ALLERGY, ASTHMA, COPD and ILD

ALLERGY,  ASTHMA,  COPD and ILD

This writing contains a little information on this disease complex.  Please do not rush to me for treatment, as I don't know much about these things.      --    Dr. T. Rama Prasad      

                                           "Goodbye to Asthma."   "A breakthrough in the Treatment of Asthma & COPD";  "FIRST NEW treatment in five decades";  "A new medicine for Asthma after 50 years.";  "A GAME-CHANGER for Asthma & COPD."   

These are the headlines in the media in November 2024.  One such news report is reprinted below.

What's all this excitement about ? A recent publication about the ABRA study in 'The Lancet Respiratory Medicine'  journal concluded that BENRALIZUMAB, a new BIOLOGIC medicine, is significantly more effective and safe than the usual therapy of the past five decades with steroids and their side effects.  Naturally, the news caused excitement across the world.   But the price depressed most of the Indian patients -- available abroad for around Rs. 1.48 lakh for one injection which is to be repeated periodically.  It is expected to be introduced in the Indian market in 2025.  FASENRA, 30 mg per ml, is manufactured by AstraZenica.

        "There are two main categories of severe asthma—Type-2 inflammation and Non-Type-2 inflammation. These categories are based on a person's response to treatment. Type-2 inflammation includes allergic asthma and eosinophilic asthma (or e-asthma) and Non-Type-2 inflammation includes non-eosinophilic asthma." 

"Sputum EPX (Eosinophil Peroxidase) is a better biomarker of the endotype  'Eosinophilic Asthma' of airway inflammation than blood and sputum eosinophil counts and Serum EPX.   The new biologic medicine Benralizumab (monoclonal antibody, & IL-5 inhibitor with anti-eosinophilic activity) may be very effective without serious side effects as an add-on maintenance treatment of 6 years or older patients with severe asthma and an eosinophilic phenotype (30 mg sc q4 weeks first 3 doses followed by q8 weeks).  https://www.sciencedirect.com/topics/immunology-and-microbiology/benralizumab .  Benralizumab works by: "Depleting the number of eosinophils. Blocking IL-5 from binding to eosinophils, which prevents IL-5 from helping eosinophils to multiply and survive. Enhancing the ability of natural killer (NK) cells to kill eosinophils."   

INDICATIONS for Benralizumab

• the add-on maintenance treatment of patients with severe asthma aged 6 years and older and with an eosinophilic phenotype.  It is not indicated for the relief of acute bronchospasm or status asthmaticus
• the treatment of adult patients with eosinophilic granulomatosis with polyangiitis (EGPA)

Despite the advancements, ACUTE SEVERE ASTHMA remains challenging even to seniors in the field.  Here are a few links opining on the management:  https://ginasthma.org/wp-content/uploads/2019/04/GINA-Severe-asthma-Pocket-Guide-v2.0-wms-1.pdf  ASTHMA

https://www.indianpediatrics.net/aug1998/aug-745-762.htm ASTHMA

https://www.medscape.com/register?client=205502&scode=msp&action=complete&lang=en&register=true&form=about&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMjk2MzAxLWd1aWRlbGluZXM_cmVnPTE  ASTHMA

https://handbook.ggcmedicines.org.uk/guidelines/respiratory-system/management-of-acute-severe-asthma-in-adults-in-hospital/  ASTHMA

    

The word ASTHMA conjures up the image of a steam engine – huffing and puffing, much like an asthmatic patient.   While the steam engine went down into the sunset,  asthma is climbing up like a rising sun in tandem with bad lifestyle and environmental degradation.   

Globally,  ‘Chronic Respiratory Diseases’ are among the leading causes of morbidity and mortality, with ‘Asthma’ (bronchial asthma), 'Allergy' and ‘Chronic Obstructive Pulmonary Disease (COPD) being the most common, killing nearly four million people worldwide each year.  But, surprisingly, treatment for these chronic conditions has not changed much in the past fifty years !  There is currently no CURE for asthma or COPD, but treatment can help one to live a fairly normal active life.   Perhaps, the recent introduction of a new antibody drug known chemically as  BENRALIZUMAB may prove to be a 'game-changer' as said by the researchers at 'King's College London'. 

