You just HAD to be different, didn’t you? :p:D
Long-time wheezer here! I was diagnosed at about age 3 (after what seems, in hindsight, to be a RIDICULOUSLY long time even for the early 60s).
I did allergy shots for many years as a child. At about age 12, I basically grew out of it, with symptoms rare-to-nonexistent except when I had a bad bad cold. As the meds back then weren’t great (they all had stuff like ephedrine in them) it was nice to not have to take them very often. IIRC, there were times of the year where I was on the stuff nearly constantly.
My asthma reared its head again back in 1986 when we got a cat. More precisely, when we got a second cat. Either that cat groomed himself a lot more, or it was just doubling the allergen load. Since then I’ve been on daily medications. After 2+ years of steadily-worsening asthma, cat #1 was put to sleep (he had a terminal illness), cat #2 was rehomed, and we moved… unfortunately, the asthma never went back into remission.
The meds are a LOT better these days. The gold standard for anything except very intermittent cases involves a steroid inhaler (with minimal-to-nonexistent systemic effects; most common seems to be Flovent / fluticasone) plus a “rescue inhaler” (bronchodilator - usually albuterol but called salbutamol elsewhere) for times when you get tight anyway.
There are several longer-acting bronchodilators (salmeterol and formoterol) which are used independently and/or in combination with an inhaled steroid. I won’t use those because there are stories of asthmatics experiencing sudden death due to severe bronchospasm when on them, and I gather they don’t really know why. Nor will I use the combinations such as Advair (fluticasone + salmeterol) because I do NOT like the fact that you can’t titrate the individual components. In addition, these are ways to wrest more money from patients in the long run : when the individual components are nearly out of patent, the combination gets them brand-name income often at MANY times the cost of the individual generic medications. I have had several direct experiences in that line in the past year (one combo cost me 70 bucks a month, the individual meds would have been 30; another one, which I didn’t fill, would have been 500 a month for 20 dollars of OTC antacids + about 10 cents worth of baking soda).
If your asthma remains mild enough, you might be like my son: he needs the steroid inhaler for a few days at a time every year or two, when he gets something really nasty (like 18 months ago when we think he had H1N1). If it’s a bit more in the mild-to-moderate range, you might need a daily dose of a steroid inhaler (my daughter requires 2 puffs a day of 110 mcg Flovent) plus, rarely, the rescue inhaler. If it’s a bit more severe than that, you might require a higher dose of the Flovent and more frequent rescue inhalers, and/or to try a longer-acting bronchodilator, and/or a bronchodilator with an anticholinergic such as ipatropium.
For more severe flares, you might need a brief course of oral steroids (I’m on the second such taper in a few weeks, as things rebounded after the first taper). Fortunately for me, this only seems to happen when I’ve got a nasty respiratory infection. Love those 'roids. And hate 'em. They mess with your stomach (less so now that I’m on Prilosec all the time). They sometimes make food taste funny. If you’re on a high enough dose you get brain fog. And of course longer-term use has some really nasty effects. But they’re cheap and so effective.
The biggest thing I can tell you or ANYONE is to get some books on asthma from the library and READ THEM. I was very poorly controlled back in '89 or so, wasn’t being monitored / educated / supervised enough by the doctor, didn’t know what I was doing… then one day at lunchtime I picked up a book by a Dr. Weinstein and oh. my. gawd. It was literally life-changing. The old phrase “knowledge is power” is sooooo true. My asthma never got that out of control again. I knew what to do at each step of a flareup. I never hesitated to call the doctor when needed.
Oh yeah: my medication regimen is:
AM: 300 milligrams of theophylline (chemically related to caffiene). 2 puffs of 220 mcg Flovent.
PM: 400 milligras of theophylline. 2 puffs of 220 mcg Flovent. One Singulair (mediates allergic response). One Zyrtec (antihistamine).
The theophylline is a bit of a dinosaur. It helps, but a lot of people find the side effects (stomach upset) more than they can tolerate, plus there’s a narrow therapeutic window between “too little to be effective” and “makes you sick”. But it happens to work fairly well for me; I suspect I would have to go on salmeterol or something if I didn’t have the Flovent.
