bricanyl or methotrexate

i went to see my asthma nurse at the hospital last week and she as said that when i go see my consultant on thursday that he will want to put me on 1 of those drugs,when i did my peak flow at the hospital it was 230 which is 60% below my average,i already take prednisolone 40mg,phyllicontin 450mg twice daily,zafrilukast 18mg twice daily,ciclesonide 2 puffs twice daily,spiriva once a day,oxis 4 puffs twice daily and salbutamol nebs 4 times a day. is there anything else which i could try other than those 2 drugs which i mentioned???? thanks x

[KateMoss]

These are two diferent sort of drugs completely.

Bricanyl is a bronchodilator just like ventolin

Methotrexate is a very strong imunosupressant and is used as a last resort as a steroid sparing agent I think.

[Hidden]

Hi Mandy,

I am sorry that you are having these problems, and are having to think of these options; I have been in a similar position myself, so I can sympathise with the stress of the situation.

As Kate says, these are two very different drugs that are used in different ways and for different reasons.

Terbutaline (Bricanyl) is merely an alternative bronchodilator, very similar to salbutamol; is your consultant thinking of exchanging terbutaline nebs for your salbutamol nebs, do you know, or is he thinking of continuous subcut terbutaline via a syringe driver?

If he is thinking of changing your reliever inhaler and nebs, some people do find that they respond better to terbutaline than salbutamol, although there is no clear cut evidence that one is better than the other. It may be worth a try to see if you get better peak flows with terbutaline nebs.

If he is thinking of subcut terbutaline, that is a fairly big step in severe asthma, that is usually started after extensive in-patient trials to see if it is effective in you - this is usually done by a specialist centre such as Heartlands or RBH. Subcut terbutaline does have some significant side effects - the most common ones are things like tremor, fast heart rate (as with nebs, only more so), muscle cramps, and site problems such as sore skin and abscesses. You also need to consider the psychological effect of constantly having a syringe driver attached to you - the pumps issued by the hospital are not much smaller than an old VHS cassette, so they are quite cumbersome. Subcut terbutaline is not suitable for everyone; some people have no significant improvement on it, which is why an in-patient trial is done before it is started, and some people can't have it due to problems like high heart rate.

Methotrexate is one of a few immunosuppressive drugs that are occasionally used in asthma to try to reduce the steroid dose (others sometimes used are ciclosporin or azathioprine). The indication for starting one of these drugs would be a prolonged period on high dose steroids, with an inability to reduce the dose without the asthma flaring, and significant steroid side effects such as diabetes, high blood pressure, bone problems or eye problems.

These are powerful drugs, albeit used at very small doses, and they do have significant side effects themselves. The worst side effect is often a suppressed immune system with increased susceptibility to infection - if you are someone who gets a lot of chest infections anyway, or who is frequently ventilated for your asthma, it may not be suitable for you.

Other potential side effects with methotrexate are liver dysfunction, bone marrow suppression with anaemia, and lung fibrosis. These side effects are very rare, but can be potentially serious. If you are started on methotrexate, you will have to have regular blood tests, initially perhaps weekly or fortnightly, and then monthly if things are stable, to make sure that your liver and bone marrow aren't being affected.

In terms of other drugs that may be helpful to you, you seem to be on a fairly comprehensive combination of treatment, and there are not a lot of other conventional options to try. Have you been considered for Xolair? If you have allergic asthma and your IgE is within the right range (and sometimes even if it isn't) Xolair can be helpful.

Are you managed by a specialist centre such as Heartlands or RBH, or someone with an interest in difficult asthma? As I said, subcut terbutaline is certainly a treatment that is best started by someone with expertise in this area. If you are not under a specialist centre, it may be worth asking for referral to one; they may have a few more ideas about things that might help you.

All the best for your appointment, take care

Em H