Asthma has a case burden of about 358 million across the world.  Paradoxically,  allergy and asthma are found to be more in the West whose environment is cleaner.  Data on the burden of asthma in India has been plagued by inconsistent recording as is the case with other diseases.  According to an estimate, the burden of asthma cases in India is about 20 million,  with a whopping 487 billion rupees (INR) being spent on treatment per year.  Even benralizumab which costs around Rs 2 lakh per year may not CURE asthma.

CONFUSING  COUSINS     Asthma, allergy, COPD, chronic bronchitis, occupational lung diseases, interstitial lung diseases, etc. are related and overlapping disease entities which cause a lot of confusion in the minds of the people and doctors as well due to some common symptoms and clinical signs.   The definitions are varied and the diagnostic tools give different verdicts in many cases.  Generally, environmental pollution is a common factor in the causation while specific factors like heredity, individual constitution and climate may also play a role.   

            Interestingly an  addition to the diseases related to electronic screens is bronchial asthma. A young child who watches TV for more than two hours a day is twice as likely to develop asthma as the one watching for less than two hours (Thorax, Vol.19, No.3, 2009).

            The‘World Asthma Day’is conducted on the first Tuesday of May to promote awareness and prevention of asthma.  

ILLUSIVE  CURE     

Patients often ask me as to when they would be free from asthma.  I refrain from saying that they would when the country is free of pollution and the people live in good lifestyle … lest they would be depressed !    Asthma is arguably the most miserable morbidity outdoing other lung diseases – catching up, in some cases, during childhood and following up to the graveyard. 

            Very extensive and voluminous research was done, and a plethora of medicines are available today,  but with  my experience of half-a-century in this field,  I may say that we didn’t make much headway to find a permanent solution.  Many new and better medicines are introduced but they also have to be taken for indefinite periods.  Mostly, once the patients stop medication, the symptoms come back.     The same is the case with allergy.  Some go for extensive and expensive tests to know the allergen or allergens to which they are specifically allergic to, and to get 'desensitisation' therapy.  This also may not mostly work out in practice.  Hence the patients switch from one doctor to another hoping for a cure.  The patients are tired of taking more or less the same medicines over indefinite periods of time.   And the doctors too do not find it satisfying to prescribe more or less the same medicines.   However, the faces of pharmaceutical industry may be lit up with impish glee as a whopping amount of 487 billion rupees is being spent by asthmatics in India !   No doubt, the industry is spending colossal amounts on developing new drugs to tackle asthma and allergy,  and has already put various new products in the market to mitigate the suffering.  Programmed by the manufacturers,  the products look scientifically authentic and very promising  in the glitter of the glitzy conference halls.

            Like in any other ailment where there is no definite cure,  a plethora of medicines are inducted into the market,  and tall claims are made,  also by alternative native systems of medicine.

PREVENTIVE  MEDICINE

           It is important that ‘preventive’ medicines are to be taken even when there are no symptoms so that the disease would not progress and become permanent.   In this context, ‘inhaler’ medicines are very valuable. But in my experience of over 50 years, I found that people are very reluctant and against the use of inhalers due to the misconception that they are “very powerful” and that once they start using them they have to be used forever.  And many educated ones fear about the ‘steroids’ in them.   In fact, inhalers have less side-effects than tablets as they contain very small quantities of drugs and as the drugs in them do not get into the blood and reach other organs in the body in any significant quantity.  As they go directly to the lungs where they are required to act, the dose is small and they don’t affect other organs much.   As long back as 2001,  I wrote the following in THE NEW INDIAN EXPRESS:

            And sadly,  most of the patients in India don’t know how to use inhalers properly.   It means that they are not only wasting medicines but allowing the disease to progress to irreversible dimensions.   In these days of frenetic pace of life,  many do not seem to have the time to train the patients patiently to use inhalers properly.

