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Health Matters: Why decrease dosage for asthma inhaler?

Q. My school-aged son has episodic attacks of asthma and is on a daily inhaler. In the past, when he had the first suggestion of an increase in wheezing, his doctor put him on markedly increased dosages of the inhaler—but no longer does so. Why?

A. Asthma, manifested by wheezing or trouble expelling air from the lungs, is a common problem, affecting children and adults alike. Fortunately, a certain percentage of children seem to outgrow their asthma, with spells becoming less severe or even disappearing as the children mature. One of the hallmarks of effective treatment of this chronic disease is the daily use of an inhaler that sprays a medicine (called a corticosteroid) on the inside of the lungs. It had become common for practitioners to increase the dose of the inhaled medication—sometimes by four or five fold!—at the first indication of any worsening of the asthma, in the hope of preventing a mild exacerbation from becoming a severe one. But two recent studies have suggested that this approach—of increasing the dose of inhaled corticosteroids—is not very effective. The first study found no benefit in pre-teenage children like your son, and the second found only a minor beneficial effect in teenagers (16 years and older) and adults—namely, only one patient demonstrated some improvement in wheezing out of every 15 patients treated with large doses of inhaled corticosteroids. So your doctor is up-to-date and spot-on—treatment for early exacerbations of asthma don't respond especially favorably to a large increase in dosing of inhaled corticosteroids.

Q. I'm confused as to whether men should undergo screening for prostate cancer with the PSA blood test. Can you provide any clarity?

A. The utility of screening for prostate cancer using the prostate-specific antigen (PSA) blood test is indeed one of the more controversial areas in medicine. Although first thought to be a very useful tool to identify patients with early prostate cancers more amenable to early treatment and thus better long-term outcomes, we've come to learn that the test's role and utility are much more nuanced and unclear. The crux of the problem is the paradox that most prostate cancers are indolent, slow-growing, and unlikely to cause major disability and death, and yet some are very aggressive and quite nasty. It was hoped that the PSA blood test would definitely distinguish between the two, but it doesn't. So many men who are treated for the indolent type of prostate cancer suffer the side effects of treatment (including impotence), but are unlikely to have a mortality benefit—even without treatment, they are more likely to die with their prostate cancer than from it. And earlier detection of prostate cancer in younger men doesn't seem to help either. A recent study of men in their fifties and sixties showed no benefit of a single PSA determination. So I don't have a really satisfying answer to your question. Whether to have PSA screening really is something that you need to discuss with your doctor. But the bottom line for many men, after they've had that conversation, is to forego PSA screening.

Wynne is vice president for health affairs at UND, dean of the university's School of Medicine and Health Sciences, and a professor of medicine. He is a cardiologist by training.

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