NHS medication recommendations, and minerals

Hi all,

as there are no asthma nurses at my current home country, doctors are God, and I never had asthma back in the UK (I miss the clear air up north!) I'm a bit at a loss about what a normal asthma therapy looks like.

I have Ventolin for whenever needed and I'm supposed to use a Salmeterol powder inhalter twice a day for maintenance. Well, the Ventolin works and has no side effects. The Salmeterol is terrible: my hands are shaking, tunnel vision, fast heart beat, loss of concentration for at least two hours, plus dry spots in my mouth which cracked upen in the end despite washing my mouth. And that's only the really bad side effects. I'm not sure if it's also responsible for some irregular heart beat at night. I've stopped it until I can see my doctor again next Monday. I feel so much better now and the wounds in my mouth are healing.

Are there other options for maintenance, either different ingredients or generally something less aggressive? Is it recommended at all for a so far one time attack? What is the general NHS recommendation on this?

Secondly: many of the mineral elements in my blood are already very low: calcium, magnesium, phosphorus too low, potassium on the edge. How do the medications influence these, and should I substitute them?

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Hi,

Salmeterol is a long acting (LABA) version of the Ventolin/Salbutamol and both can make you shaking, tachycardia etc. I have huge problems with both and, as I have a heart condition do not take them as they make my heart rate sky high.

There are alternatives which might be worth investigating if possible - Formoterol is also a LABA which I can take with less side effects. The other thing that strikes me is that you shouldn't really use these without a steroid which is why they often come as a combination inhaler. I take Fostair which is a steroid and Formoterol and Symbicort is Formoterol and a different steroid. It doesn't sound like Ventolin is a problem but if it is contributing to your side effects (they are very similar) Terbutaline/Bricanyl is a reliever which I have found reduces the side effects. Unlike salmeterol, Formoterol can be used to relieve symptoms as it works very quickly so you can use some doses as a preventer/reliever.

In the UK, asthma nurses etc tend to use the stepwise approach which might be worth looking at (it is widely available on the web) and gives other options in terms of treatment. Monteleukast is a tablet which is good for allergic asthma etc and might also be an option. There are so many different meds around which do similar things it can take a bit of trial and error to find what is right for you and even then it can change (I have had asthma for nearly 30 years and have tried all of the above before finding something which for me (at least for now).

I'm not an expert but I think some of the leaflets do mention low potassium as a rare side effect but perhaps something to check out with somebody who knows for sure.

Hope this helps.

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Thanks a lot KaylaCP,

yes, that certainly helps! My doctor seems to put more emphasis on a LABA as main part of the therapy, while I read in the NHS recommendations that those should only play a role in the third step

So, according to those recommendations:

STEP 1: SABA, which would be Ventolin, but also Terbutaline/Bricanyl?

I do have minor versions of side effects described above with Ventolin, but at least I'm able to work. Ventolin could work a bit better for me though. What is really annoying is that my nose also blocks up, and I simply cannot breathe through my mouth. As soon as I stop thinking about it I close my mouth again and breath through my nose. When I have a cold and my nose is blocked when sleeping I often wake up trying to figure out why oxygen levels are low, and only then remember to open my mouth. I'm on nose spray for two weeks now and am trying to find alternatives for it (hot water inhallations, honey).

STEP 2:

Add in low dose inhaled steroid if uncontrolled.

Quoting from you:: ""Fostair which is a steroid and Formoterol and Symbicort is Formoterol and a different steroid"" Looks like my doctor skipped this step.

STEP 3:

Consider choices of add-on therapy (LABA or LTRA) to inhaled steroid

My doctor also prescribed me Montelucast for nights to try out, but I'm not sure if it's working or not. It certainly unblocks my nose and I don't get any side effects from it.

I don't think the demi-God of a doctor will like it if I come with suggestions but I'll bring a print out of the recommendations along for the next consult anyway.

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Glad it helps - it certainly did when someone on here pointed it out to me.

Just a quick notes, step 2 would be just the steriod which are inhalers like clenil and Flixotide. Step 3 would be adding the LABA (Formeterol or Serevent) but these days they both drugs are in one combined inhaler like Fostair, Symbicort and Seretide (which contains Serevent). If your nose is often blocked and Montelukast helps it could be it might be an allergy which can contribute to asthma. My nose is also always blocked due to several allergies.

I felt a little uncomfortable first suggesting things to the doctor and thought I would look like I was asking for stuff that they might not feel I need. However, my GP now asks me if I have found anything on each which might help (my asthma is very uncontrolled at the moment).

Take care and let us know how you get on.