                   A recent (2019) publication in the 'British Medical Journal (BMJ)' noted that 'Metered Dose Inhalers (MDI)' contain the propellent gas 'Hydrofluoroalkane (HFA)' which is a potent 'Greenhouse gas',  and that this gas is not present in the alternative inhaler called 'Dry Powder Inhaler (DPI)'.  This raised the question as to whether DPI is to be preferred.  Excessive 'Greenhouse gases' lead to 'Global warming' and its deleterious effects on environment. But the amount released by inhalers is insignificant (0.1%).  Unhesitatingly, one may use whatever inhaler is prescribed by the doctor.

Doctors, especially in India, have their own perceptions about 'preventtive' medicines in Allergy and Asthma.  One drug which is widely prescribed is MONTELUKAST.  Read below its story :

MONTELUKAST

Vega, a medical student, posed a poignant question: “Sir, MONTELUKAST is very commonly prescribed in India for patients with allergy with or without asthma, along with other medicines, whereas in countries like the USA, the UK and Australia it is discretely used.  Why ?”         Yes, caution is exercised in various countries (due to warnings and regulations) while, in India, this drug is largely used routinely and irrationally with little warning and regulation.  It is very common to see Montelukast in the prescriptions given for Allergy / Asthma.  The sale of the drug in India increased exponentially --  the annual sales of Montelukast (April 2023–2024) reached over Rs. 2400 crore !

After the publication of various neuropsychiatric side effects, including the suicide of a 14-year-old British teenager Harry Miller in 2018,  some countries issued regulatory warnings.  Harry Miller died by suicide after struggling to cope with mental health issues for two years.  Miller, who had been suffering from asthma, had been prescribed Montelukast on an ongoing basis for two years. In March 2020, the US FDA affixed a black box warning (its strongest type) for Montelukast due to serious mental health side effects. These include agitation, depression, sleep disturbances, hallucinations, anxiety, behavioural changes, and, in some cases, suicidal thoughts, actions, or suicides. The FDA noted that reports continued even after earlier warnings (from 2008/2009), and many healthcare providers/patients were unaware of the risks. They advised restricting use for allergic rhinitis / hay fever to cases where other treatments fail or aren't tolerated, and to weigh benefits vs. risks for asthma, while monitoring patients closely.

Montelukast was developed by Merck and Co in 1990, and was approved by the FDA of USA in 1998.  The oral medication was approved to be prescribed daily for long-term use as a “preventer” or “controller” of asthma and allergic rhinitis. There is universal consensus, based on multiple comparative studies, that as a treatment for asthma, the drug is inferior to inhaled corticosteroids, which are considered as the first-line therapy for the control of the disease. For allergic rhinitis, most guidelines across the world recommend intranasal corticosteroids and/or antihistamines; montelukast is not recommended as the first-line therapy.  Of course, the steroids have their own side effects.  That’s a different story.

The concerns about the neuropsychiatric side effects of Montelukast, including rare cases leading to suicidal thoughts or actions, are valid and well-documented in medical literature and recognised by various international medical regulatory bodies. The side effects include agitation, depression, sleep disturbances, hallucinations, anxiety, behavioural changes, and—in some cases—suicidal thoughts, actions, or suicides. The FDA noted that reports continued even after earlier warnings (from 2008/2009), and that many healthcare providers/patients were unaware of the risks. They advised restricting use for allergic rhinitis / hay fever to cases where other treatments fail or aren't tolerated, and to weigh benefits vs. risks for asthma, while monitoring patients closely.