During a flare, I do use a nebulizer. Those have gotten a lot less expensive over the years - our 13 year old monster (the size of my size-12 shoeboxes) was 200+ dollars but now could be had for 50. The more portable ones are more money. They work better than inhalers, but the medication is pricier (a 24 dose package just cost me as much as a 120-dose inhaler would have). And because you get a better dose, the side effects (jitteriness / racing pulse) are worse. I make the doctor give me Xopenex for the nebulizer - it’s like the left-handed version of albuteril (like Prilosec vs Nexium). Seems to have less of a cardiac effect, anyway.
Really? That’s what the doctor prescribed that seemed to work. She originally prescribed some other inhaler (I forget what kind because I don’t have it with me), and told me to take two puffs from the inhaler plus a Claritin tab prior to working out. When that wasn’t helping, she had me try Advair, and the first night I took it I breathed better than I had in months. So well, in fact, that I took a few moments to do nothing but sit on my bedroom floor taking deep breaths and reveling in the fact that I could once again take deep breaths. Although that seems awfully fast acting for it to work so well the very first time, so maybe the placebo effect had something to do with it. Either way, Advair seems to be working pretty well.
Well, remember: Advair is a long-acting bronchodilator plus a steroid, so it’s not surprising you’re breathing better with it :). I’m actually surprised it worked that fast, however. For what it’s worth, separate salmeterol and fluticasone inhalers should work exactly as well as the combination.
I admit, my refusal to use these is my own personal prejudice and I’m not saying I wouldn’t EVER use them - just saying that I have some not-unfounded concerns over the safety of the salmeterol. I’d feel better if they had explanations for why the deaths occurred. I do gather that salmeterol + steroid is safer than salmeterol with no steroid.
The combination meds, however, are NOT something I like both for economic and medical reasons. Medical: can’t adjust the individual components as needed. Economic: depending on your insurance, it might be cheaper to go combo, but with mine it’s often a LOT more since the combo meds aren’t in the lowest tier, while the individual ones are. The combo meds are easier compliance-wise.
I have a combo preventer inhaler and I’m in the UK, so I’m pretty sure my doctor’s not prescribing it to get more money out of me; actually, although I don’t have to pay for prescriptions right now, if I did, the combi would save me money. Every so often the brand name changes as the doctor negotiates a better deal with the suppliers.
The lack of control doesn’t bother me because if I need a long-acting beta 2 antagonist then it’s highly likely that I need a steroid inhaler too.
There is some research being done on this. I want to emphasize that this is preliminary only and needs to be confirmed, but apparently there is some evidence that for a certain percentage of the population salmeterol is ineffective for genetic reasons. Their body simply can’t make use of it. So… for most people salmeterol is helpful but for those folks it’s as if they’re taking nothing, and as well all know if you stop taking effective medication for asthma it gets worse. IF this is true it would account for why most people are helped but for a few the death rate goes up. Clearly, the ideal would be a simple test to spot those with the no-salmeterol gene and put them on some other medication, and the rest of us could keep the salmeterol option.
There is also the issue that some people might be using salmeterol as a “rescue inhaler” which is not appropriate and could lead to death during an attack that doesn’t receive proper treatment.
And finally, in some people, salmeterol apparently can increase irritation rather then reduce it. Again, there may be some genetic component to this, it may be due to overuse, or both.
So… bottom line if you use salmeterol use it ONLY as directed, keep your rescue inhaler nearby, and if it’s not helping you talk to your doctor.
Well, I was prompted to check with my insurer’s website and it turns out that (if I looked up the correct dosage equivalents), Advair (the combination) would be cheaper than the individuals (214 dollars for a 3 months supply of the separate inhalers, vs 160 for the same amount of Advair).
Here in the US, though, once the individual meds go generic… the combo is a LOT more expensive. e.g. Arthrotec (which is an NSAID plus a stomach protector): 200 dollars for a 3 month supply - vs. about 30 dollars for the two meds separately. They have a patent on the combination (no other company can sell the combination until that extended patent expires).
Anyhow… this is just my own ranting on drug companies’ tricks to increase profits. And using the combination (Advair) does enforce that you’re following current recommendations (which are to use the salmeterol only along with a steroid).
wind, while I don’t necessarily disagree with anything Mama Zappa is saying, you should put it all out of your head. Like about a billion other people, I’m on Advair and it’s hugely effective for me. She’s right that you can’t titrate the individual components, but I don’t know that there’s medical evidence that suggests that would be helpful. But I’m quite sure it woud cause compliance issues. (I know that my compliance was modest at best back when I was on separate meds. Yes, it was because I was a callow youth, but one puffer twice a day is a lot easier to manage than multiple meds with possible different dosages.) The compliance benefits provided by a single pre-measured dose are significant and – please don’t take offense – I think MZ might be discounting them because she tracks her meds carefully and is not the type of person who is going to have compliance problems.