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Just to re-iterate. You shouldn't ever be on a LABA without being on an inhaled steroids - i'm surprised that any country has a policy of doing this!! What a LABA does is the same as ventolin, except in a way that lasts a bit longer. The trouble is it doesnt work fast like the ventolin. This means if bronchoconstriction and inflammation are building up (inflammation will build up in an asthmatics lungs if they are not on an inhaled steroid) then when the LABA wears off you can suddenly be having a sudden, severe attack. Most asthmatics ONLY need a steroid inhaler to go with their SABA. Most people's asthma day-to-day is primarily inflammation which is what the steroid treats. You possibly would have no need for any treatment beyond that! They do however take a couple of weeks to work.

Both SABAs, LABAs, and some other asthma treatments (like theophylinne) can lower potassium. This effect would usually be seen with taking 'too much' however some people are particularily sensitive. Potassium is a suppliment that should be monitored by a dov=ctor. High (or low) levels can cause significant cardiac symptoms without you noticing until you're in a lot of toruble. You might wish to eat things like bananas which are high in potassium and i'm pretty sure you can't OD on baananas (and if you can my niece is in trouble!!). Interesting thing about the magnesium is that i know a few people who benefit with their asthma taking a magnesium suppliment, monitored by doctor, and I personally know I hugely benefit from IV magnesium during a severe attack! Calcium is very important if you ever have oral steroids, but tbh is kinda important anyway, i'm surprised that if they know you have low levels they arent giving you suppliments. You'd have to ask if that is something that needs monitoring, but i'm sure they are available over the counter which to me suggests it is difficult to overdose. Phosphate can be lowered by a few things, including chronic mild hyperventilation. Do you 'pant' when you are breathing at rest? It is quite common for asthmatics to over-breathe, or breathe in an ineffective way due to the problems we experience breathing when our asthma is bad. It might be worth concentrating on slow, deep breaths. I would recommend a referral to a resp physio if you do tent to over-breathe, but it depends if that is available where you live!

If you are needing to use your reliever innhaler (SABA) more than three times a week that would normally indicate uncontrolled asthma (on the AUK page they have a control test somewhere). the mornal order as I think has been mentioned would be SABA, steroid (increasing the dose to find an effective dose), then LABA, then an additional 'add-on' therapy (montelukast, theophylinne, etc), and then long term oral steroids. This is a slightly over simplified version, but that would be the general expected pattern. Each time you would stop if a particular treamtnet didn't work for you. All this would go alongside individual treatments to assist avoiding triggers (which could potentially involve antihistamines to treat allergies, PPIs/reflux preventing medications to treat reflux which can trigger asthmaticcs, medication/talking terapy to treat anxiety, physiotherapy to treat breathing pattern disorders). Once you got to an add-on therapy not working then a GP would probably look at refferal to a respiratory consultant at the hospital. Obviously you arent at the stage of getting through all of these yet, but i thpught id explain it in full for your reference.

In terms of 'only having had one attack' that isnt really relvant. You shouldnt be experiencing daily symptoms, optimal asthma control would mean your asthma did not stop you doing anything you wanted to do. So it is only once the side effects of medication out weight the benefits of gaining optimal asthma control that you would 'settle' for daily symptoms.

Assuming you are using a spacer device, and rincing your mouth out (and rushing your teeth) after using the Salmeterol, and that the symptoms you desribed persisted for a few weeks of use then i would say your reaction is probably enough to consider it an allergic-type response. Certainly the cardiac effects are worth mentioning!! I would reccomend that if you don't get relief from the steroid inhaler you try a different LABA. It is possible you are just highly sensitive to LABAs and then you and GP would probably have to work out the best plan of action (possibly skipping that step and going to alternative add-on therapies)

This is my understanding of UK asthma management! I hope it is correct and makes sense

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Thanks a lot!

Your answers really help a lot I feel bad for asking all these questions but I feel like i need to figure out everything myself.

I would be surprised if my country of residence has any medical policies at all. They hire doctors from all over the world, and everyone has a different background and knows different policies. I don't think the government cares much.

I'll see my doctor again today and talk to him about what you mentioned. I also read the same in other European countries' policies.

Side effects: Yes, I do have reflux every now and then. I was given a PPI which I also need to discuss. I now know that's the culprit for my stuffy nose; and various mucous membranes started bleeding as well. Argh! I wonder if there's one medicine around that I can take without side effects! I know I'm particularly sensitive (while friends took ecstasy at raves in the 90s all I needed was an over the counter pain killer with coffein for the same effect!), but this is getting ridiculous.

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Thanks a lot again. I've been prescribed Symbicort now. It might be a bit of an overdose at the moment, but the doc thought I should try it as he's seen less side effects than with other medications, considering my ridiculously long list of side effects. So far it seems to work ok with the exception that it seems to reduce my lung volume a little bit unless I use a reliever with it once Right, that's back to the doctor then. I'm testing this now, but I think the stuffy nose is actually caused by the reliever. Argh!