In this situation, patients have a cough that is chronic or recurrent with the presence of normal lung function.
What medications treat asthma?
Prior to modern medicine, people smoked a variety of plants and herbs in an effort to treat asthma. Some were mildly efficacious, while others were just plain dangerous. Oral and inhaled forms of epinephrine and ephedrine once were the only effective medications for treating asthma. Beginning in the 1980s, newer medications were introduced that target more of the abnormal conditions in asthma and do so more effectively than epinephrine or ephedrine. For example, prescription inhaler forms of short-acting beta2-agonists (SABA), including albuterol (Proventil, Ventolin, ProAir, Xopenex), and metaproterenol (Alupent), inhaled corticosteroids (ICS) including Beclovent, Flovent, Qvar, Asmanex, Asmacort, Arnuity, Pulmicort, Aerospan, Alvesco and AeroBid, anticholinergics (ipratropium, tiotropium bromide, glycopyrrolate, umeclidinium, [Atrovent], Spiriva, Incruse, Bevespi), and other medicines are now widely used because of their greater effectiveness and fewer side effects. The use of inhaled anti-inflammatory medications that include steroid agents such as fluticasone, budesonide, beclomethasone, and flunisolide has become the mainstay of initial asthma therapy. Unfortunately, none of these medications is available without a prescription. Often, doctors prescribe these medications in combination with a long-acting beta agonist (LABA), such as salmeterol, formoterol, or vilanterol. Some of the more common versions include Advair, Symbicort, Dulera, and Breo.
How do over-the-counter (OTC) asthma medications work?
Epinephrine acts by relaxing the muscles of the airways, thereby opening up the airways and allowing air to flow in and out of the lungs more easily. Ephedrine also relaxes the muscles of the airways. Essentially, these drugs work by stimulating the beta sympathetic receptors. However, these agents are not very specific and stimulate all beta receptors, resulting in increased side effects, including elevate blood pressure and heart rate.
What factors should patients consider in choosing and using OTC epinephrine or ephedrine?
Despite the development of newer medications, epinephrine and ephedrine remain available as OTC medications. The choice of epinephrine or ephedrine should involve consideration of several factors. Most importantly, the asthma should be mild and less frequent, defined as occurring less than once per week and resolving almost immediately. It's best to use OTC epinephrine or ephedrine under the guidance of a physician, if used at all. A patient should seek medical attention and prepare to switch to a prescription asthma medication in most cases, but especially if:
- moderate to severe asthma develops;
- frequent or regular doses of epinephrine or ephedrine are needed to relieve symptoms;
- episodes of asthma occur once or more per week; or
- asthmatic episodes develop at night.
OTC epinephrine is available in various concentrations for oral inhalation or as a solution in vaporized form (nebulization). Both forms may or may not contain alcohol or sulfite as preservatives. For example, AsthmaHaler Mist does not contain alcohol. Alcohol and sulfite preservatives may trigger an asthma attack, and therefore, patients whose asthma is sensitive to these preservatives should read product labels carefully. The nebulized epinephrine solutions may or may not require diluting with a separate saline (salt) solution before use. Several saline solutions are available OTC in various concentrations. Again, careful reading of the label will provide information about combining an epinephrine solution for nebulization with a specific saline solution. Oral epinephrine is unavailable because it is rapidly broken down in the digestive system before it can reach the lungs. Once inhaled, epinephrine should provide rapid relief of symptoms (within five to 10 minutes) and continue working for one to three hours. Good inhaler and nebulizing techniques are critical in the use of epinephrine. If patients use epinephrine frequently, tolerance to its effects occurs; that is, repeated inhalations provide progressively less and less benefit. Previously chlorofluorocarbons (CFCs) were used as the propellant for inhaler therapy. These have been banned and replaced by alternative propellant, hydrofloroalkane (HFA). The CFCs were felt to contribute to damage to the ozone layer.