Alerts similar to that of the FDA exist from other regulators:

• The UK's MHRA (and later updates) reminds prescribers to watch for neuropsychiatric reactions and consider stopping if they occur.
• Australia's TGA (as recently as 2025) strengthened warnings, noting reports of suicidality (including rare fatalities) across age groups.
• Events are generally rare (e.g., suicidal behaviour very rare, <1 in 10,000 in some estimates), but can be serious and persist if not addressed promptly.

Regarding causality and validity:

• Post-marketing reports (including completed suicides) have been linked temporally to Montelukast use, often with preceding neuropsychiatric symptoms.
• Some large observational studies and systematic reviews find no strong association with suicide/depression overall in asthma patients, though risks may be higher for anxiety, insomnia, or in certain subgroups (e.g., older adults or children in some analyses).
• Recent meta-analyses suggest a modest increased risk for anxiety but not consistently for depression or suicidal behaviours.
• A 2025 study in children/adolescents found no increased risk for neuropsychiatric events.
• Overall, the evidence supports the warnings as precautionary and evidence-based, not that the drug always causes these effects, but that they can occur (sometimes reversibly upon discontinuation), and alternatives should be considered when possible, especially for mild cases.

In India, Montelukast remains widely overused and overprescribed.  Some Indian specialists   have echoed the global concerns, advising caution or avoiding it in mild cases due to these potential neuro side effects.   The core concern is legitimate: Montelukast carries recognized neuropsychiatric risks (including rare suicidality), backed by regulatory actions worldwide. Doctors should discuss these with patients/caregivers, monitor for mood/behaviour changes, and consider alternatives (e.g., inhaled corticosteroids for asthma and intranasal corticosteroids for nasal allergy) if risks outweigh benefits. 

                             Dr. T. Rama Prasad,  Perundurai,  India

 If you have the time to waste,  click on :  

https://drtramaprasad.blogspot.com/2023/01/montelukast-neuropsychiatric-symptoms.html  

https://drtramaprasad.blogspot.com/2017/04/asthma-allergy-copd_29.html

 

CAUSATIVE  FACTORS

While in many cases there is an overlap of asthma and COPD, there are ‘pure’ cases of COPD where it is a progressive disease despite treatment. Many of them end up in ‘chronic respiratory failure’ necessitating indefinite oxygen supply through ‘home oxygen machines’.  The causes for COPD are mostly chronic smoking and air pollution which are also associated with lung cancer. 

PREVENTION

The morbidity, mortality and the economic burden of asthma and COPD can be decreased by providing access to preventive care, early treatment and use of primary health care instead of running to emergency departments at a late stage.   More focus is to be put on adherence to treatment by the patient, and adherence to rational guidelines of treatment by doctors (https://www.ncbi.nlm.nih.gov/pubmed/25948888?dopt=Abstract).   Generic barriers to better health such as environmental pollution, smoking, recklessness to health issues, poor infrastructure, poor nutrition, illiteracy, unawareness to public health, etc. are to be addressed.

INTERSTITIAL  LUNG  DISEASE  (ILD)

 

Interstitial lung disease (ILD) is an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe and get oxygen to the bloodstream. Lung damage from ILDs is often irreversible and gets worse over time.  Many people with ILD have trouble in breathing and a cough that does not go away. In more severe cases, complications can be life-threatening and include high blood pressure in the lungs, right heart failure, and respiratory failure (the lungs do not deliver enough oxygen to the body).  The condition, which is part of a group of disorders known collectively as interstitial lung disease, causes inflammation and scarring of the lung tissue.  The average survival for people with this type is currently 3 to 5 years . It can be longer with certain medications and depending on its course. People with other types of interstitial lung disease, like sarcoidosis, can live much longer.

 

 Even so, in some cases, the causes are never found. Disorders without a known cause are grouped together under the label of idiopathic interstitial pneumonias, the most common and deadly of which is idiopathic pulmonary fibrosis (IPF).  While there are not formal categories of IPF, doctors and patients sometimes think of IPF in four different stages depending on symptoms and treatment needs. IPF can be a scary diagnosis, but it's not a death sentence. IPF progresses differently for everyone. Some live with the disease for many years.

