Rather strange GP appointment

[WindsweptRissa]

Hi there

For background info, I'm 44 and have had asthma since a toddler, which improved as a young adult and then worsened again as I got older. I'm on Flutiform (250, two puffs twice daily), montelukast, salbutamol, cetirizine and recently carbocisteine (for persistent productive cough). Apart from the persistent productive cough I'm generally pretty good with minimal asthma symptoms, although any sort of virus/infection can cause worsening of symptoms.

Anyway I had a cold/cough/viral illness last week which caused a worsening of my symptoms (breathlessness, cough, night coughing and reduced peak flow). I decided to go to the G.P. today because this had been going on for a few days and even with taking the salbutamol inhaler several times a day, I was still having problems and thought I might need a short course of steroid tablets to get me back to normal. I expected the GP to listen to my chest and find no infection (as I wasn't feeling ill as such any more) and maybe do a peak flow reading, and then give me the steroid tablets. But it didn't quite go like that. Now I live in a small Scottish island and our GP surgery relies on a lot of locum doctors. We do have a regular GP but he is only here for a few weeks at a time (he doesn't live here) and the rest of the time it's locums. The doctor I saw today was one I have never seen before.

He did hear me cough, but he didn't listen to my chest at all and prescribed me antibiotics (500mg of clarithromycin twice daily for a week) "to get rid of any residual infection". He looked at all my medication and asked if I had been checked for COPD. I said I had had some spirometry a couple of years ago, which came back better than normal, and that this had been done because my mother has COPD from having asthma since childhood and because of my productive cough. He said that once I am better from this flare up I should either have some more lung function testing or I could try a third type of inhaler (he didn't say what is was called) which if it got rid of my productive cough would prove I had COPD. He thought the inhaler option would be better as he said in the early stages of COPD lung functions tests can come back as normal and he seemed to think that I did have COPD. At this point although I was a bit confused as to how readily he gave me antibiotics (it must be at least 10 years since I had any) I was listening attentively, because frankly I'd try most things to get rid of my annoying cough. But then it got a bit weird. He wanted to tell me how to take my inhalers properly as he said a lot of people don't know. He told me that when I had a flare up like now I should be taking my preventer inhaler and also the rescue inhaler maybe 6 times a day (OK so far as this is what I do until symptoms have gone) and then I should continue taking the preventer only for a few more weeks and then I should stop it (now this is when I thought WTF). He went on to say that I may feel a bit breathless in the morning at first but I will get used to it, and when I get another flare-up I should start the regime again as before. He said that if I do this I will gradually have longer and longer inhaler free periods which is good because long term use of inhaled steroids means the steroids get into your system. Now I have never heard anyone suggest this before. The GP who put me on flutiform after several virus induced flare ups decided not to even try bringing the dose down because if accidentally miss a dose I generally start to feel uncomfortable a few hours later. Now after his guidance on inhaler use I don't know what to make of the first part of the appointment. I've started taking the antibiotics anyway and will keep an eye on my peak flow and symptoms (I'm not in the danger zone). I need to find out when this GP goes (hopefully he wont be back again lol).

[PMRPete]

Interestingly strange! With some very strange remarks about inhalers.

Not surprising after reading an article about GP's in Shetland; a fork-lift driver applied for an associate GP's job!

[WindsweptRissa in reply to PMRPete]

We don't have any problems getting appointments where I live compared to a lot of places in the UK, but it is a bit hit and miss as to what you get. I've had to deal with differences in opinions between Drs on other matters, but this is definitely the most bizarre one yet.

[Hidden]

I was recently told by a pretty clued up doctor that if my asthma is seasonal or caused by an allergen, to only take a preventative inhaler during that season or when I know Ill be exposed to the allergen. He also said there is a newer Corticosteroid that targets just the lungs and doesnt activate in other body cells, like you I didnt get the name.

[WindsweptRissa in reply to Hidden]

Although I do have allergies, I don't have seasonal asthma. I'm also triggered by exercise, viruses, changes in temperature and irritants (e.g. Walking into a room where someone gas sprayed a body spray). My inhaler is a combination inhaler and if I say accidentally miss it in the morning, because of the long acting bronchodilator component, I'm starting to feel uncomfortable by the afternoon. I'm also on the highest dose of that inhaler. That advice may well be suitable for someone who has mild asthma and is only triggered by one thing, but this doctor was giving this advice as though it were standard for everyone, which I found a bit alarming.

[ChrissieMons]

Tailing off the inhalers to see how you are is an option. However, the results can be skewed by what you expect to happen: if you think it will make you worse, then it will. The idea is to get you on the least medication you need to keep you well. Didn't work for me, in spite of my positive thinking, but at least I tried it. He was quite right to check your inhaler technique. The jury is out on the effects of long term steroids as some say that they have no significant effect, but others think they just might. Some people, especially some with late onset asthma, can do well with the regime he suggests of only taking it if you feel you might be going down with a bug, or your breathing is more laboured than usual, but it is a very individual thing.

You know yourself best. I can only suggest you consider your options, look up as much as you can online esp on the asthmaUK website and decide what you think will be best for you before you see the GP again.

[Matman]

Maybe consider getting a 2nd GPs Opinion on what the 1st one suggested. If the idea proposed turns out to be a good one, you don't want to deny yourself the opportunity of testing it.

[green881]

I've had my share of minor mis-directions from GPs although since I have long experience I usually don't let it get into a complete goose chase.

Having said that, the general idea of tapering your ICS and re-starting is actually the same idea as my pediatrition-allergist-asthma specialist I had from 0-18. Actually British trained. And he was brilliant.

So I wouldn't reject it it totally out of hand - it sounds like a ton of new information not sure how much time you had and whether he can write some of the key points down. Maybe you misunderstood the more bizarre sounding points.

In fact, tapering and titrating (lowering the dose to the lowest level needed to control) in general seemed to have gone out of style in the last 20 years, not sure if it's making a comeback.

Of course you know yourself and your asthma best, so proceed with caution. If you think you're in a better phase you might want to try it, but I would stay under close care and monitoring from the doctor/nurse at least by phone. And of course, keep ventolin on you at all times while doing something new like this.