Asthma inhalers (May 29, 1998)

Cecil's Columns/Staff Reports
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In the May 29, 1998 column, the merits and drawbacks of steroid-based asthma inhalers were discussed. When I was diagnosed with asthma, I was given a prescription for an inhaler called Isuprel. This stuff was great: two shots, and I was breathing normally again. Some time in the late 1980s, Isuprel was removed from the market because it allegedly raised a person’s blood pressure. As was noted, every drug has some side effect, and since my blood pressure is very low to start with, this one didn’t bother me. At any rate, the current steroid-based inhalers don’t work as well as Isuprel did. And their side effects seem more menacing to me than Isuprel’s were.

My asthma has somewhat diminished since leaving Michigan, and I don’t recall having any problems with it while living in Arizona. Still, when I need relief, I’d like it to be effective, without doing more damage elsewhere.

Are there currently any asthma inhalers that aren’t steroid-based? And what was Isuprel’s formula?

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There are essentially 2 kinds of inhalers, John.

1> bronchodilators. These include Isuprel, Albuterol, Terbutaline, Primatene Mist and others. They act by interacting with adrenaline receptors in the airways, stimulating the muscle fibers around the airways to relax & open.
ADVANTAGES: Quick effect
DISADVANTAGE: Short duration, dependence, progressively lowered responsiveness over time. These are actually blamed for the fact that asthma deaths are INcreasing - people get used to stopping their own attacks, but when the life-threaning attack occurs, their body can’t respond to these inhalers any more.

2> Preventive-type inhalers - steroids, cromolyn, newer ones I can’t remember, since I don’t treat asthma much. These are intended to prevent asthma attacks from occurring in the first place. THey will have virtully nil effeect on an attck in progress; most advise users that it takes 3-7 days of regular use before they can expect to see a reduction in attack frequency.

ADVANTAGES: Prevention of attacks
DISADVANTAGES: Long interval between initial use & effect, no attack-aborting effect.

Normal strategy: Mild asthma cases - use only a bronchodilator as needed (or pre-exercise if that is the known trigger)
Moderate-Severe asthma cases - use preventive-type inhalers regularly + bronchodilators as needed. Goal is to reduce bronchodilator use to < 3-5 times/week.

In direct answer to your question, yes there are bronchodilator inhalers available, although Isuprel is not. They may or may not be the best treatment for you; you should see your doc to discuss this.

Sue from El Paso

Experience is what you get when you didn’t get what you wanted.

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Sue, thank you for your detailed reply. You cleared up some misconceptions that other asthmatics, and even my doctor, gave me. Before I forget (as I did the first time), the initial article was here:
http://www.straightdope.com/columns/980529.html

The inhaler I currently have is Albuterol (a Ventolin substitute), which you describe as a bronchodilator. I’m assuming this means it’s steroid-free. If so, this is where other asthmatics and my doctor misled me: they all claimed that every asthma inhaler is now steroid-based. I also remember using the brand name Alupent (sp?), though not recently.

The dosage recommendation is, “Use 2 puffs up to three times daily as needed for wheezing.” I try not to overdo any medication, but sometimes I’ll need to use this inhaler 3 times in a day. I never had to use Isuprel more than once per day, and often, I felt better right after the first puff. Relief from Albuterol seems delayed in comparison.

However, my problems are seasonal, not constant, and nowhere near as frequent as they were. In fact, the expiration date on this inhaler was 9/10/99. Before getting asthma, I was diagnosed with allergies to ragweed, mixed grasses, and mixed fungi. My asthma was attributed to these allergies. This is not to say such pollen doesn’t exist here in Austin, but apparently it’s not quite as thick as in Michigan.

I also lived in El Paso for about 9 months, getting there just in time for the record snowfall about 12 years ago. I don’t recall any asthma attacks there, though my nose constantly bled, perhaps due to the higher elevation.

Maybe we should be looking at preventative measures. What causes the muscle fibers around the adrenaline receptors to tighten and close? Are there vitamins and/or mineral supplements that I should be taking to keep the muscle fibers loose? Is my diet lacking in some basic food group? Is the pollen in Michigan that much thicker, or is the higher humidity a factor? Do asthmatics commonly have lower blood pressure?

Again, thank you for your information. I’ll try to see the doctor before lawn needs mowing

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John asks:

To clarify my original response, the muscle fibers encircle the bronchii, or airways. Adrenaline, and other compounds (Albuterol, Alupent, Terbutaline, Isuprel, Primatene) stimulate receptors in the cell membrane of the muscle cells, causing them to relax, so that the airway expands (bronchodilation), and breathing becomes easier.

