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Friday, July 28, 2017

Fading glory: Indian pharma industry in uncharted terrain

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Mumbai: At the turn of the millennium when the rich world was fighting the Y2K bug, India’s drug makers were busy plotting a raid.

In a market that began opening up just a decade earlier, they had learnt to make cheap copies of patented drugs. Local laws permitted such copying if it used a production method different from the patented process. These companies had also gained expertise making ingredients for multi-national drug makers.

Finally, it was time to step out. Among the first Vikings were Ranbaxy Laboratories Ltd, Dr. Reddy’s Laboratories Ltd and Cipla Ltd.

In 2001, Hyderabad-based Dr. Reddy’s hit the jackpot in US when one of its drugs—a generic version of anti-depression drug Prozac—secured exclusive marketing rights for a limited period. The outsize profits from that one launch attracted many more drug makers to the US.

Meanwhile, Yusuf Khwaja Hamied, the scientist-chairman of Mumbai-based Cipla Ltd, started offering medication for AIDS-ravaged Africa at cut-rate prices, while the drug giants sold the same drugs at over 30 times more. For millions of patients in Africa, Hamied was god. For Big Pharma, he was captain of the pirate ship.

Suddenly, the world was the playground for India’s drug makers who had stayed home until the economic liberalization of 1991 set them free. The US would quickly become the largest market for India’s large generic drug companies.

The dream run would continue for many years. Until the engines started stalling.

Then, and now

Fast forward to 2017, and it’s not a pretty sight. Even after surviving tough scrutiny to sell drugs in the US, their profits there are no longer what they used to be. Revenue and margins have been squeezed. Alarmed by news of inspections, warnings and import alerts, investors have fled the sector.

For the first time, India’s largest drug maker, Sun Pharmaceutical Industries Ltd, on 26 May said it expects a single-digit revenue decline this fiscal, shocking investors. According to an official at a Mumbai-based pharma firm, who spoke on condition of anonymity, generic oral solid drugs, which fetched 40-60% margins till about five years ago, now earn only 20-25%. For the sector, the near-term outlook is bleak.

Pharmaceutical exports to the US jumped from $0.3 billion in 2005 to $5.9 billion in 2015, according to a February report of industry lobby Indian Pharmaceutical Alliance (IPA), which cited data from the US Department of Commerce and the US Bureau of Census. However, with the generic growth tapering off, the industry is compelled to tweak its business model.

What spelled the end of the dream run for Indian pharma? Two reasons, mainly: One, prices have fallen with rising competition and distributors buying jointly in the US; two, quality issues.

The US generic drugs market expanded at a compounded annual growth rate (CAGR) of 15% in 2010-15, but is expected to slow down to 5% CAGR in 2016-20 due to the lower value of patented drugs expiring during this period, broking firm Edelweiss Securities had said in its November 2015 report.

Brokerage firm Credit Suisse said in a May report that annual price erosion in generic drugs in the US is likely to increase to 10-12% from 7-8% currently. This is because product approvals are on the rise and consolidation has enhanced the bargaining power of pharmacy chains.

In 2012, big pharmacy chains such as Walgreens, CVS Health, Express Script and Rite-Aid bought 55% of generic drugs in US, while smaller firms bought the rest. Since then, the smaller ones have tagged on to the larger ones, resulting in four large consortia that account for nearly 90% of purchasing in 2016, the report said. Recently, Express Script started participating in the Walgreens consortium, meaning there are three giant consortia with tremendous bargaining power at the negotiating table.

As new companies enter US and existing ones seek to introduce more products, competition has increased, depressing prices and making it tough to maintain market share. While there is higher competition from more Indian companies in the US, Chinese firms are also increasing their presence.

“Historically, the Chinese cornered the API (active pharmaceutical ingredients) market, but they are getting stronger in formulations. India has had language and other skills advantage in terms of ANDA filings and regulatory process, but China is gradually importing talent and they are very good at squeezing costs,” Sameer Sah, associate partner at legal firm Khaitan and Co., said.

ANDA is short for abbreviated new drug applications filed with the US Food and Drug Administration (FDA) for a generic product approval. APIs are the essential ingredients in a drug, while formulations are the final products.

According to company officials and consultants, it’s critical for pharma companies to develop complex generics, specialty products, biosimilars and innovative products, which will drive future growth and offset pricing pressures in plain vanilla generics.

