Ask anyone who has it: asthma is no fun. Probably few sensations are as unsettling as not being able to breath, and that’s what happens to those with asthma. Now imagine being a kid with asthma, as an increasing number of children worldwide are. Not only is breathing sometimes almost impossible, the condition may seriously impair one's ability to participate in sports, can strike with apparent randomness, resulting in hospitalization, and may even cause death. Can use of an antibody medication help? That’s in the current issue of NEJM and provides fodder for discussion in this week’s podcast.
This study enrolled 419 inner city children 6-20 years of age, who had had at least one asthma attack requiring an emergency department visit or hospitalization in the previous 6 to 12 months to study entry, despite use of an asthma control regimen. I think it is sobering to reflect on the fact that asthma in general is much more severe among our youngest residents of inner cities due to their exposure to allergens like cockroach dander.
All of the study subjects were brought up to speed on managing their asthma with medications and other measures such as bedding covering, then half were randomized to receive subcutaneous injections of the antibody every two or four weeks, or placebo. The study continued for a year.
Use of the antibody, called 'omalizumab,' resulted in about a one-quarter reduction in symptoms, but hospitalizations due to an acute exacerbation of asthma were 6.3% in the placebo group versus 1.5% in the treated group. That's huge. And side effects of treatment for the duration of this study were minimal.
A couple of points I raise in the podcast: this medication is expensive, and represents a bit of an inconvenience since it's an injection. I also feel obliged to bring up FDA imposed 'black box' warnings regarding use of this medication. There is a risk of a severe allergic reaction when the antibody is injected, so it must always be done in a physician's office. Additionally, when the medication is used long term there may be an increased risk of certain types of cancer. Finally, right now the drug is not approved for use in children younger than 12 years of age, although the average age of participants in this study was about 10. We don't know what impact the drug might have when therapy is begun so early in life and prior to adolescence. Rick's point is well-taken: this therapy should be reserved for children with asthma who, despite the best medications and strategies to keep their condition controlled, continue to experience acute exacerbations. For those who do, however, it offers hope.
Other topics this week include two others from NEJM: a novel 'bunyavirus' identified in China, and stents versus bypass surgery for quality of life issues. Finally in JAMA, use of high dose clopidogrel isn't helpful for people at risk of forming clots after they have a stent placed in one of the heart's arteries. Until next week, y'all live well.