Expert: Marc Rubin, RPh Asthma Educator - 7/27/2009

Question
QUESTION: I have asthma for now seven years but my asthma symptoms have never been very acute. It is as if I am always 75 to 80% of my normal physical ability, which still can make you feel bad all the time. Excess cough blocking my airways are the prime reason for my asthma. My doctor first gave me flovent and then changed to symbicort, which did help my asthma symptoms. However, both these medications has side effects on me. I can not sleep well and always feel super active in my brain (in a bad way as if I am crazy) all the time. I also feel feverish all day long. I was wondering if there are any medication which do not use steroid and are they effective?

ANSWER: Hi Arun,

Does your doctor have you on any other meds also, e.g.: nasal sprays, antihistamines, acid reflux medication (like Prilosec, Pepcid)?

What is your environment like?
1) Pets?
2) Older home/apartment that may have mold issues in the basement, attic, or leaky window frames?
3) City or rural?
4) What is the nature of your work/work environment? In and out of your car? Manufacturing? Etc.?

To best guide you, I'll need to know these factors. 50% of treating asthma is medication, but the other 50% is recognizing and responding to outside triggers to reduce risk.

Any other background info may also be helpful.

I'll watch for your response. (Choice of which inhalation steroid, as well as other non-steroidal medications will definitely be something I'll be looking at)

Sincerely,

Marc

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

QUESTION: Hi Marc,
      Thanks for responding to my question. I will provide some more information about my asthma condition.
1) I am 30 years old male working in a University as Researcher. I am confined in my cubicle almost entire day. Air quality in my office may not be that good but I believe its not that bad either.
2) I live in a two bed room apartment with wooden floors on the first floor. I clean my house as often as possible. I have an Air purifier (HEPA), which I use every night to clean air in my bedroom. I also have allergy proof covers for my mattress and pillows.
3) My doctor hasn't prescribed any other medication apart from symbicort. However, whenever I take Allegra-D I feel perfect. My doctor unfortunately doesn't recognize this fact.
4) I always get cough right after I eat food. Suspecting food allergy, I started systematically eliminating some food. I found that soy, corn syrup, and yeast may be  possible allergens causing troubles. I still need to go through an allergic test to confirm it.
5) I strongly believe that my asthma is triggered by allergy. My observations suggest that some type of food, dust, and cold are the biggest culprit triggering my Asthma. Therefore I am looking for some other option than steroid which can control my allergy and hopefully Asthma. Once I learn about the option, I can discuss about that option with my doctor.
      I appreciate your help.

Answer
Hi Arun,

I apologize again for the delay. My vacation begins Monday, and I had a lot on my plate to clean up before taking off.


Thank you for filling in the details of what is going on. You are taking the correct approach in trying to identify those triggers which are affecting your health. You also understand that going through skin testing will also clarify those issues that are not so readily apparent.

Your physicians approach may have a lot to do with not being current on the changes made in the NHLBI Expert Panel #3 Guidelines, which therefore would exxplain his apparent indifference to your Allegra-D response.. In the past, treatment was based upon initial assessment and testing of the patient to determine the stage of the disease: Mild Intermittent, Mild Persistent, Moderate Persistent and Severe Persistent. Therapy was then readjusted based upon response. In the new guidelines, the approach to assessing severity is to look at two paradigms: Impairment and Risk. From the guidelines: "to emphasize the need to consider separately asthma's effects on the quality of life and functional capacity on an ongoing basis (i.e.:in the present) and the risks asthma presents for adverse events in the future, such as exacerbations and progressive loss of pulmonary function. These domains of asthma may respond differentially to the treatment". Additionally, one of the tools to be used in monitoring the control of the disease is an written evaluation questionnaire. I prefer the ACT: Asthma Control Test.
( http://www.asthmacontrol.com/ ) Use it to monitor your progress, and definitely do one prior to each medical visit.

I have a few concerns to share with you. First, the difficulty with sleeping and being over-energized may be due to the pseudoephedrine in the Allegra-D. This is a very common side effect which may be minimized by using the Allegra-D 12 hour for the daytime, and the Allegra 60mg tablet for overnight. It would be important to take the Allegra-D 12 Hour as early as reasonable possible in the morning to diminish the effect on sleep.

This is not to imply that the Flovent or Symbicort could not also be the source of the problem, but just as you are assessing your allergens, we must also assess the medications. It is noted with inhalation steroids that these issues may arise, as shown in post-marketing feedback, but the degree is small, and as in all post-marketing issues, based upon patient feedback without our necessarily knowing contributing factors.

What may be of issue here, if proven that you are truly having these effects which can be directly due to the steroids is that a tremendous amount of research is being done identifying phenotypical variations in asthmatics which point toward individual response. What this means is that we are identifying genetic variations in individuals where the disease manifestations and responses may vary  widely. We've learned that some individuals do not respond to steroid inhalation (or a specific steroid), and some individuals do not respond at all to the short acting rescue medication albuterol. There are dozens of variations of asthma which therefore require us to truly individualize the treatment (and this is just the tip of the iceberg!).

In addition to all this new knowledge pointing to the need of individualized treatment, one also cannot just limit the approach of treatment to those meds only directly affecting the lungs. One must also assess the potential of contributing factors such as allergic rhinitis/sinusitis and esophageal reflux. Either of these conditions may contribute to lack of control.

Therefore, here is the approach I'd suggest for you:

1) Address ruling out the effect of the decongestant pseudoephedrine in creating the disturbing side effects. If you should find this is not the source, then resume normal Allegra-D dosing and...

2) Request that montelukast (Singulair) be added to your therapy. It is a once daily tablet, taken at bedtime, which reduces the level of leukotrienes, elements which increase inflammation. After a few days, stop the Symbicort, and see if you are maintaining control. If yes, also note changes in the side effects which you were experiencing.

3) Should the control of your asthma go down, I'd add Ciclesonide (Alvesco), an inhalation steroid to your Allegra-D and Singulair. It is unique in that it is a "pro-drug" that it becomes activated in the lung tissue, and in European studies has shown to be lower in side effects. As I mentioned earlier, genetic variations in patients have been shown to affect the response to different steroids. Even Singulair has failed to show effectiveness in a number of patients due to this. I'm looking at very individualized treatment. If this does not resolve the issue, giving 3-4 weeks for reassessment, then we must address the potential of allergic rhinitis/sinusitis. If the sinuses are inflamed, they can trigger the lungs to react.

4) Nasal Steroid added. Fluticasone (Flonase) or Ciclesonide (Omnaris- the nasal version of Alvesco). Technique, as with any medication device, is very important. It is NOT sprayed up into the septum, but either towards the outer nare wall or the back wall of the nose. Otherwise there is increased risk of nosebleeds and fungal sinus infections.

5) Assessment of GERD. If you are a coffee/tea/cola drinker using caffeinated products, these frequently cause GERD, and the acid reflux inflames the vagal nerve causing bronchospasm. If this is a possibility for you, cut out the caffeine, and then if no improvement, may add acid blockers like Omeprazole (Prilosec) and Famotidine (Pepcid).

I hope this helps to get you to a better quality of life.

Keep me posted on your progress. Although I'll be on a vacation break until the end of August, the majority of the time I will still be checking here for questions and replies.

Once again, I apologize for the delayed response.

Sincerely,

Marc