“Indian companies are still focused on a low-pricing approach. However, in a changing landscape where margins are low and pricing pressure is high, companies need to diversify their product range, adopt differential strategies and focus on evolving as innovators,” said Utkarsh Palnitkar, partner and head-infrastructure, government and healthcare, and life sciences-KPMG in India. It is also crucial to resolve compliance issues and raise overall quality.

That is easier said than done, especially while maintaining margins and profits.

Inflection point

“The Indian generic industry is at a critical inflection point. In the next five years, it will be imperative for the industry to transition to a specialty/innovation player or a strong biosimilar organization. However, this transition is not easy because we don’t have inherent skills of building an innovative/specialty business, which is a completely different ball game,” Glenn Saldanha, chairman and managing director of Glenmark Pharmaceuticals Ltd, said.

Ahmed Raza Khan/Mint
Yet, leading Indian drug makers such as Sun Pharma, Dr. Reddy’s Laboratories, Lupin Ltd, Cipla, Glenmark Pharmaceuticals, Cadila Healthcare Ltd, Aurobindo Pharma Ltd, and Biocon Ltd have made investments to create such products (see table for research and development spends).

“In the past 4-5 years, most leading companies are talking about specialty. It has gone from being nice-to-have to must-have. All of us, I would still say, have taken smaller bites in specialty. We need to get a lot more deep,” Nilesh Gupta, managing director of Lupin, said.

The discipline required to be a specialty company is much higher than a generic company. Plus, the specialty product offerings must have a clear clinical advantage; otherwise, doctors and insurance companies may not cover it.

Specialty drugs are high-value products used to treat complex, chronic conditions such as cancer, rheumatoid arthritis and multiple sclerosis. These products may have special handling and mode of administration.

Nearly half of the medical spend in the US currently goes towards specialty therapies. Moreover, new product launches in specialty therapies have been higher than in traditional therapies, due to substantial unmet needs, Fitch Ratings said in a November 2016 report.

“Specialty margins are significantly higher and much more stable than the generic side. Typically, brand margins are 90% plus, generic margins are 50% or thereabout. So, you can see what it means for the Ebitda (Earnings before interest, taxes, depreciation and amortization). There is no reason why 30% Ebitda cannot be maintained over a period of time,” Lupin’s Gupta said.

According to a July 2016 report by JM Financial Institutional Securities Ltd, Indian companies have been slow to make investments in the complex generics and specialty drugs space, and those that have will find the investments return-dilutive in the short-to-medium term, given the complexities and long gestation period for developing and bringing these products to the market.

The product development cost for a complex generic is around $5 million, compared with $1-2 million for a simpler final dosage form, Dr. Reddy’s said in its annual report for 2015-16. Development spends on an inhalation, complex injectable or a biosimilar product is much higher.

“Different companies are at different evolution stages but all are not going to get there. It is a very tricky battle,” Sujay Shetty, pharma leader India and Asia Pacific at PricewaterhouseCoopers Pvt. Ltd (PWC), said.

Biosimilars, a similar version of innovative biologic drugs, is also a big opportunity, but Indian firms are lagging here as well.

“In the branded space now, biologic constitutes nearly 50% of drugs by value. So, I believe the next wave of growth will come from biosimilars. Indian companies are nowhere in this area. None of their biosimilar ventures have actually taken off, but this is an area we cannot miss if India is to be relevant in future,” Sriram Shrinivasan, emerging markets leader for life sciences and global generics leader at EY, said.

As new companies enter the US and existing ones seek to introduce more products, competition has increased, depressing prices and making it tough to maintain market share. Photo: Hemant Mishra/Min
The global life sciences industry is gradually moving from chemical-based drugs to biologics.

The global sales contribution of biologics is expected to increase from 24% in 2015 to 27% in 2020, Palnitkar of KPMG said.

Some Indian companies are developing biopharmaceuticals such as vaccines, biosimilars, insulin and monoclonal antibodies. In the near term, the biosimilars play for most firms will be confined to emerging markets, including India. As of now, Biocon Ltd, along with partner Mylan Inc., is the only company that has succeeded in filing applications for biosimilars in the regulated markets of the US and Europe.

Biosimilars have huge potential in emerging markets and a lot of Indian companies are looking at it; but as far as regulated markets are concerned, it is going to be a game of deep pockets, Abhijeet Mukherjee, chief operating officer of Dr. Reddy’s, said. He added that investments for biosimilars are huge and, hence, Indian companies would pursue these opportunities through partnerships.

Innovator companies are expected to queer the pitch, Shetty of PWC said.

