Wheezing is difficult, noisy breathing common in asthma sufferers.

A toxin is poison produced by a living organism.

While much creative energy is being devoted to basic research in the mechanisms that underlie the immune response, other allergic disease entities are being studied. We now shift our focus from the laboratory to an examination of some specific diseases currently being studied. Although asthma is usually defined as a reversible obstruction of the air passages, knowledge of the structural changes that occur in asthma has been gained through examination of the lungs of people who have died of severe, nonreversible asthma. An asthmatic tends to have overly reactive, smooth muscles in the bronchial tree. Muscle constriction, increased mucous secretion, and swelling of the lining of the air passages all contribute to attacks. Secretions occasionally become so thick that obstruction is complete and fatal. The air passages, or airways, are controlled to some extent by nervous innervation, in which the signals for muscle relaxation and those for constriction are unbalanced. The nervous system itself, or the receptors of the signals to the bronchial tree, or both, may be faulty in individuals with asthma. Understanding the possible defect in control mechanisms involves vigorous research. The term nervous, as used in this context, does not imply psychological or psycho­somatic involvement but rather refers to the autonomic nervous system which controls involuntary processes. The effect a person’s psycho­logical makeup has on asthma is a subject for later discussion. During an asthma attack, special chemicals called mediators are released into lung tissue and the circulatory system that promote constriction of the smooth muscles, secretion of mucus, and swelling of tissue. Scientists are expanding the knowledge of these mediators — where they are produced, what effect they have, and how that effect is achieved. Another aspect of this research concerns the mechanisms involved in quelling asthma attacks by inactivating or modifying the mediators. The first step in searching for the optimal therapy is observation of the changes that occur in asthma. Medication that helps relax bronchial muscles or that halts the release of an allergic mediator is discussed in other chapters. Much research effort has been devoted to study of the chemistry of these drugs, with an eye to improving their therapeutic properties while diminishing side effects. Another aspect of research in therapeutics is the leap from the laboratory, where the structure and function of a drug are first observed, to clinical situations, where the reactions of volunteers are evaluated in ascertaining the drug’s safety and effectiveness. Other research focuses on measuring the active drag in the body fluids in an attempt to determine optimal dosages. In summary, asthma research efforts are aimed at delineating the pathological changes that occur during and after an asthma attack and a better understanding of the pharmacologic modification of the problem.

by Sheldon L. Spector, M.D.
Not all the material in this chapter applies uniformly to every patient. Only by working closely with your physician can you understand your condition and improve it.

Beclomethasone dipropionate (Vanceril), a recently marketed aerosolized corticosteroid, has proved effective in treating some pa­tients. Although the drug has benefited many patients its effect has been most dramatic among those who require large daily doses of steroids. Beclomethasone is strongly advised for patients who are not doing well on more than four pills of prednisone (or an equivalent) on an alternate-day schedule. The prednisone should not be discon­tinued too rapidly while a patient is being switched from oral steroids to aerosolized steroids, or adrenal insufficiency could result. As men­tioned in the discussion of cromolyn sodium, these medications are used as a means of prevention; they will not help during an acute at­tack. Occasionally, the medication may have to be discontinued if the Freon propellants aggravate the asthma symptoms. Once the aero- solized corticosteroids are broken down in the body the end products are not particularly active. Their effect, then, is a local one, much like the effect of steroid cream on a rash. Patients should be cautioned against overusing this medication, because it will also suppress the pituitary adrenal axis and may cause more general steroid side effects. The most common side effect is thrush, an easily treated fungus infec­tion in the mouth that produces white patches discernible on the tongue and in the throat. There is probably an increased risk of de­veloping thrush when antibiotics and large doses of oral corticoste­roids are used together with an aerosol. Other contributing causes are diabetes and poor dental hygiene. The patient should be instructed to rinse the mouth after each treatment, either with an alcohol-based solution or with water. If these measures are not effective, the physi­cian may have to prescribe a specific antifungal mouthwash.

