Expert: Marc Rubin, RPh Asthma Educator - 3/17/2010

Question
QUESTION: Why would a pulmonologist prescribe Symbicort60/4.5 to a patient that does not have asthma, copd, or emphyzema but smokes

I live in a city in south Florida.  I do not have any pets.

I am currently taking diovanHCt 80/6.25 mg. one a day as well as 2000mg vitman D3 and flax seed oil 3xday

ANSWER: Hi Honey,

I'll have to assume at this point that the pulmonologist has run pulmonary function testing, and the results from that testing failed to show the presence of asthma or COPD.

The fact that you smoke, inflammation is still occurring in the lungs, and the swollen tissue would potentially cause airway restriction with associated difficulty in breathing. If indeed this is the case, after a couple of months (if the therapy has shown benefit), then it would probably be appropriate to reduce down to only using an inhalation steroid, rather than the combination of the steroid + bronchodilator. If your breathing stays consistent, then you would not need to return to the combo drug.

Have you considered quitting smoking? The ONLY benefit of smoking is to those who manufacture cigarettes, and the funeral industry. Yes, I know we all eventually will pass on, but it is the quality of life that is of the greatest concern, more so than the length of life that is important. Living for years, struggling to breath, is not quality. Even late in life, quitting will result in improved airflow, higher oxygen levels, more energy, and a better life. But ultimately, this is a decision that you have to make.

If this appeals to you, and you would like some more guidance, feel free to get back to me.

Sincerely,

Marc

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

QUESTION: Marc
Thank you for you answer.  Perhaps I should have added the fact that I work out 3-4 times per week.  I usually do 40 minutes, (2miles) on a treadmill at 3.2 mph. while talking on the phone.  I have no shortness of breath or discomfort other than a knee sometimes bothering me.  The reason I had gone to the the pulmonologist was to evaluate a CT scan where there was a small spot 2-4 millimeters.  I had just gotten over a case of bronchitis (previous case was 52 years prior) and after the bronchitis developed  I caught a cold with sneezing and coughing on an airplane.  The literature that I read on the prescription indicated that this was a steroid and beta blocker and that once one started taking it you could never get off it.  According to the symptoms for asthma, copd and emphysema that I read I DO NOT have any of them.  I am certainly  aware of the dangers of smoking but truthfully I am more concerned with the dangers of this drug. Please advise and many thanks.

Answer
Hi Honey,

Did the pulmonologist do a spirometry exam which was repeated after giving you an inhalation treatment of a bronchodilator? If yes, did he state the reason for treating you? Did he discuss the future possibility of a needle biopsy of the identified spot?

Depending upon the diagnosis, the Symbicort is not necessarily a once you are on it, it is forever drug. The dangers of the drug are minimal (inhalation steroids have very low absorption, unlike oral steroids), especially compared to the assortment of chemicals in cigarettes. And yet you have greater worry about the medication, than the potential that the small spot may, among other things, be early cancer caused by your smoking.

Patients with COPD (emphysema and chronic bronchitis) indeed are on this type of medication, and more, for the rest of their lives. These are used to reduce lung inflammation, swelling and bronchospasm, all of which cause a significantly impaired quality of life. Once COPD sets in, 20% will die in the first year from a severe attack. These meds are used to slow that progression down.

He is probably treating you for bronchitis. It becomes chronic bronchitis when it occurs for 2 or more years in a row, generally lasting ~ 3 months. This is when it gets categorized as COPD. Should this be the case, you'll probably be on the Symbicort for a couple of months until all the symptoms resolve, then it will probably be discontinued.

Does your physician have you on a cholesterol medication? Even though the primary use is to help keep cardiac blood vessels open, the statins (Crestor, Lipitor, Zocor, Mevacor, etc.) also have an effect of reducing lung inflammation, even in smokers.

It is important that your pulmonologist explains his concerns, and the goals of his medication management. The MD-patient relationship needs to be a partnership. You are appropriately seeking information, which is terrific, but he needs to make things clear to you so you are dealing with all the information.

Let me know what else you find out.

Sincerely,

Marc