“Earlier, Big Pharma did not care if you were making generics. This has changed in recent years due to less products coming out of pipeline. Due to lower opportunities, they have come very hard on generics and in biosimlars, they are very serious; they won’t vacate the market. This means, the cost of launch and risk of launch will be tremendously high, say $50-100 million. Very few Indian generic companies can afford that,” he said.

For a generic drug maker, transforming to a specialty- and branded drug-focused company will take a minimum of three years. These years will be tough. Also, the key will be to raise quality standards to global levels as it will lead to a steady flow of revenue which can be used for innovation initiatives, consultants said.

Then there are the inspections.

Inspections

In 2009, the US FDA found severe lapses at the manufacturing units of erstwhile Ranbaxy (now merged with Sun Pharma). With India accounting for 40% of US generic drug filings, FDA decided to ensure the drugs from India are of top quality. Inspections rose from 108 in 2009 to 290 in 2015. India has the highest number of US FDA-approved plants outside the US, with the total at 572 currently, compared with 433 in 2013.

Indian drug makers currently facing FDA’s warning letters, observations or import alerts include Sun Pharma, Dr. Reddy’s, Lupin, Wockhardt Ltd, Ipca Laboratories Ltd and Divi’s Laboratories Ltd.

To be sure, the rise in inspections is also due to the 2012 Generic Drug User Fee Act (GDUFA) in the US, which sought to speed up generic approvals and eliminate disparity in inspections of US and foreign manufacturing facilities.

One-fifth of the FDA inspections happen in India and China currently, up from 11% in 2012, said Edelweiss Securities in a February report.

FDA has also made other changes. It has cut prior intimation time for plant inspections to as little as 24 hours from 25-30 days and inspection frequency has increased to once or even twice a year from once in two-to-three years earlier.

The regulatory overhang is likely to persist as over the next three years, US FDA will inspect the pending 190 Indian facilities, which it hasn’t audited in the past five years, Edelweiss Securities said.

“Most Indian companies are working on increasing the level of awareness and compliance to meet US FDA standards and, in the long-term, this will also become a sustainable competitive advantage,” Mukherjee of Dr. Reddy’s said.

US FDA’s norms on good manufacturing practices keep evolving and companies need to keep pace with the changes. A plant that had cleared an FDA audit earlier may be pulled up for some violation of norms in any subsequent inspection. The crucial part here is that companies should not get repeated quality lapses observations from FDA for the same plant as it indicates that remedial measures and investments in quality upgradation were inadequate.

Consultants advising companies on quality compliance say the management’s mindset should be to overhaul the entire system in order to ensure higher quality of products in the long run and not have short-term goals.

Enhancing efficiency

At a time when costs are rising due to higher investments in research and development (R&D) and quality compliance, bringing operational efficiency will be crucial to maintaining profitability.

Companies will try to improve the product mix with more reliance on niche products, reduce cost of production, and sell higher volumes, D.G. Shah, secretary general of IPA, said.

“We need to continue to look at cost structures and productivity to find ways of improving our performance on total delivered costs. Investing in products, segments and markets that offer relatively more price stability would be the other way (to improve operational efficiency),” a Sun Pharma spokesperson said in response to an email query.

Shrinivasan of EY said there is a lot of inefficiency in the sector. Capacity utilization and inventory management need to improve, which will help in enhancing competitive advantage of companies.

This downturn (in the pharma sector) gives us an opportunity to tighten up in a way we have never done in the past and improve operational efficiency
– Nilesh Gupta, managing director of Lupin
“Companies need to further bring down costs. During the good years, there are several areas where costs had increased; but because of strong growth and margins, companies could absorb it. For example, staff costs of companies have risen significantly over the years,” Rahul Guha, partner and director at The Boston Consulting Group (BCG), said.

“This downturn (in the pharma sector) gives us an opportunity to tighten up in a way we have never done in the past and improve operational efficiency,” Lupin’s Gupta said.

Pharma companies have come up with strategies to deal with the challenges and propel growth, but the key will be execution. Adoption of information technology tools will be necessary to bring operational efficiencies.

BCG’s Guha said while the US remains the biggest market, firms should evolve their model to profitably serve other regulated markets like Europe and Japan, as well as in emerging markets.

India’s pharma exports to Europe have been around $2 billion in the past five years, while exports to Japan have come down to $34 million in 2016 from $62 million in 2012, according to data from the International Trade Centre, a joint agency of the World Trade Organization and the United Nations.

As firms enter uncharted territory of specialty and innovative products, they will need to acquire capabilities they lack, which means mergers and acquisitions and collaborations will be routine, analysts said.