The patent issue she mentions is certainly true, but again, I wouldn’t recommend that you should let it effect your treatment, especially at the beginning of your experience with the disease. We’ve all had literally decades of learning how our asthma works. You haven’t.
The one piece of advice she and I might agree on is this – get a pulmonologist. Don’t rely on your GP to control your asthma. Probably they’d do an OK job, but they’re not going to be as well briefed on the current state of the art as a specialist. And in the future, a pulmonologist is likely going to be more willing to discuss modifying your treatment regimen because she’s going to understand the various drugs and how they act in the body and interact with each other better than a GP who has to spend her day learning about a much broader field.
–Cliffy
Since I was a kid. The last five or six years (I’m 28) are the first time I haven’t needed an inhaler, although occasionally I think I might need a rescue inhaler.
Could someone please tell this to my health insurance company? Their attitude is basically “you haven’t been in the hospital this year, we won’t pay for a specialist”.
Urgh. How frustrating. I thought that decision was left up to the primary care doc!
For what it’s worth, I have my asthma managed primarily by the internist… then again, I was managed by an allergy/asthma specialist in the 90s, and got well educated by those guys, and know enough to seek help when I get in trouble (this was NOT true before that time).
For garden-variety asthma, for day to day management, any reasonable primary care doc should be able to handle it. A consult with a pulmonologist or allergist at the outset, with an occasional visit every year or three once things are well-controlled, should be fine. This assumes you’re proactive and do a lot of reading on your own, so you know the questions to ask.
If you’re more brittle, having more trouble getting things under control etc. then I’d vote for seeing a specialist more routinely.
I do concur that a specialist will have a better handle on the latest and greatest. For example, I use theophylline. This hasn’t been a first-line choice for many years (it was, in 1985 when I started), however it works well for me. The therapeutic range was originally 10-20 (not sure what - amount per cc of blood or whatever) but an asthma specialist told me in the early 90s that they’d lowered that to 5-15. My primary care doc still insists it’s 10-20. I know I’m fine if it’s in the 16-17 range but others might have trouble. So I work with the doc and titrate to try to keep it around 15. Difference of opinion, but it works OK for me. And I’ve got a little wiggle room if I think I need to bump the dosage.
All very true!! I’m very up front about the fact that the Advair concern is just my own prejudice, and combo inhalers are a LOT easier compliance-wise. I suspect I’m more careful than most folks and if I forget a med, it’s because I’ve forgotten to take anything that morning. So a combo inhaler wouldn’t make me more compliant.
The take-away lesson is educate yourself, figure out what works for you, empower yourself, ask a LOT of questions, stick with whatever regimen you and your doctor(s) come up with, don’t fool around with it without discussion (e.g. you know X month is better so maybe you and the doc can decrease your regimen that month), and also have a plan for what to do when things escalate. If your doctor is worth anything, he’ll be happy to spend a few more minutes with you during a scheduled office visit, than to get an emergency “on the way to the hospital” call at midnight because he couldn’t be bothered to come up with a better plan in advance.
I have a type of asthma that only appears due to exposure to to perfumes and chemicals (Intrinsic Asthma). I have to avoid the triggers to avoid an attack, but extreme humidity can also trigger an attack.
My biggest problem is the choking sensation I get. I keep a Primatene Mist inhaler around for the wheezing type of attack, but most of my attacks show up as coughing fits.
My doctor has me use Magnesium Sulfate under the tongue for one minute to stop that choking. I was *amazed *at how well it worked the first time they had me try it at the doctor’s office. The stuff tastes terrible (it’s actually meant for IV use) but I could not believe how fast it worked to relieve me of that terrible choking sensation! It allowed me to breathe much better and faster than I ever had using Albuterol (or it could have been Ventolin – it’s been a while since I had a prescription inhaler).
So, I just keep my little dropper vial of Magnesium on hand (along with some lifesavers to kill that horrid taste when I swallow it) along with my PM inhaler and that seems to work for me.