Expert: Marc Rubin, RPh Asthma Educator - 5/10/2008

Question
Hi,
My doctor gave me both Singulair and Advair (at different times) for my mild asthma but I have not taken them yet. I actually asked him for the prescriptions and he said fine, that I could take whichever one I wanted. But I have not taken either because I have heard so many bad things about both medications! I am a 44 year old white female and I just quit smoking less than a month ago (which has made my asthma worse, figure that out). I took Advair years ago for about a week and I seemed ok. Please give me your opinion. My asthma is worse and I need to take one of these medications, or something. Thank you!

Answer
Hi Diana,

First, I want to congratulate you on quitting smoking! That is outstanding, and a difficult thing to do. Smoke is one of the biggest triggers for asthma, and eliminating it will help you in the long term. Keep up the good work.

Unfortunately, the vast majority of "bad things" you've heard about the medications are from an overzealous press that likes sound-bites more than facts. For example, Advair, and the long-acting bronchodilator issue resulting in a "black-box" warning. The study that the information originated from was called the "S.M.A.R.T. Study", which has been retitled by practitioners as the "Not-So-Smart Study". Patients who died had failed to take their steroid medication, and only took the long-acting bronchodilator. This goes completely against the asthma guidelines. Since they didn't take the steroid, their inflammation went out of control to the point that the bronchodilator was no longer effective. The study itself was defective. For Singulair, the four suicides have not been shown to be directly due to the drug, but the warning was put on while the issue is looked at> all in part of an attorney looking for something to point a finger at. In the largest study of Singulair, with 11,000 patients, there were zero reports of suicide or abnormal psychological behavior. If you have concerns about the safety of the medications, you need to directly address the issues and get them resolved. Then therapy can be formulated to get you under control. If you are not compliant with your medication, then you put yourself at risk of a serious episode. This is why patient education is so important.

From the sounds of it, your physician didn't do any in-depth evaluation of your status. He just gave you what you asked for. This is unlikely to occur with an allergy specialist.

Until you get yourself into one, I'd take the Advair, twice daily, morning and evening, 12 hours apart. Initially, the long-acting bronchodilator component of the formula will keep your lungs open, allowing time for the steroid component to kick in. It takes a few weeks for the steroid to start having its effect take hold, and 6 months of continuous use to reach the maximum benefit. If you are still having night-time awakenings of once a week or more, add Singulair at bedtime. These are controller medications to be use continuously, not just when needed. Also, get yourself a peak flow meter. It is a tool which aids in determining the amount of airway restriction you have, and when you need to adjust your meds.



As a guide to evaluate your breathing status, take the "Asthma Control Test" at http://www.asthmacontrol.com/ This is now part of the guidelines, and should be administered by the doctor on each visit. You can use this at home to see how you are doing.

Finally, you do need to get yourself into a specialist. If you go to http://www.aaaai.org/physref/ , you can put in your zip code, and find one close to your home. Also at the site > http://www.aaaai.org/patients/resources/fact_sheets/default.stm , there is patient education and information for you to review. Understand that drug therapy is only half of the treatment. The other half is understanding what triggers your episodes, e.g.: pets, allergies, mold, chemicals, weather, etc. The more you learn, the better control you will have, and the better quality of life you'll enjoy.

Hope this helps!

Sincerely,

Marc