“Inorganic growth can help Indian pharma firms access new markets and enhance technological capabilities in developing new drugs. Collaborations in areas such as R&D, manufacturing and marketing, can also help enhance value by reducing cost and increasing efficiency,” KPMG’s Palnitkar said. PwC’s Shetty said given the current financial profiles of Indian generic drug makers, the deal size for acquisitions is unlikely to exceed $1 billion and that, too, limited to leading firms.

Until then, the pharma sector is likely to remain under pressure.

“Pharmaceutical companies can adapt to disruption through shifts in their business models and refocus on new fields of play. However, even these changes are unlikely to generate the kind of growth and revenue that shareholders demand,” Palnitkar said.

The market has got used to rapid growth but now investors will have to take a longer-term view because for the next two-to-three years, the ups and downs in the industry are expected to continue.

The pillbox built by the early entrepreneurs has cracked, and a new one is yet to be built. For Indian drug makers, the unbridled optimism at the turn of the century is gone. This is a time to adapt, regroup and reinvent.

News in Numbers: Sun Pharma founder Dilip Sanghvi’s net worth down to $11.2 billion

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What is it? The number of anti-riots police personnel sent to Mandsaur district in Madhya Pradesh on account of the ongoing farmers’ protest.

Why is it important? The protests by MP farmers—who are demanding loan waiver, higher minimum support price, among others—have spread to six other districts in the state. The protests have intensified following the killing of five protesters during firing on Tuesday.

Tell me more: As protests continue, MP chief minister Shivraj Singh Chouhan announced a Rs1,000 crore price stabilisation fund and that the state would buy tur, urad and moong from farmers starting 10 June. The central and state governments might have to do more than providing sops to pull the country out of the farm crisis.

$11.2 billion

What is it? The net worth of Sun Pharma founder Dilip Shanghvi.

Why is it important? It’s down from $21.5 billion in 2015, which made him India’s richest person. The drop of over 50% reflects the troubles faced by India’s generic drug industry, including intense scrutiny by US Food and Drug Administration, and pricing pressure in the market.

Tell me more: Sun Pharma Stock has fallen by nearly 30% in the last one year.

82.67%

What is it? The percentage of currency that has been remonetised, according to the Reserve Bank of India (RBI).

Why is it important? This partly explains why some parts of the country continues to face cash shortages. In November, the government demonetised nearly 87% of currency in circulation or an estimated Rs15.5 trillion in old Rs500 and Rs1,000 notes. The growth in digital transactions, which saw a spike during demonetisation, is back to earlier range.

Tell me more: The percentage of remonetised currency has doubled since January. By volume, 108% of currency is back in circulation, RBI said.

20

What is it? The estimated number of employees fired by Uber Technologies, the US-based cab-hailing app company.

Why is it important? The move comes after a company-wide investigation into 215 human resources claims of harassment. Uber has been plagued by questions about its company culture and accused of doing little to fix it.

Tell me more: In addition, head of Uber’s Asia Pacific business Eric Alexander has left the firm. According to Recode, Alexander had obtained the medical records a 26-year-old woman who was raped by an Uber driver in Delhi in December 2014, and shared it with Uber CEO because they suspected that she was not raped.

$239 million

What is it? The amount Marissa Mayer got for her five years of work as Yahoo chief executive officer, according to Equilar, a research firm.

Why is it important? Mayer oversaw the sale of the firm to Verizon for $4.5 billion, which is expected to complete next week, with Verizon shareholders are voting on the bid on Thursday. Mayer’s $900,000 a week paycheck has become a talking point even as 1,000 employees are reported to be facing pink slips after the merger.

Tell me more: Mayer took over the reins of Yahoo with much fanfare, and according to several observers, didn’t live up to the expectations (except those of the shareholders). Two big privacy breaches took place during her tenure.

Strides Shasun gets USFDA approval for Parkinson’s drug

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New Delhi: Strides Shasun on Thursday said it has received approval from the US health regulator, Food and Drug Administration (FDA), for Amantadine Hydrochloride, used for the treatment of Parkinson’s disease and select viral infections, in the American market.

“The product has received approval in 15 months under the USFDA’s new product clearance regime of GDUFA. The product will be launched immediately,” Strides Shasun said in a BSE filing.

Amantadine Hydrochloride is used for the treatment of Parkinson’s disease and Shingles (Herpes Zoster) to reduce pain. Quoting IMS data, Strides Shasun said the US market for Amantadine Hydrochloride is approximately $25 million with three generic players.

