Asthma and Emphysema: What is the Best Treatment If I Have Glaucoma??

Asthma and Emphysema: Concerns of Treatment with Glaucoma 

Dear Dr. Mahler: What is a good medication to treat someone with ASTHMA/Centrilobular Emphysema who also has closed angle glaucoma? Darlene from Tulsa, OK Dear Darlene: Both asthma and emphysema (a type of COPD) are diseases of the lung. In asthma, the primary problem is inflammation and narrowing in the breathing tubes (airways), while in emphysema the primary problem is damage/destruction of the air sacs (alveoli). In someone who had both asthma and COPD, the condition is called asthma-COPD overlap. The figure shown below illustrates the overlap between asthma and COPD (chronic bronchitis and emphysema).
Diagram shows overlap between asthma and emphysema

Diagram shows overlap between asthma and COPD (chronic bronchitis and emphysema)

It is estimated that about 25% of those with COPD have features of asthma. In general, those with both features of asthma and COPD have worse symptoms (cough and/of shortness of breath), poorer quality of life, and an increased risk of flare-ups (exacerbations) compared to those with COPD alone. Treatment for Both Asthma and Emphysema First, it is important that you not smoke and avoid all irritants in the air, such as dust, fumes, particles, smog, etc. Inhalers are used to treat the inflammation of asthma and bronchodilators to open the breathing tubes for both asthma and emphysema. Use of one or more inhaled medications depends to a great extent on how severe are your symptoms and whether you have had frequent flare-ups. Typically, “triple therapy” is used that includes an inhaled corticosteroid and both types of long-acting bronchodilators – beta-agonists and muscarinic antagonists. Types of Glaucoma You mentioned that you have “closed angle glaucoma.” As you know, glaucoma is an increase in pressure in the eye. There are two major types of glaucoma – open angle and closed or narrow angle.
In a healthy eye, excess fluid leaves the eye through the drainage angle, keeping pressure stable.

In a healthy eye, excess fluid leaves the eye through the drainage angle, keeping pressure stable.

Open angle is the most common (90%) type and typically occurs after age 50. Closed angle is usually hereditary and affects those who are far-sighted (trouble seeing near). The prescribing information for the muscarinic antagonist bronchodilators (brand names are Atrovent, Combivent, Incruse, Seebri, Spiriva, and Turdoza) states that these medications “should be used with caution in patients with narrow angle glaucoma.” A safe approach is for you to use a combination of a beta-agonist and inhaled corticosteroid. There are different combination inhalers  (brand names are Advair, Breo, Dulera, and Symbicort) approved for treatment of asthma and/or COPD Darlene – If these medications do not control your breathing symptoms, then you should ask you eye doctor (ophthamologist) whether a muscarinic antagonist can be tried safely. Sincerely, Donald A. Mahler, M.D.  

Donald A. Mahler, M.D. is Emeritus Professor of Medicine at Geisel School of Medicine at Dartmouth in Hanover, New Hampshire. He works as a pulmonary physician at Valley Regional Hospital in Claremont, NH, where he is Director of Respiratory Services.