Maximum fostair dosage and a smart plan

[telephonejunkie]

I am very concerned about a suggested change to the management of my asthma following a Pharmacist phone call to check my medication.I have been on a maximum dosage of fostair 2 puffs 200mg B.D for 2 years. I had 2 acute events last year(I don't know if I had covid) and I have daily wheezing having to use my Ventolin now daily. The suggestion is that I reduce to a 100mg fostair inhaler 2 puffs b.d. taking this inhaler for my exacerpations through the day up to a total of 800mg. I used to work in pharmaceuticals training nurses be asthma nurses and the Laba is intended to be long lasting. I also understand that swilling my mouth out with a sip of water which I swallow is insufficient to remove the inhaled steroid and prevent thrush. I have just had treatment for thrust down my gullet! I have now looked up the smart/mart protocols and it indicates it is for people within the mild/moderate management zones. Have I missed something? or is this, as I suspect cost-cutting without actually considering the daily challenges my asthma is causing

[Lysistrata Administrator Community Ambassador]

If you've now looked up the MART regimens, you presumably know that specific inhalers with a long-acting beta-agonist reliever component (LABA; spelling it out for others reading in case they don't know the term) can be used this way.

Fostair has been available for MART (maintenance and reliever therapy for those unfamiliar with the term) since about 2013, Symbicort for longer. However, I assume if you were working for companies making other combination inhalers that can't be used for MART, then you wouldn't necessarily have been aware of the protocol when you were training nurses on how to use your company's products.

Regarding the rinsing, if you're able to gargle with the water and find somewhere to spit it out, that should help against thrush - that's what I do after taking mine and I'm on high dose Fostair, not had any issues with thrush.

If you really think MART isn't going to work for you for practical reasons and/or doesn't work for your asthma, then I would get back in touch with your GP or asthma nurse. It sounds like you should be doing that anyway if you're needing to use Ventolin daily, and it seems that your standard dose of Fostair isn't helping to control your asthma as it is.

It might help to call the Asthma UK nurses beforehand to chat through your options and ask about the MART regimen (0300 2225800 M-F 9-5; WhatsApp - 07378 606728)

This post may also help with other options your GP can look at: healthunlocked.com/asthmauk...

[telephonejunkie in reply to Lysistrata]

Thanks for the response. Although I haven't worked in the industry for a number of years As I'm a Medicinal chemist and my husband has very poorly controlled asthma with permanent damage I do try to keep up to date with changes in asthma care. I didn't believe this protocol applied to severe asthma patients. The main problem with this new regime is that during the day when I use the fostair there is nowhere to spit out the water I wash my mouth with. (I have been using 200mg 2 puffs b.d for 2 years with little problem from oral thrust. In the last week I have used the ne regime of using fostair prn and rinsing and swallowing and I already have oral thrush. This isn't going to be an ideal situation so I think I'm just going to contact the asthma nurse.

[Lysistrata Administrator Community Ambassador in reply to telephonejunkie]

I wasn't sure when replying to your initial post how much you knew about MART, since you said at first that LABA is intended to be long-lasting - obviously MART does allow LABA to be used more than twice a day.

As you say however, MART isn't suitable for everyone, even without considering severity, and it sounds like practically speaking it isn't ideal for you if nothing else. I wasn't sure if you already used water or something more for morning/evening doses - some people use mouthwash, but I agree swallowing it isn't the best and apparently isn't working.

As I mentioned, it seems like the Fostair at the dose you were on may not have been optimal for you even without MART, so contacting the asthma nurse definitely seems like the best approach.

[Poobah]

I've been down this road, with a new consultant changing my meds to the MART protocol despite my known limited response to steroids and the long acting bronchodilator in LABA inhalers. After a heated debate I insisted on carrying my Ventolin but I would try using my Symbicort 200/6 up to 8 times a day to control my symptoms, for 6 months - a big departure from my usual regime. My asthma declined and when I returned to the respiratory clinic after 6 months I saw the lead consultant who was bewildered by the decision to put me on MART. I was put on Fostair 100/6 but this was changed up to 200/6 in order to avoid too much long acting bronchodilator. But doses are strictly twice a day, with Ventolin as a rescue, if needed. I spoke to another consultant in December and he explained that my non-eosinophilic asthma just won't respond well to steroids beyond a certain amount and explained the need for Ventolin, within agreed parameters.

Knowing my asthma phenotype has certainly helped me understand what meds are more effective and what I can personally do to improve my health by changing diet etc.

There's been several posts by people who have faced the "no Ventolin" policy. Even though there's been a shift in attitude towards Ventolin, in that some asthmatics over use it and mask their decline in health rather than seek asthma reviews, there is no ban on Ventolin. I suspect that pharmacists, GPs and other primary care professionals have been reminded to be aware of patients with an over dependence on Ventolin but this communication has been misunderstood by some. An article on unsafe prescribing was published by Asthma UK here: asthma.org.uk/about/media/n...

If we have ongoing communications with our GPs & Asthma nurses, with regular reviews, then knee jerk reactions to Ventolin use shouldn't happen. If you know that Ventolin plays an important role in your agreed asthma plan, then have a chat about your concerns with the pharmacist's intervention with your asthma nurse or doctor.

[telephonejunkie in reply to Poobah]

Thanks for your thoughtful response. Patient overdependence on ventolin has been a "problem" since I first worked in pharmaceuticals nearly 30years ago. Ideally, we shouldn't even be using the emergency reliever every day. What I believe is going on with me has no regard to the management plan.

[Loopylou99]

So the pharmacist has recommended cutting your daily maintenance dose by half, even though you’re struggling? Just no. Perhaps you should be having extra medication added or a referral to secondary care.

[telephonejunkie in reply to Loopylou99]

My thoughts exactly which is why I am asked the forum as a sencor check.