Depression and anxiety are common among asthma patients. Stress can exacerbate wheezing and coughing and make you feel more anxious, which only ramps up asthma symptoms. Depending on the severity of asthma symptoms, it can have adverse effects on the quality of everyday life, leading to feelings of stress and low mood. Anxiety and depression are often associated with poor asthma control. These mental health symptoms can also be a side effect of medication. When your medications are mismatched to your DNA, they can cause more harm than help. A pharmacogenetic test can help to understand any genetic risks you have to certain drugs and to select asthma and depression treatment that minimizes side effects and provides optimal relief for your symptoms.

Medications for Asthma

There are several different types of medications typically prescribed for managing asthma. The most common include:

• inhaled corticosteroids to prevent and reduce airway swelling
• short-acting beta-agonists agonists a short-acting bronchodilator “rescue” medication for treating sudden asthma symptoms (taken in combinations with corticosteroids)
• leukotriene inhibitors, or LTRAs (montelukast, zafirlukast, zileuton), which are non-steroidal anti-inflammatory bronchoconstriction preventers

New FDA warnings on montelukast (Singulair)

Montelukast (Singulair) is used to treat asthma and seasonal allergy (perennial allergic rhinitis). Montelukast helps to reduce the frequency and severity of asthma attacks, which can be triggered by physical exercise and stress. Montelukast is taken orally and helps decrease the reliance on inhalers, but it doesn’t relieve acute asthma attacks.

Several studies linked the use of montelukast to psychological reactions, such as anxiety, aggression, depression, nightmares, headaches and suicidal thinking. Recently the US Food and Drug Administration (FDA) added “black box” warnings advising healthcare providers to avoid prescribing montelukast for patients with mild symptoms due to significantly increased risk of depression and suicide. For seasonal allergies, montelukast should be reserved only for patients who have not responded adequately to other therapies. If you take montelukast and are experiencing depression symptoms, it would be wise to talk with your doctor and consider alternative medication.

Unfortunately, there is no way to predict who might be at higher risk of mental health side effects on montelukast. Unlike most drugs, montelukast is not metabolized by liver enzymes. It is eliminated out of the bloodstream by kidneys. Variations in several genes, including UGT1A3, LTC4S, LTA4H, ALOX5, have been associated with the risk of montelukast side effects, but these genes still cannot be used to guide prescribing of this medication.

Please consult with your pharmacist or doctor on whether you should stop taking montelukast if you are experiencing depression while taking taking it.

Bronchodilators and your DNA

Salbutamol (also known as albuterol) and salmeterol are two drugs, which are the main component of multiple asthma medications: Aeromax, Arial, Astmerole, Fujimycin, Salmetedur, Serevent, Advair 100/125/250/500 Diskus (fluticasone + salmeterol). Indacaterol is an oral medication that acts as an ultra long-acting bronchodilator. Indacaterol is used by people with COPD (chronic obstructive pulmonary disease) and can also be used by people with severe asthma. Indacaterol is metabolized by the liver enzyme called UGT1A1. Individuals who have reduced activity of this liver enzyme are more likely to experience indacaterol side effects but may still be able to use inhalers.

Genetic variations in the ADRB2 gene, which encodes the drug target beta-adrenoceptor, have been associated with response to indacaterol, salbutamol (also known as albuterol) and salmeterol. People with specific variations in the ADRB2 gene may have lower bronchodilator response and may need additional drugs such as steroids to control asthma attacks. Pharmacogenetic tests such as Pillcheck can help to assess how your body responds to salbutamol, salmeterol and indacaterol and your risk of side effects.

NSAIDs

Although non-steroidal anti-inflammatory (NSAIDs) can help to improve mood and inflammation, NSAIDs, and aspirin can exacerbate asthma symptoms. The risk of aspirin-induced asthma is higher in people with reduced CYP2C9 liver enzyme, which is essential for clearing ibuprofen, celecoxib and other NSAIDs. If you suffer from asthma and depression, it is best to avoid long-term use of NSAIDs, particularly if you have inherently reduced CYP2C9 function. A pharmacogenetic test like Pillcheck can indicate whether you can safely use NSAIDs.

Antidepressants for asthma and depression

If you suffer from asthma and depression, the Pillcheck medication DNA test can also reveal how your body processes anxiety and depression medications. Antidepressants help manage anxiety and reduce the risk of stress-induced asthma attacks. Antidepressants can impact the immune system. For some conditions, antidepressants can help to reduce excessive inflammation and are used to manage Irritable Bowel symptoms. It is thought that antidepressants suppress the production of proinflammatory cytokines, which are also increased in asthma patients, thus can work synergistically in patients with asthma and depression.

Antidepressants are primarily metabolized by the CYP2D6 and CYP2C19 liver enzymes. Genetic variations in these drug-metabolizing genes determine your response to antidepressants and the risk of side effects. Pillcheck medication DNA test also includes CYP2D6 and CYP2C19 genes.

Based on your DNA and experience with asthma and depression medications, Pillcheck pharmacists can advise how to adjust your overall treatment.

Conclusion

• If you are experiencing asthma and depression symptoms, you should avoid taking montelukast.
• Pillcheck medication DNA test can help to provide insights on your response to asthma medications containing salbutamol or salmeterol.
• Antidepressants can reduce the incidence of anxiety-triggered asthma attacks and manage depression symptoms.
• Pillcheck assesses response to asthma and depression medications; an expert pharmacist can advise how to change your treatment to reduce the risk of side effects and improve tolerability.

References:

Zielinski TA et al., Depression in Asthma: Prevalence and Clinical Implications Prim Care Companion J Clin Psychiatry. 2000 Oct; 2(5): 153–158.

Krommydas G et al., Therapeutic Value of Antidepressants in Asthma Med Hypotheses. 2005; 64(5):938-40

Lechin F, van der Dijs B, Lechin AE. Treatment of bronchial asthma with Tianeptine. Methods Find Exp Clin Pharmacol. 2004; 26 :1-5

https://www.ajmc.com/view/fda-steps-up-warning-for-montelukast-for-risk-of-mental-health-side-effects