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Physicians Question Asthma Treatment

Heartburn medications may cause more problems than they solve

April 9, 2009

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Lung experts from Johns Hopkins and elsewhere are calling on physicians to suspend the routine use of potent heartburn medications in asthmatics solely to alleviate recurrent attacks of wheezing, coughing and breathlessness.

Calling the longstanding practice "ineffective" and "unnecessarily expensive," the experts say there is no benefit from using so-called proton pump inhibitors in the absence of the stomach upset.

The condition plagues five million asthma sufferers in the United States, of whom half have what is known as "silent" reflux, and lack the characteristic symptom of heartburn from the backup of acid into the esophagus.

Overall, as much as $10 million is spent each year in the United States treating gastroesophageal reflux disease in asthmatics struggling to control their lung symptoms.

The scientists base their call on their latest research, believed to be the most extensive monitoring ever done of how well the drugs — first made available in the 1990s — tame respiratory flare-ups in asthmatics for whom steroid therapy and other drugs have already failed.

Senior study investigator and Johns Hopkins pulmonologist Robert A. Wise, M.D., says the results dispel some common assumptions about the disease, offering the first solid evidence against silent acid reflux as having any significant role in poor asthma control.

Reporting in the New England Journal of Medicine online April 9, researchers at 20 medical centers in the United States collected detailed health reports on 412 men and women who still have asthma symptoms despite drug therapy. Half took daily doses of the most commonly used proton pump inhibitor — 80 milligrams of Nexium — while the rest received a placebo.

After six months, the average number of self-reported episodes of breathlessness — those that required use of inhalers, and which stirred nighttime awakenings or led to visits to the hospital emergency room — were the same for both groups, disproving any drug benefit.

Moreover, researchers saw no improvements in overall health or other quality-of-life measures, such as how much time study participants spent going out with friends, or how well they performed their work or kept pace with their college coursework.

"The bottom line here is that proton pump inhibitors do not improve control of asthma on their own," said Wise, a professor at the Johns Hopkins University School of Medicine.

Four out of 10 asthma sufferers, he notes, are struggling to control their asthma, whether or not they have symptoms of gastroesophageal reflux disease, or GERD.

Patients can easily confuse their heartburn symptoms with their asthma symptoms, which Wise says only adds to the difficulty in deciding about which treatment to use.

Yet surveys also show that as many as 65 percent of these people take proton pump inhibitors anyway, because doctors have presumed that it may improve their asthma.

But until now, no study had closely monitored asthmatics shown to have the silent form of GERD by taking precise measures of esophageal pH acidity levels, in which only patients free of any heartburn were treated.

"Our recommendation to physicians is that these drugs should only be considered for asthmatics who have symptoms of gastroesophageal reflux, at least twice a week," said Wise.

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