Asthma Treatment in Pregnancy

Andrew:

Dr. Schatz, let’s talk about pregnancy. Help us understand for someone who is asthmatic whether pregnancy should be a traumatic event as they also are trying to control their chronic condition.

Dr. Schatz:

Well, everything that is involved in trying to understand and treat asthma in pregnancy is to try to prevent that, so it certainly shouldn’t be, and doesn’t have to be, for almost anybody. But the point you make, is that when you’re dealing with pregnancy plus something else, it adds some additional issues.And certainly for a patient with asthma, among those important additional issues, is making sure that the asthma’s well controlled. Again, there are a lot of aspects of this, but I think probably the first thing to realize is that the pregnant woman is not only eating for two but also is breathing for two.

The baby’s totally dependent on the mother for oxygen, and therefore, the control of the mother’s asthma is essential for the baby to get enough oxygen.

Andrew:

When you talk about control, you often talk about medications. There are some medications that are not appropriate to use in pregnancy. How do you control and yet preserve the health of the baby in other ways?

Dr. Schatz:

Right, and there’s sort of three answers to that, I think, and the first comes back to the issue that the control of the asthma is still the most important priority. And so the answer to how you control it is, ideally, whatever it takes.The second piece of that answer is that you certainly would like to look at things that would help control the asthma and not involve medicines, and one of those is making sure that allergy and asthma triggers are being avoided. There’s certainly no more important time than pregnancy to really go through the triggers and see what can be avoided. Certainly cigarette smoking has just got to be discontinued during pregnancy as it not only can trigger asthma, but also is not good for the growing baby.

Mothers will often do some things around the house and eliminate pets, perhaps even temporarily, if they are triggering asthma so as to have less asthma and need less medicine.

So, avoidance of triggers is one way to solve both issues, that is, avoid medicines and control asthma. Allergy shots, if they are working and if the patient is already on them, is another way to hopefully control things without needing medicines.

But then the third piece of that is that in spite of doing all that, patients often still need medicines, and then the key is to choose the most appropriate medicines.

And, again, one important general principle is control the asthma, the other general principle is that when you use medications, you basically are saying that the risk of using this medicine is less than the risk of the uncontrolled asthma that would result if it wasn’t used.

Q: How do we stand today? Do you have in your armamentarium, if you will, medications that you can use during pregnancy to control asthma that you feel comfortable with?

Dr. Schatz:

Yes. Fortunately, I think, really, it’s a relief for everybody that although we certainly don’t have as much information as we would like or as could be, and we’ll talk about perhaps how to get more than that, based on the information that is available, there are a number of medicines – very effective medicines, some even relatively new medicines – that appear to have less or minimal risk. Therefore, their benefit would outweigh the risks, and they should provide the type of control that’s necessary.Another important issue that people need to understand is that when you talk about safety of a medicine, probably in general, but certainly during pregnancy, you can’t talk in terms of absolute safety. Because you really can’t do the type of studies to prove that. And an example that I think helps people understand, is that if you were doing a study to prove a medicine’s safe during pregnancy, the way you would do it is you would take thousands of pregnant women, ideally with no underlying illness. Half of them ideally would get the medicines. Again, the reason that you’d ideally not have them have an underlying illness is you want to make sure that the illness itself doesn’t cause a problem. So, half of them would get the medication, which by definition they wouldn’t need, half of them wouldn’t, and then you’d compare outcomes. That would be a way to prove that a medicine is safe during pregnancy, but it would never happen. I mean, no IRB today or patient would feel that that’s ethical.

But in the absence of that, you can’t prove a medicine’s safe, and you have to look at less stringent information. And so you talk about suggestions of safety, or information that would support the use without being able to say absolute. And with that in mind, there are medicines that have that sort of supported data that again, it’s a push for trying to get more information, and we’ll talk about that.