Histamine, which is released by the cells involved in allergic reactions (mast cells) act on other receptors in these muscle cells, causing them to contract, narrowing the diameter of the airway & making breathing easier. Steroid-based inhalers work by preventing mast cells from releasing histamine, preventing airway narrowing (bronchoconstriction) from occurring in the first place. Other preventive type meds (both inhalers and pills) work similarly.

The bottom line on bronchodiltors (adrenaline-like inhalers):
The more often you use them, the more you need them.
The more often you use them, the less effect they have (the muscle cells over time put fewer adrenaline receptors in their cell membranes when they are constantly exposed to high levels of these meds)
They are potentially dangerous in that they can make you think you’re blocking a serious attack, but if the airway narrowing progresses despite the use of bronchodilators, the adrenaline receptors are already in full use, so that additional bronchodilator administration has minimal effect, and you can only hope that you can get to an ER fast enough.

The nose bleeds in El Paso are most likely due to the lack of humidity here.

If you are needing to use the Albuterol more than 3 times a day, it probably is time to discuss use of preventive medication with your doctor. In Austin, ragweed pollen may already be at dangerous levels for you.

The good news is that preventive meds often do not need to be taken year-round. If, as you describe, there are identifiable triggers, you may only need to use these meds during peak times for these allergens.

One possible explanation for your confusion with the Albuterol being steroid-based (it is not): Some companies combine a steroid with a bronchodilator. I, personally prefer the flexibility that separate inhalers provide, but many patients like things simple & inexpensive, and a combined product may offer that… By any chance, is your Albuterol inhaler a combination product? Otherwise, I confess to being puzzled by why you understood from your doctor that Albuterol is steroid-based.

Sue from El Paso

Experience is what you get when you didn’t get what you wanted.

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I have seasonal asthma and it’s fairly mild unless I have a cold. I got a prescription from my doctor for albuterol and an oral steroid whose name I can’t remember. I try not to use the bronchodilator very often.

If my asthma was keeping me up, I would use the steroids for a week or so and usually the symptoms would subside. I don’t know if they were going to subside anyway.

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Sue, thank you for the clarification. I’d hoped that some food or vitamins might help keep the muscle fibers in their natural state, or at least not react so harshly when exposed to pollen, so that I might have less reliance on medication. I’m using filter masks when mowing the yard, and for milder breathing problems, I’ll try VapoRub first. When I resort to the inhaler, I want it to be effective.

And effectiveness is what I miss most about Isuprel. Albuterol works, it just doesn’t work as well as Isuprel did. At least it’s not steroid-based.

I don’t think that I’m abusing the inhaler: I didn’t notice that the expiration date had passed until responding to your earlier post. Perhaps the last time I used it, it was in a weakened state, and that was at least two months ago, maybe longer. The cannister feels like it’s more than half full. No, I’ve never gone over 3 times per day, and recall reaching that point only twice (I never used Isuprel more than once per day). In fact, I’ve tried to avoid using it unless absolutely necessary, because I thought it WAS steroid-based. As you say, that’s probably a good strategy, regardless.

I’m not sure how to determine if this is a compound. The canister and mouthpiece are separate, if that helps. Here’s what the label says, in part: “Warrick Pharmaceuticals Albuterol, USP. 17g, 200 metered inhalations. Contents: Each canister contains a microcrystaline suspersion of Albuterol, USP in propellants (trichloromonofluoromethane and dichlorodifluoromethane) with oleic acid. Each actuation delivers 90 mcg Albuterol, USP from the mouthpiece.”

Also, I don’t have one specific doctor: I use a clinic. It’s rare that I see the same doctor twice in a row. The one I asked may have just given me incorrect information, and this was about eight years ago, after I moved back to Austin from Phoenix, and learned that Isuprel was no longer available. I’ll go there during the day next time, and try to consult with a more experienced doctor. And when I get a prescription, I’ll ask for the most effective steroid-free bronchodilator.

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1 - No steroid; just albuterol, then in your current inhaler.

2 - The best way to ascertain how full a container is is to float it in water.

Full - sinks to bottom]
Half - floats to top; remains in vertical position
Empty- floats to top; floats on its side

3 - (as I’m sure you know) Get a fresh inhaler. Or at least call the pharmacist - generally they’re the best source for potency info after the expiration date.

Sue from El Paso

Experience is what you get when you didn’t get what you wanted.

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Great answers, Sue, thanks.

As for this:
[[The nose bleeds in El Paso are most likely due to the lack of humidity here.]]

My dad got a lot of nose bleeds growing up in El Paso, and I suspect they were from other causes.
Jill

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Just tested – the cannister is half full. But it doesn’t matter: if it’s expired, I’m not going to use it. Last week, I threw out a half-empty bottle of Ibuprofin that expired two months ago.

Sue, thanks again for all of your helpful information.