Expert: Marc Rubin, RPh Asthma Educator - 2/6/2009

Question
QUESTION: hello. i have been searching for answers in regards to the medicines my son takes and if there are any long term side effects.  my son, just turned 6, has been hospitilized numerous time (probably close to 10).  everytime it is in the (ohio) winter months.  he typically stays anywhere from 3 days to 2 weeks.  if he is not in the hospital, he is on meds to keep him out of the hospital. his meds daily include, qvar, zyrtec, and albuterol as needed.  and he is on and off orapred all winter long.  are there any suggestions you might have? or will these harm him in the future?

ANSWER: Hi Kristine,

Sorry for taking so long to get back to you.

From what your telling me, he is definitely under poor control, and unless his inhaler technique is incorrect (not uncommon, and should be checked each time he sees the doctor. Also, cut and past this link to review proper inhaler technique  ( http://tinyurl.com/9hgl7z )

Is he also prescribed any nasal sprays?

Is he presently under the care of a board certified pediatric specialist? If not, get him to one. Here is a link to help you locate an asthma specialist: ( http://www.aaaai.org/physref/ )

Has he been tested for his allergies to see what is triggering all this?

Also, answer the following:
1) How old is your home, and does it have a basement or crawl space?

2) Are you aware of any mold present in the home, from leaky plumbing or roof?

3) Do you have pets, and are they allowed in his bedroom?

4) Are any family members smokers?

5) Has he had a flu shot this year, and do you get one for the family every year?

6) What country, state, city do you live in, and is it city, suburban or rural?

7) Do you have a humidifier in the house running in the winter months, and do you have the unit cleaned each year and replace the filter medium?

8) Does he wear a scarf over his mouth and nose when going outside when it is cold?

9) Do you use a peak flow meter, and if you do, do you re-evaluate your son every 6 months to determine his new personal best? (Lungs grow until the age of 25, so you must re-adjust what his zones are every 6 months)

My greatest concern is the risk of severe attack, and being somewhere where he cannot get timely help. Under the new asthma guidelines, there are twin parameters for treatment: 1) evaluation of the level of impairment or severity, and 2) assessing the level of risk of a severe attack.

Regarding long-term effects. While a child on high-dose inhalation steroids (I don't know how many puffs your son is taking/day) may have reduced growth height (up to a centimeter, which is less than 1/2 inch), chronic illness with the poor control he has may leaad to the same consequence. A properly structured therapy has as one of its goals: the use of the minimum amount of medication that keeps the condition under control. During the year, this may mean times of higher dosing, and at other times fewer drugs and lower dosing. This reduces the risk of long-term effects. Poor control has the risk of death to to a severe attack that is inadequately treated.

Once I have the above details, I'll be able to provide you with a clearer picture.

Sincerely,

Marc



---------- FOLLOW-UP ----------

QUESTION: Is he also prescribed any nasal sprays?yes, but it's just a saline spray

Has he been tested for his allergies to see what is triggering all this? yes. he is allergic to dust, mold, dust mites, cats, mice, cockroaches.

Also, answer the following:
1) How old is your home, and does it have a basement or crawl space? our home is about 7 yrs old. with a crawl space.

2) Are you aware of any mold present in the home, from leaky plumbing or roof? no. not that im aware of.

3) Do you have pets, and are they allowed in his bedroom?no

4) Are any family members smokers?no

5) Has he had a flu shot this year, and do you get one for the family every year?he gets one every year. and my other 2 children got one the past 2 years.

6) What country, state, city do you live in, and is it city, suburban or rural? mt. vernon, ohio, usa, rural

7) Do you have a humidifier in the house running in the winter months, and do you have the unit cleaned each year and replace the filter medium?no humidifier, air purifier in his room, cleaned 1x per month. allergen furnace filters during winter replaced every 2-3 weeks.

8) Does he wear a scarf over his mouth and nose when going outside when it is cold?no

9) Do you use a peak flow meter, and if you do, do you re-evaluate your son every 6 months to determine his new personal best? (Lungs grow until the age of 25, so you must re-adjust what his zones are every 6 months)no

he was on flovent 2 puffs 2x per day. now qvar 1 puff 2x per day.  10mg of zyrtec per day. and albuterol as needed. he has a puffer and neubulizer for this. i just wish we could find the right combination for him.

Answer
Hi Kristine,

Okay, now here are some suggestions to address the issues:
1)approach your physician about starting a nasal steroid spray. There are a number of them that are approved for 6 years of age and above, and Flonase is one that also comes as a generic (made in the same factory), so it is much less expensive. What is very important is using the proper technique to maximize effectiveness and minimize side effects like nose bleeds.

2)Should there not be any improvement after 1-2 weeks, I'd approach the doctor about changing to the combination medication Advair in place of your present inhaled steroid. This is approved in children over 4 years of age. There have been warning about the long-acting broncho-dilator in this product, but that applies to patients NOT TAKING INHALED STEROIDS. I sense that it is your pediatrician treating your child. If your physician is uncomfortable with this, I located an asthma specialist within 20 miles of Vernon: Dr. F. Cano, who is board certified. Here is his information: http://www.aaaai.org/physref/detail.asp?id=37047&loc=4738

3)does your son have any stomach distress on a regular basis? Acid indigestion can also bring on an asthma attack, and is something that your doctor can address.

4)go to your hardware store and pick up a testing kit for mold detection. This should be placed in the crawl space, and follow the directions. This area of the house is often a culprit. (If this should be negative..GREAT...but then I'd be investigating the age of the school and if there has been any testing there)

5)In cold weather, he needs to wear a scarf over his mouth and nose, warming the air he breathes. An alternative would be to check out if a local sporting goods store carries "neck gators", basically a turtleneck sweater without the sweater. They are generally made of polar fleece, and are very soft, comfortable, and easy to wash. Here is a site I found for kids: http://www.winterkids.com/products.cfm?CatID=50

6)I'd check with your pharmacy about getting a peak flow meter, which is an inexpensive device that helps monitor decreasing lung function. Should you go to the specialist, he'll probably be able to give you one for free. Just as you take a temperature for infection, this easily tells you how his breathing is, and can help to determine what he may be allergic to.

7)since you live in a rural area, the doctor should put together an action plan form for you. By assessing your son's symptoms and/or peak flow scores, you would adjust his medication under worsening conditions. Here is a link so you can bring the form in to the office. This is developed by both the physician and you communicating quality of life expectations Treating asthma is a team approach, and the best way to achieve success. A tool to assess how your son is doing I'll also include below. It is a simple questionnaire that helps determine progress: the Asthma Control Test

Asthma Action Plan: http://tinyurl.com/q5j2v

Peak Flow Meter: http://tinyurl.com/6h4g9

Asthma Control Test: http://www.asthmacontrol.com/

8) and finally, for getting education for yourself and son, there are many online resources. I like to start with Mothers of Asthmatics, and also add a game for your son to play online that will help him learn too!

Mothers of Asthmatics: http://www.aanma.org/

Quest for the Code: http://asthma.starlightprograms.org/

I hope this helps get your son under control. I'd strongly advise he sees an asthma specialist based upon the past history you've presented.

Sincerely,

Marc