Expert: Marc Rubin, RPh Asthma Educator - 3/8/2010

Question
QUESTION: Hello... Recently I went to my doctor for a cough that wont go away. I have a runny/stuffy nose in the morning, afternoon and Night.  It goes away and comes back.  My cough is worse when I exercise along with the runny nose.  I drink a lot of water to help sooth my throat when I exercise and through out the day.  My doctor says it's Asthma because of the coughing I do when I exercise. He didn't do any Asthma testing, but gave me "Singulair" 10mg once a day, and Ventolin inhaler to use before I exercise.
I've taken the "Singulair" for 6 days now and have only used the inhaler twice.  Since taking the "Singulair" my nose is still runny/stuffy off and on...but i've notice my upper chest hurts...it feels raw but not sore, a "Halls" cough drop helps till it's gone...I had a coughing fit the other day while I was exercise and had to stop for a bit to clear my nose and throat, but was able to finish my workout.  I go back next week for a follow up.  My concern is that he might be treating me for Astma and it's not.  What should I ask for in the order of Testing.. and If I decide to stop taking the Singulair and Ventolin till I'm tested what should I watch out for, could stop taking these meds put me at great reach for issues?
Thank you for your time and help  :o) Kim

ANSWER: Hi Kim,

The tests that should be done are: 1) spirometry, a lung function test, and 2) a CBC w/ differential. I'd stop the Singulair until after the CBC is done, since it can have an effect on the CBC results. If the doctor did do a blood test, then stay on the Singulair. It should be taken at bedtime for maximum benefit.

First, spirometry is a tool where you blow into a device to determine lung volume. It is repeated to attain 2 readings that are very close. This is done to insure the technique is correct, and the results are valid. Then you are given a treatment of Ventolin (albuterol), and the test is repeated after 15 minutes. If the improvement post-Ventolin is greater than 12% and/or 200ml, you have reversible airway disease...and in all likelihood, asthma. This procedure should be done by someone specifically certified, usually at a hospital, or at the office of a pulmonologist or allergist.

The CBC with diff is specifically looking for a white blood cell type called eosinophils. If you are under 30, elevation of eosinophils is indicative of a allergic situation, the most common cause of asthma in the young. Later in life, airborne irritants can bring on asthma: air pollution, solvents, particulate matter (people in bakeries are prone to asthma from the constant dust in the air, for example), etc. Much of this is related to occupational asthma: due to the work environment. We see elevation of other CBC components like macrophages, rather than the eosinophils.

You are correct in being concerned as to the correct diagnosis. One lecture program that I put together had as a presentation: "Not all that wheezes is Asthma". This is specifically why proper diagnostic procedures should be followed to come to the correct conclusion, not the quick assessment.

Should you indeed have asthma, I can provide free education for you to teach you control. Medications play a major part in taking control, but also the recognition of what specific "triggers" you have and using a tool called a "peak flow meter" for a quick assessment of airway restriction, will guide you to safety and improved quality of life. In short order, you will be able to go back to exercise with minimal or no impairment.

In the meantime, always carry your Ventolin with you, and use it pre-exercise (about 15 minutes ahead).

Let me know how things go. Also, explain step by step on your use of the Ventolin unit. Do you exhale deeply first, inhale fast or slow, are you looking up, straight ahead or down when you inhale, how long do you hold your breath, etc.

Sincerely,

Marc

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

QUESTION: Hi Again Marc....Well interesting week I've had...Had my follow with my doc on Thursday, was feeling GREAT, the best in months, my nose wasn't runny, I could breath out it and feel Wonderful.  Till the Nurse took my BP, it was 180/110. WOW.. she took it twice, doc took it once... all the same...I asked it the singulair could be the cause he said NO.  I told him I felt GREAT, I was told I will need to stay on the singulair for quite a bit, since I still cough a bit while I exercise... I'm also going for a PFT test this coming Friday.  Doc wanted to put me on BP meds and I said NOOOOOOOOOO... he said in 2 wks when I come back for a check, he will do a complete Blood work up....and will have the results of the PFT.  I was so bothered my by BP I know it was up even more my ears were so HOT... the nurse told me to stop by again Friday and she would check me again.... so come Friday I stopped by after work feeling good as can be.. work was fine always is...I sat in the waiting room for a bit talking to others laughing etc... relaxing as much as I could figure to do... my BP was 178/100....  I was to say the least HOT again... I tried to leave I was so mad the doc stopped me... he insisted on seeing me ... we talked about the BP and all the things that could happen with it.. and I understand.... I just can't help think its the singulair doing it... he still said NO... he wrote a script for something... I have not filled it and 'am not taking it....I want to wait for the PFT to be done first.  I've never had any problems with my BP being so high... there have been times it might of been up a bit if I were sick or just came in and didn't get a change to relax. I'm 42(w/f) 5'5" 155 lbs... I was working execrising regularly till I got the BP news and Now I'm a bit afraid to do so.... I've always have been in GREAT HEALTH... I hardly get a cold etc... I still can't help wondering if the singulair is the cause of my BP being so high... I did stopp taking it and have bee off it for 2 days and so far... things are fine... other than the crap I clear from my throat all day long... I'm just not ready to give up control of my life to a pill box.....OH I have took it upon myself to take an asprin at night, yes I'am a bit scared... I just can't help think that its the singulair making my BP so high... had a bit of a headache as I write this just behind the ears in the back my neck... Crazy all this is.. when I just went to see my doc for a runny nose and a simple cough.. thinking is just allergies and he would give me a good Allergie med.... More to come after all the tests.... so what do you think of this????

ANSWER: Hi Kim,

I'm waiting to hear back from a friend of mine who has a high-level clinical position in respiratory medicine with the manufacturer of Singulair. My research showed only a couple of cases, but we need to clear up whether this is coincidental, or something Merck has seen. If it is something they have seen, there should be specific issues your doctor should then look at to verify the situation, rather than dismiss is out of hand.

I'll get back on this as soon as I hear.

Marc

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

QUESTION: Thanks Marc..... I will be waiting to hear back... In the mean time.. I have stopped taking the singulair as of last Thursday Night 3/4... I have not used the ventolin havent been to the gym)....I can not take the hydrochlorothiazide that my doctore prescribed... Im allergic to sulfa.... I called today Monday to  let him know this...since he didn't look at my chart very close... HMMmm..I have a consist dull headacke now, stiff neck (motrin400/800) takes the edge off... blood pressure is still high...(I have the means to check at home) he now has prescribed Prinivil... which I really hate to start on..... I can't help but wonder if there is something else going on... I mean this is all flippin Crazy... I just can't figure out what I'm doing that is making my BP so high...I'm starting to get very frustrated.....thanks for your time, thoughts and input.
Kim

Answer
Hi Kim,

Late last night I finally heard back from my contact at Merck. There are no reports of high blood pressure due to Singulair, and the only cardiovascular events observed were rare cases of heart palpitation.

With that accomplished, you need to allow the doctor to address the blood pressure. I know you are not fond of taking medications, but you certainly do not want to have a stroke, brain hemorrhage or heart attack. The medications used today are generally very low on side effects.

Should you have a weight issue which may contribute to the blood pressure, getting down to normal weight that is appropriate for your height and age will probably reduce the need for medication.

Let me know how everything goes.

Sincerely,

Marc