Expert: Marc Rubin, RPh Asthma Educator - 3/24/2010

Question
QUESTION: Hi, I have a question that doesn't seem to fit in anywhere else, which is also probably why my doctor is like a chicken with her head cut off right now. I am lifetime asthmatic, I have always lived in a small town up until recently when I moved into a larger city. My problems began before that, though. I have a dog, who is hypo-allergenic, as I suffer from numerous allergies all year. I take Singulair once a day, Advair twice a day, and Ventillin when needed. Here is my issue: I have had trouble breathing since the summer, I feel as though it is my chest MUSCLES. In the past few months I have experienced "sweat flashes", severe cramps in my calves, feet, and thighs, weak muscles in my legs, back, and arms, and a high level of fatigue. I also took a few blood pressure tests that indicate I have a lower BP than most. I am not sure if all of this is related or something was caused by something else. I am wondering if any of my symptoms could have been caused by my asthma or perhaps the medications I am on. Recently my doctor told me to take two doses twice a day of the Advair (versus the one dose twice a day I was one before) and I haven't noticed a change. I am breathing heavily right now. Any suggestions on it's relatedness to Asthma or how I can control my out-of-breath lungs??

Thanks!

ANSWER: Hi Stefanie,

First, before I get into anything else, there is absolutely no such thing as a hypoallergenic dog, cat, horse, bird, etc., with the exceptions being a painting of photo of one.

Moving to a city exposes you to airway irritants you may only have had minute exposure in your hometown. Particulate matter from diesel smoke, fumes, ozone, as well as a different mix of pollens may all be contributing to this.

If the Advair you are on is the metered dose inhaler (w/ compressed gas like your Ventolin), I'll accept the dosing increase, If, on the other hand, it is the round, purple discus unit, IMMEDIATELY return to 1 puff twice daily. The long-acting bronchodilator can cause the muscle symptoms you describe. Also, you need to see an allergist specialist as soon as possible.

I have major concerns that you are having frequent night time awakenings which subsequently cause the exhaustion. Your asthma is not in control, and your primary care doctor should have referred you to a specialist (as the asthma guidelines call for), when she was stumped in how to properly treat this level of impairment.

Right now, you should immediately focus on getting yourself to an allergy/immunology specialist that has the right, up to date training to get you on track.

Final note, returning to the first sentence, the dog should not be in your bedroom at all, and you need to do a thorough cleaning of your bedroom (fresh sheets, pillow cases, dusting, vacuuming, etc.), to reduce the allergens you inhale at night. Lung function naturally goes down at night, and having animal dander in your sleeping environment aggravates the lungs even more.

Get back to me after you have seen the specialist. When you call, clearly express to the receptionist the muscle pain and exhaustion issues you are having. Also, follow this link to the Asthma Control Test ( http://www.asthmacontrol.com/ ) and report that you took this test, and what your score is.

Sincerely,

Marc

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

QUESTION: I just did some research on Advair side effects. I was wondering if you have encountered anyone with severe Advair side effects? My problems seem to all fit into the Advair side effects. I hope you can give me some feedback on Advair!!

Answer
Hi Stephanie,

Fortunately, I haven't had someone with serious side effects due to Advair. I'm sure that part of this is due to educating the patient from the onset about the disease as well as proper use and administration of the medications. Most issues medically can be minimized by early intervention. That said, the skill level of the medical provider plays a significant role. The challenges to general practice physicians is keeping up on ALL areas of medical practice. For instance, in November 2007, the latest asthma guidelines came out, all 470+ pages. There are over 1600 disease state guidelines, so you can see the challenge here. The critical issue for the patient is can you have faith that the doctor knows at what point to refer to a specialist. From my experience, all the guidelines I've come across make it clear to the generalist where the threshold for referral lies. It is then the responsibility of the practitioner to always practice in the best interests of the patient. It is not about ego, but humility, and this is not a weakness, but an absolute strength.

I'm glad your doctor has referred you. I'm confident your issues will be properly addressed and resolved. If you feel that you would like to have a greater understanding of asthma, I'd be more than happy to not only provide links for you top investigate, but can also provide educational pieces at no cost to you. I'd just like first to have some baseline from you of the level of knowledge you presently have, and we could go from there. Let mw know how all this works out.

Sincerely,

Marc