Shares of the company were trading 2.29% higher at Rs958 on BSE.

Cadila Healthcare overtakes Lupin as second most valuable pharma company in India

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Mumbai: Cadila Healthcare Ltd overtook Lupin Ltd to become India’s second most-valuable drugmaker on Wednesday as investors, cheered by US regulatory approval for a generic drug produced by the firm, drove its shares to a lifetime high.

Shares of the Ahmedabad-based company closed up 9.6% at Rs537.25, off the intraday high of Rs542.40, on a day the benchmark Sensex ended 0.3% higher at 31,271.28.

With a market capitalization of Rs55,000.57 crore, Cadila is now behind only Sun Pharmaceutical Industries Ltd, which remains the most valuable Indian drug firm with a market capital of Rs1.23 trillion. Lupin Ltd has slipped to the third spot with a market value of Rs52,128.57 crore.

Investors have been heartened by the US Food and Drug Administration (FDA) approving Cadila’s generic version of Lialda, a drug used in the treatment of chronic inflammatory bowel disease.

Cadila Healthcare is the only company whose generic version of Lialda has been approved so far by the regulator. The market size for brand Lialda was $1.145 billion in the year to April 2017, the company said in a statement on Monday, citing data from IMS Health. Brokerage firm IIFL Institutional Equities said in a report on 29 May that the generic version of Lialda can contribute $150 million to Cadila Healthcare’s revenue over FY18 and FY19.

At a time when the US business of several large Indian drug makers has slowed because of pricing pressure and compliance issues, Cadila Healthcare is likely to buck the trend, given FDA’s clearance for its Moraiya plant in Gujarat that will lead to higher product approvals, analysts said.

Shares of Cadila Healthcare have surged 51% so far in 2017, while those of Sun Pharma, Dr. Reddy’s Laboratories Ltd and Lupin Ltd have declined 19%, 17% and 22%, respectively.

Lialda generic is the second product to be approved in one week from the Moraiya plant, which was issued a warning letter by the US FDA in December 2015 due to violation of so-called good manufacturing practices. On 2 June, the company received approval from the US FDA for its generic levofloxacin injection, an antibiotic.

Edelweiss Securities Ltd said in a report on 2 June, “The US FDA has given the first product approval to Cadila’s Moraiya unit post its inspection in February…should lead to a flurry of approvals in the next one year. This is a significant development within all the gloom and doom in the industry with respect to FDA audits.” The plant was cleared by the regulator in February after a re-audit. Cadila is among the few Indian firms to have resolved compliance issues with the FDA; larger firms like Sun Pharma and Dr. Reddy’s continue to grapple with such issues.

In a post-earnings conference call with analysts on 27 May, Pankaj Patel, chairman and managing director of Cadila Healthcare, said the company expects to receive 40 product approvals in the US in the current financial year, of which 30 products would be manufactured at the Moraiya plant. The company’s business in the US, which accounts for almost 40% of revenue, suffered on account of regulatory issues at Moraiya. In 2016-17, its US sales were Rs3,710 crore, down 8% from a year ago. Total consolidated sales were flat at Rs9,630 crore.

Now, say analysts, such problems are behind the company. “Cadila is one of the few large pharma companies that is currently free from regulatory overhang and possess a lucrative product pipeline, which we believe will begin to fructify starting FY18,” Amey Chalke, analyst at HDFC Securities, said in a 29 May report.

Broking firm India Nivesh has named Cadila its most preferred pick in the pharmaceutical space, given the visibility on faster pace of approvals in the US market. The company has pipeline of around 200 products filed with the US FDA, which includes complex generics such as transdermals and injectables.

BY DR. CHAITALI LADDAD (FOUNDER & DIRECTOR, THEPEDIATRIC NETWORK)

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Asthma is a respiratory ailment where the airways are hypersensitive / hyperactive to a variety of factors known as triggers resulting in narrowing/spasm and swelling of airways which in turn manifests as wheezing,cough and breathlessness. A trigger is anything that can lead to an asthma attack. When your child is around something that triggers symptoms, keep track of it. This can help you find a pattern in what triggers symptoms. Maintaining a symptom diary /asthma diary would definitely help track.The common triggers are pollens, cigarette smoke, dust mites, pet dander,
cockroaches,viral infections.

