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Oral gold therapy (Ridaura® [auranofin]), methotrexate, cyclosporine, azathioprine, hydroxychloroquine, dapsone, intravenous immunoglobulin (IVIg) and omalizumab (Xolair®) gammaglobulin are therapeutic agents that have been studied for their ability to suppress steroid-dependent asthmatic symptoms.While initial individual case reports and limited clinical trials offer some promise for these agents, their use for the treatment of asthma is still considered experimental, with the exception of Xolair® which is FDA approved. The Asthma Center specialists will consider use of these medications only after standard treatments fail to control symptoms and your asthma is very severe.
Hydroxychloroquine, or Plaquenil,® is an uncommonly prescribed agent amongst this group. Plaquenil® is a medication used to treat malaria and inflammatory disease of the skin and joints. It has shown benefit for some steroid-dependent asthma.While its exact mechanism of action is unknown, it may suppress the inflammatory response in the airways. Plaquenil® is used on a daily basis as an oral medication and is generally administered over a six month trial period before a response is noted. Side effects include nausea, vomiting and dizziness. Serious toxicity to the retina of the eye can occur rarely with this therapy after long term use at higher doses than that used for treatment of asthma. The Asthma Center specialists recommend baseline and follow-up eye examinations while on this medication.
METHOTREXATE
Description:
Methotrexate is approved by the Food and Drug Administration (FDA) and is currently available for treatment of certain diseases: adult rheumatoid arthritis, severe psoriasis (a skin disease) and certain cancers.
Over the past several years, there have been scientific reports of the use of methotrexate in very difficult-to-treat asthma. This treatment may be used when, in addition to standard asthma drugs, you have required frequent oral corticosteroid treatment or prolonged use of daily oral corticosteroids (prednisone, methylprednisolone, etc.). The use of methotrexate may help reduce the amount of oral corticosteroids needed as well as help decrease the risks of side effects with oral corticosteroid treatment.
Although methotrexate is not approved for use by the FDA as an asthma medication, the experience of The Asthma Center specialists and the experience reported in the medical literature suggests that the potential benefits of methotrexate if you are steroid-dependent, especially regarding its potential to decrease your need for oral corticosteroids, outweigh its potential risks for side effects.
Use:
Methotrexate is usually given as a weekly intramuscular injection or orally on a weekly basis.
Risks and Precautions:
Methotrexate may cause the following side effects: nausea and/or stomach discomfort, headache, dizziness, skin rash or itchy skin, a decrease in the blood cell count and pneumonia. As with any drug, there may be unanticipated side effects. The amount of the drug administered for asthma treatment is relatively low (much lower than the dosage used for treatment of cancer), and therefore the possibility of these side effects is generally decreased. After prolonged usage of methotrexate, there is a risk of inflammation and/or injury to the kidneys, lungs, or liver and/or increased risk of infection. These potential side effects are carefully monitored during follow-up visits with your asthma specialists.
INTRAVENOUS IMMUNOGLOBULIN (IVIg)
Intravenous immunoglobulin (IVIg) has been found in several clinical trials to benefit severe chronic steroid-dependent asthma. IVIg is approved by the FDA for treatment of primary immunodeficiency; however, it is not approved for the treatment of asthma at this time. This is an extremely expensive and time consuming form of therapy. Treatments consist of 4 - 8 hours of infusions once a month.
Risks and Precautions:
IVIg is a sterile highly purified human immunoglobulin derived from large pools of human plasma. Rapid infusions can cause nausea, vomiting, back or abdominal pain, leg cramps, chest tightness, rapid heart rate, anxiety, itching, hives and flushing. Slowing down the infusion usually eliminates these symptoms. Rarely, severe anaphylactic (allergic) reactions occur. If you have a history of heart disease, strokes, thrombosis, or blood clots, you should not receive this therapy. Aseptic meningitis syndrome has been infrequently reported to occur and is associated with severe headache, stiff neck, drowsiness, fever, nausea and vomiting. Kidney disease has been reported as a complication.
This is one of the newer types of experimental treatments for severe steroid-dependent asthma. The exact mechanism of action is unknown. However, permanent side effects are rare, and IVIg therapy is considered by some specialists to be a reasonable alternative to continuing treatment with high dose, daily oral corticosteroids with their associated risks of significant side effects.
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