order of adding new medications

Hi All,

Sorry, posting with questions again – I only seem to post with questions not responses for others, will try and be better.

Just wondering about possible additional meds, and when new things can get added. Specifically, when people are taking theophylline type medication or atrovent, was this added in addition to pred, or are some people taking either of them without being on long term pred?

I’m currently just on symbicort, singulaire and ventolin, managed six months off maintenance pred but over the last couple of months have been having so many courses I think I’d have been better back on a maintenance dose (overall dose would have been lower). Don’t really want to go back on maintenance pred – the consultant has drummed into me what a bad thing it is, and besides I’ve actually managed to start losing weight at last! I’ve had aminophylline and atrovent (IV and neb respectively) when in hospital, though cant really tell if they had a positive effect or if it was the other stuff, but I’d be interested to know if they only come in later or if anyone is taking them without the pred, if I could maybe suggest this to the docs? Asthma is allergic type with chronic gunkiness, not sure if this makes a difference to what meds might be used as routine.

thanks for any info.

Ali

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Like yourself I have had many courses of pred in last year but never maintance dose as I don't seem to benefit a great deal from it but after a 4 week admission in August this year I have started on Uniphylin which is one of the theophille products alongside my other meds which feel like loads. You can but ask.

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Hi Ali,

I take both theophyllin and atrovent without being on long term pred. I take 200mg of Uniphyllin morning and night and have an atrovent inhaler which I take 2 puffs morning and night. They have both been very effective in terms of asthma treatment and I'd hate to think what I would be like if I came off the theo.

Hope this helps

Sparkly Fairy

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Hi Ali,

As others have said, it's quite common to be on these medications for chronic management without being on long-term pred, although some consultants have their own reasons for not using specific medications in specific patients.

I am on both theophylline and tiotropium (Spiriva - similar to Atrovent) and have been for about 12 years (well - Atrovent, initially, before Spiriva was produced) - during that time I've sometimes been on long term pred and sometimes not.

The British Thoracic Society certainly suggest trying these before using long-term pred. You can see the full guidelines here: brit-thoracic.org.uk/c2/upl... - but just to summarise briefly:

Step 1: Mild intermittant asthma

- short acting beta-2 agonist to be used as required (eg salbutamol (Ventolin), terbutaline (Bricanyl))

Step 2: Regular preventer therapy

- short acting beta-2 agonists; plus

- inhaled steroids, started at a moderate dose and titrated down to lowest dose necessary to control symptoms (eg beclomethasone, budesonide, fluticasone)

Step 3: Add-on therapy

- short acting beta-2 agonists; plus

- regular inhaled steroids; plus

[this is where the guidelines start to get a bit complicated and vague - there isn't good evidence for the 'best' add-on therapy, and it's highly variable from group to group, so the suggestion is to try each alternative for six weeks and then stop if ineffective]

- add-on therapy - sequential trials of -

- increasing inhaled steroids to max dose

- long acting beta-2 agonists (eg salmeterol (Serevent), formoterol (Oxis))

- leukotriene receptor antagonists

(eg montelukast (Singulair), zafirlukast (Accolate))

- theophyllines

- slow release beta agonist tablets

[rarely used these days - high level of side effects]

Step 4: poor control on moderate dose inhaled steroids and add-on therapy - addition of fourth drug

- use of more than one of the add-on therapies described above

- referral to specialist to be considered

Step 5: continuous or frequent use of oral steroids

[self explanatory!]

You will notice that there is no mention of ipratropium (Atrovent) in that summary - the guidelines comment that 'addition of short-acting anticholinergics [eg ipratropium] is generally of no value'. I think a lot of respiratory physicians would feel from personal experience that they can be of value in a certain group of patients, though.

You can see from the above that you're currently on Step 4 - because you're on four agents - and that the BTS guidelines would certainly support trialling different add-ons before long term steroids.

As others have said, there's certainly no harm in asking! As Sparkly Fairy says, certainly, theophylline has made a huge amount of difference to me, and I hate to think what I'd be like without it!

Hope this helps

Em H

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Thank you so much everyone. I'd been getting quite despondent as I had a good 18 months on pred before with no one being able to suggest anything else I could try, and if I'm honest since getting off it asthma has been getting increasingly grumbly. I was thinking I'd have to either resign myself to increasing shortness of breath or resort to going back on the stuff. i feel a whole lot more positive now that there are maybe other things that could be tried to get me better control. I have a GP appointment on Monday so I'm going to go along and be assertive, backed up with those guidelines thank you Em, and ask about these options.

thank you, from a whole lot more chirpy Ali

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Hi Ali

I am on atrovent at the moment, as well as seretide 250, singulair, ventolin (inhalers and nebs as needed) and only a reducing dose of pred after an admission, where I was given IV magnesium and nebulised salbutamol (2.5 mg upto 5mg during the night) and nebbed atrovent too. I too have had several short courses of pred (4 five-day courses and one 2-month course this year already, and it isn't even properly winter yet :S)