Unfortunately, this is a disease which goes on increasing inspite of medical treatment which may slow down the speed of progress of the pathology.  The ultimate weapon is LUNG TRANSPLANTATION. Fibrotic interstitial lung disease (ILD) refers to a group of lung disorders characterized by progressive scarring (fibrosis) of the lung tissue, leading to impaired lung function. The interstitium, the tissue surrounding the lung’s air sacs, becomes thickened and stiff, reducing the lungs’ ability to expand and transfer oxygen effectively. Common types include idiopathic pulmonary fibrosis (IPF), the most severe form, and other conditions like connective tissue disease-associated ILD or hypersensitivity pneumonitis.

Symptoms typically include shortness of breath, especially during exertion, a persistent dry cough, fatigue, and sometimes weight loss. The disease often progresses gradually, though the rate varies. Causes can include environmental exposures (e.g., asbestos, silica), autoimmune diseases, or genetic factors, but in many cases, like IPF, the cause is unknown.

Diagnosis involves high-resolution CT scans, pulmonary function tests, and sometimes lung biopsies. Treatment focuses on slowing progression and managing symptoms, as there is no cure. Antifibrotic drugs like pirfenidone and nintedanib may help in IPF, while corticosteroids or immunosuppressants are used for other forms. Oxygen therapy and pulmonary rehabilitation can improve quality of life. In severe cases, lung transplantation may be considered. Early diagnosis and management are critical to preserving lung function.  Nintena  Soft Gelatin Capsule is primarily used to treat idiopathic pulmonary fibrosis (IPF) in adults. IPF is an irreversible disease marked by a progressive decline in lung function. The tissues in the lungs become swollen and scarred over time, which makes it difficult to breathe deeply.

Nintena  Soft Gelatin Capsule contains nintedanib, which helps reduce the scarring and swelling in the lungs by decreasing the release of naturally occurring growth factors in the body, allowing one to breathe better.

In some cases, one may experience common side effects to NINTEDANIB such as nausea, tiredness, diarrhoea, indigestion, loss of appetite, headache, and photosensitivity. Most of these side effects do not require medical attention and will resolve gradually over time. There are many diseases which cannot be CURED by modern medicine.  This is one among them.

Interstitial Lung Disease (ILD) - American Lung Association

https://www.lung.org › lung-health-diseases › interstitial-l...

https://www.lung.org › lung-health-diseases › interstitial-l...

New drug significantly slows progression of fatal lung disease

https://www.uhs.nhs.uk › Newsandpublications › Latestnews

https://www.uhs.nhs.uk › Newsandpublications › Latestnews

Interstitial Lung Disease: Symptoms, Causes, Tests

https://my.clevelandclinic.org › health › diseases › 178...

https://my.clevelandclinic.org › health › diseases › 178...

Interstitial lung disease - Symptoms and causes - Mayo Clinic

https://www.mayoclinic.org › syc-20353108

https://www.mayoclinic.org › syc-20353108

Interstitial Lung Disease: Life Expectancy, Treatment, and Types

https://www.healthline.com › health › interstitial-lung-dise...

https://www.healthline.com › health › interstitial-lung-dise...

 

Dr. T. Rama Prasad, 

'PAY WHAT YOU CAN’ Clinic, Perundurai, Erode Dt., TN, India.

Former Medical Superintendent (Special), RTS & IRT Perundurai Medical College and Research Centre, Perundurai.

*  Website: www.rama-scribbles.com  *  Blog: https://drtramaprasad.blogspot.com  *  Twitter: @DrRamaprasadt       *..Facebook: T Rama Prasad  * E-mail: drtramaprasad@gmail.com  * WhatsApp: +91 98427 20393.

The following is a list of some of my 'scribblings'.   To open them, click on any of the titles.  --  T. Rama Prasad

 

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