Expert: Marc Rubin, RPh Asthma Educator - 2/18/2011

Question
QUESTION: I have another question for ya! My six year old son was put on Flovent for his maintenance medicine. He also takes Xopenex on the nebs as his rescue.  He used to take the inhaled pulmicort but it became increasingly difficult to make him sit for it. The pediatrician(not specialist) decided to go with the flovent. I was on board because it's quick and my son has no problem taking it. He uses an aero chamber and takes two puff twice a day.

He is normally the most easy going kid in the world. Mr. Personality we call him...but lately (since the flovent) he has started to become just angry. He just flies off the handle. He has been on the flovent for a week.  He has been on oral steroids..and I always see that affect his behavior. He becomes impatient and angry...:We call it the "roid rage". IT is very similar . My doctor looks at me like I have three heads when I mentioned what I think the flovent is doing.  But I just find it hard to believe it can't be when that is the only thing that has changed??

My daughter takes Flovent also. She is 13 and she does fairly well with it. But she had a similar thing happen with Advair. So I won't give my kids Advair. We have tried singulair for my son...but the results weren't good. It didn't seem to help him.

Could this be a side effect? Thanks so much!!!

ANSWER: Hi Alaina,

Even inhalation steroids may cause mood swings. I don't understand why the doctor would switch from Pulmicort Respules for nebulization to Flovent, rather than putting him on the Pulmicort Flexhaler.He would not even use the AeroChamber, since it is a dry powder inhaler, and not a pressurized product.

A concept that is slowly trickling down through the medical community is the role that our genetics play in how we respond to medication, both positive responses as well as side effects We are seeing that more in MANY disease states: blood pressure, clotting, asthma, COPD, cancer, etc. I've seen drug failure with one inhalation steroid, yet the patient was successfully treated with another inhalation steroid.

I'd suggest the doctor try him on the Pulmicort Flexhaler, and observe the outcomes. One additional nice thing about Pulmicort is that a well controlled patient may be able to take the medication only once daily, as compared to twice a day with Flovent.

In regards to your daughter, keep in mind that Advair is a mixture of two drugs: Fluticasone (the steroid that reduces inflammation), as well as salmeterol, a long acting bronchodilator (a cousin of albuterol). In her case, re may have had a problem with the salmeterol, and if the doctor needed to add a long-acting bronchodilator to her therapy, he could try formoterol (Foradil) instead.

Singulair is a good add-on therapy to inhaled steroid, or sometimes in very mild asthma cases. Here again, genetics plays a role. If I remember correctly, it is effective in ~ 40% of patient, not everyone.

Let me know how this goes with your son.

Sincerely,

Marc

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

QUESTION: oh thank you so much!! During the past couple days, I called the doctor and they told me that it absolutely wasn't the flovent. I didn't even know there was a pulmicort inhaler.  If you knew my son, he is the easiest going happy kid I have ever seen. It is a big difference in behavior. I will definitely call and ask about the pulmicort!!!

Answer
Hi Alaina,

Let me know how it goes. I was just at a pulmonary meeting last night, and the table was in agreement that the appropriate measure to take would be to try the Pulmicort Flexhaler.

Also, see attached, and show this to your doctor. It is directly from the manufacturer, and on page 8, under "6.2-Post-Marketing Experience / Psychiatry: Agitation, aggression, anxiety, depression, restlessness. Behavior changes, including hyperactivity and irritability, have been reported very rarely and PRIMARILY IN CHILDREN."


http://us.gsk.com/products/assets/us_flovent_hfa.pdf

A little research goes a long way! :-)

Sincerely,

Marc