A lot of taboo has been associated with asthma and there are quite a few myths and misconceptions in prevalence. Childhood is a period when respiratory ailments are at its peak and asthma is a fairly common ailment. When diagnosed and managed properly asthma does not affect the quality of life, however appropriate followup is essential.
It is however also overdiagnosed/mislabelled . All that wheezes is not asthma: A single episode of wheezing is not asthma. Wheezing particularly in younger children is most commonly associated with viral infections. Almost 30% of children younger than 3 years have atleast one episode of wheezing .Many children outgrow this problem by the time they are 6 years old. Hence the diagnosis is not made in younger children. Asthma is a chronic disease and is associated with recurrent episodes of wheezing or other symptoms. Asthma is not a contagious disease and cannot spread from contact . It does have a genetic predisposition, Children with 1 or more parents with asthma have a greater risk of having asthma. Many children develop asthma even though there is no
family history of the disease. There is nothing that you can do to prevent onset of
asthma.

One can however predict the risk of developing asthma in a child. There are higher chances of developing Asthma if he has 3 or more wheezing episodes per
year and has 1 or more of the following high risk factors –
#Skin allergy –eczema/atopic dermatitis
#Family history of asthma or allergies
#Allergic rhinitis
#Wheezing without associated colds.
Diagnosis is mainly based on a clinical history and examination in addition to response to medicines. however the doctor may prescribe certain tests to support the diagnosis or rule out an alternate diagnosis. CBC ,Xray Chest is generally done at the time of presentation/first episode. bedside Peak flowmetry is helpful in older children. Pulmonary function tests may be done in adolescent children.
It is not necessary to get an allergy test for every child with asthma. Many
paediatricians do not advice to go for allergy tests in children with asthma. There are
many possible allergens in our environment and it is not possible to test for all of
them reliably. Also false positive reactions may occur sometimes. It is not possible to
avoid some common allergens completely like dust, pollens, molds.

Asthma is spasm of airways and inflammation /swelling of the airway lining . Management of asthma is a culmination of avoidance of triggers , medicines: inhaled and oral medications, and Monitoring and followup with home treatment plans. Inhaled medicines act directly at the site of swelling and hence faster action. also lesser side effects as the medicines do not enter the blood.There are two types of medicines for management of asthma: the Relievers and the Controllers. Relievers are used for acute attacks and Controllers for long term suppression of reactivity . In moderate to severe cases controllers need to be used for a prolonged duration …3-6 months on an average.Another misconception is about steroids in asthma ,which belong to the controller category, parents are apprehensive that steroids are STRONG /HARMFUL/ADDICTIVE.
Please do not be scared of steroids used for asthma. These are inhaled steroids
and most kids are started with minimum dose and low potency steroids. Even for children on high dose or high potency steroids, the systemic side effects like hypertension, obesity, growth retardation are extremely rare.
There are other drugs available for asthma prevention but steroids are usually the
preferred drugs and are totally safe.
Serious side effects are rarely seen with inhaled steroids.Chances of local side effects like
thrush can be reduced by using spacers and gargling and rinsing mouth after each use.
It is important that your child is regularly reviewed by your paediatrician to ensure
that he/she are using the lowest dose needed to control asthma and to look for any
possible side effects.

Many children have mild asthma but for some people it can be a severe and lifethreatening
disease. Even people who usually have few symptoms can have severe
asthma attacks and they can start very suddenly. The good news is that asthma
symptoms and control can almost always be improved with the right treatment.
If your child indeed has asthma, then it will not go away. But if he/she is having
recurrent wheezing and is younger than 6 years of age, then you should definitely be
hopeful. Sixty percent of young kids with wheezing outgrow it by the time they are 6
yearsold.There is no permanent cure for asthma at present.

DIET and PLAY

Contrary to popular belief, there are no “cold”foods as such which aggravate cough.
i.e. milk/curd/rice/citrus fruits,etc . Hence no need to avoid them. Many food
colors, additives are known to trigger wheezing, hence try and find out if any specific food item triggers an attack of wheezing. A wholesome diet is essential for growth and development and there is no need for a generalised ban on milk, fruits, nuts etc.

There should be no restrictions on children’s ability to play, take gym class, orcompete in sports just because they have asthma.A well-controlled asthma doesn’t interfere in day to day activities.If your child has been instructed to take medicine before physical activity, however, make sure that she does so everytime even if the child seems fine.If your child has poorly or incompletely controlled asthma or children on long term steroid inhalers should take the influenza vaccine yearly. To conclude, tackling asthma is a team work with the parent and doctor working in tandem to help maintain a symptoms free and unrestricted lifestyle for the child and to achieve his potentia

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