OTC ephedrine is available only as an oral medication in combination with guaifenesin as caplets, tablets, or syrup. (Guaifenesin is an expectorant that reportedly loosens mucus in the airways and facilitates its removal by coughing, though health researchers haven't proven this conclusively.) Use caution when first starting these products since they occasionally irritate the airways of some patients and may make the asthma worse. OTC ephedrine should provide relief of symptoms within 15-60 minutes and may continue to be effective for three to five hours. Continued use of ephedrine, like frequent use of epinephrine, leads to tolerance.
Discontinue epinephrine or ephedrine if thick mucus or sputum (colored mucus) develops and/or a persistent or chronic cough occurs with the asthma. These may be signs of infection in the lungs and require immediate medical attention. If OTC asthma drugs do not relieve an episode of asthma within 10 (for epinephrine) or 60 minutes (for ephedrine) or the symptoms worsen, the patient should seek immediate medical attention. Repeated use of these agents should be strongly discouraged, unless under direct medical supervision.
What side effects and drug interactions are there with OTC asthma medicines?
Ephedrine poses a greater risk of causing adverse drug effects or drug interactions than epinephrine because it must be absorbed into the body to be effective. Nervousness, sleeplessness, anxiety, nausea, reduced appetite, rapid heartbeat, tremors (the "shakes"), and urinary retention are the most common adverse effects. Immediate medical attention may be necessary for these side effects.
Monoamine oxidase inhibitors (phenelzine, isocarboxazid), clonidine, selegiline, guanethidine, and ergotamines (ergotamine tartrate, dihydroergotamine mesylate) may increase blood pressure when used at the same time as ephedrine. Methyldopa or reserpine may reduce ephedrine levels in the blood and thereby lessen the effectiveness of ephedrine. Tricyclic antidepressants (desipramine, amitriptyline, doxepin, and imipramine) may block the effect of ephedrine. The carbonic anhydrase inhibitors acetazolamide and dichlorphenamide may increase ephedrine blood levels and the risk of side effects from ephedrine. Patients taking any medications should consult with their physician or pharmacist before starting OTC ephedrine.
Since patients with asthma inhale epinephrine directly into the lungs and little is absorbed into other organs of the body, there is less risk for side effects. Epinephrine may cause rapid heartbeat, irregular heart rhythms, high blood pressure, tremor, or anxiety.
Since there are specific risks with epinephrine or ephedrine in certain medical conditions, physician advice and supervision should be sought before taking epinephrine or ephedrine if there is heart disease (coronary artery disease, congestive heart failure, irregular heart rhythms), high blood pressure, thyroid disease, diabetes, or difficulty urinating due to enlargement of the prostate. In addition, patients should seek medical advice before taking ephedrine if they are already taking antidepressants.
What are additional measures in the management of asthma?
- Patients should avoid known triggers of asthma attacks (for example, exercise or allergens).
- Good control of allergic rhinitis (nasal allergies) helps to control asthma. Now there are OTC inhaled nasal steroids (Nasonex, Flonase) that are available and very effective in treating allergic rhinitis. It is important to understand that using these agents does not immediately relieve symptoms. It often requires seven or more days of use to realize the true effectiveness of these medications. Chronic sinus disease also often is associated with asthma.
- Some patients with asthma must avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and Motrin since they may induce an episode of asthma.
- All asthma patients should try to avoid beta-blocker drugs (Inderal, Tenormin, Visken, and Lopressor) because they may worsen asthma or precipitate an episode. This is not always the case, but an asthma history is an important consideration when prescribing.
- Gastroesophageal reflux (GERD) is often associated with asthma, sometimes as a precipitant and at other times the result of treatment.
- All patients with asthma should seek professional advice from their physicians on optimally managing their condition. It is probably best to avoid over-the-counter treatment unless directed to do so by a physician or practitioner knowledgeable in the treatment and diagnosis of asthma.
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Lougheed, M. Diane, et al. "Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults." Can Respir J. 19.2 March-April 2012: 127–164.
"Over-the-counter Medications." Asthma and Allergy Foundation of America.
"Safety Concerns with Asthmanefrin and the EZ Breathe Atomizer." FDA. 2013.