Following is a list of drugs com­monly used to treat allergies: Adrenalin (epinephrine) A hormone produced by the adrenal glands. As a drug, it is used in the treatment of severe acute allergic reactions such as anaphylaxis and asthma. It is usually injected, al­though it can be administered by inhalation (see chapter 3, "Allergy Emergencies and How to Cope with Them"). Aminophyllin See theophylline below in this listing. Antihistaminics Drugs used in treating allergic symptoms. The chemical structure of antihistaminics is similar to that of histamine: they act by blocking the action of histamine, a substance liberated during allergic reactions, which is responsible for many allergic symp­toms. Antihistaminics are especially useful in treating nasal allergies, particularly sneezing and runny noses. Several chemical groups of antihistaminics are available, to which patients may have varying re­sponses. Drowsiness is a common side effect of antihistaminics. Al­though the side effects are not serious, a change of medication in some patients may be necessary. Beclomethasone An inhaled steroid (cortisone) used in the treat­ment of severe and chronic asthma. The main use of beclomethasone is in treating patients with chronic severe asthma who would otherwise have to be treated using oral cortisone. Its advantages are that it causes fewer steroid-induced side effects and can be given in relatively small doses. Bronchodilators Drugs that relax the smooth muscle of con­stricted bronchi. The main use of bronchodilators is in treating asthma. Cromolyn A drug used in the treatment of asthma. The effect of cromolyn is unique; it is not a bronchodilator, nor does it block any of the chemicals released during an allergic reaction. Instead, it ap­pears to prevent the release of these chemicals following the antibody reaction on the surface of the sensitized basophils and mast cells. Corticosteroids (cortisone) Hormones produced by the cortex, or outer part, of the adrenal glands. Corticosteroids are extremely useful in treating severe allergic reactions and can be given orally, topically, or by injection. The onset of their action, however, is delayed, which reduces their effectiveness in such acute life-threatening reactions as anaphylaxis. Decadron A type of corticosteroid drug used in the treatment of severe allergies. It can be given intravenously, orally, or intramuscu­larly. A special preparation called decadron turbinaire, given by nasal inhalation, is often highly effective in treating nasal allergies that do not respond to conventional antihistaminic decongestive treatment. Depo-Medrol A corticosteriod drug of sustained action that is administered intramuscularly. Depo-Medrol is occasionally used in treating patients with severe chronic allergies when tablets cannot be used. Ephedrine A drug used in the treatment of asthma. Ephedrine is a component of numerous oral preparations in common use. With the recent appearance of more effective medications, the use of ephedrine has diminished. Theophylline A group of xanthine derivatives used in the treat­ment of asthma. The most important effect of drugs in the theophylline group is their ability to relax smooth muscle, causing a dilation of the bronchial tubes, with an accompanying subsequent improvement of asthma symptoms. At one time, these drags were commonly used in combination with other bronchodilators in single pills or were given intravenously in the case of severe asthma attacks. Recently, use of theophylline drags has undergone a major revision as the preparation of these drags has been improved and methods have been developed for measuring blood levels. Theophylline drags are today recom­mended for the everyday treatment of asthma patients.

No serious side effects from guaifenesin have been reported. The iodides Potassium Iodide USP and Organidin can cause various allergic manifestations and such side effects as nausea, abdominal cramps, and diarrhea. A group of symptoms called iodism often accompany chronic use; this group usually includes an unpleasant brassy taste, a burning sensation in the mouth and throat, sore teeth and gums, and increased salivation. Other symptoms are: sneezing; runny stuffy nose; eye irritation and swelling of the eyelids; headaches; coughing; a variety of rashes which resemble acne; enlarged painful salivary glands similar to those in mumps; fluid in the lungs (pul­monary edema) and rashes, which may be severe and can on rare occasions cause death. Fever, loss of appetite, and depression, occur occasionally. Iodism usually subsides within a few days after the drug is discontinued. Hypothyroidism, impaired functioning of the thryoid gland, has also been known to occur. Iodides should not be used during pregnancy. Water intoxication sometimes occurs among people suffering from neurotic or psychotic forms of compulsive drinking, or from certain other diseases. Persons with active asthma or chronic obstructive respiratory diseases, however, usually do not drink enough water.

If you or your child is allergic to wheat, learn to avoid the follow­ing ingredients: flour; wheat flour; wheat starch; gluten flour; graham flour; cracked wheat flour; enriched flour; m onosodium glutamate (MSG); hydrolyzed vegetable protein (HVP); whole wheat flour; heat germ; bran, cake, and pastry flour; and durum wheat. Foods to be eliminated absolutely include biscuits, breads, and bread crumbs; candy of unknown composition; breaded products (tor example, fish, poultry, and meat); malted milk, beer, ale, wine, and instant coffee containing wheat flour; luncheon meats, ham­burgers, hot dogs, and sausages (unless they are pure meat); cheese sauces and spreads (unless they are wheat-free); noodles (unless made with potato or rice flour); potato dishes containing wheat flour; and certain canned soups. Sometimes liquor, which is usually made from wheat, cannot be tolerated in any form. Be careful with items labeled "starch"—they may have wheat starch. Avoid medica­tion, such as vitamins, that may contain wheat, as well as patent medicines whose labels do not identify ingredients. Always check with your physician or pharmacist before having a prescription filled or purchasing medicine. Wheat can be replaced by products such as Ener-G-Foods’ rice baking mix and barley mix, as well as by’ tapioca, sago, rice, potato, soya, corn, arrowroot, buckwheat, rye, oats, or barley. Chinese grocery stores sell noodles in all shapes and sizes made from rice flour. Many patients are able to tolerate 100-percent sour-rye bread, which is sometimes available at specialty food stores. (Be sure it contains no wheat flour.) The following substitutions can replace one cup of wheat flour: 1/2cup barley flour 1 1 /4 cups rye flour 1 cup rye meal 1 1 /3 cup ground rolled oats 1/2cup rye flour and 1/2cup potato flour 2/3 cup rye flour and 1/3 cup potato flour 5/8 cup rice flour and 1/3 cup rye flour

Subcutaneous is an adjective meaning "under the skin."