What is Normal

[Homely2]

I am on fostair 100 under the mart regime.

Most weeks I get one major asthma attack taking me down to approx 50 percent of my peak flow, cannot walk or talk, and the rest of the week more minor attacks daily. The major attacks are a little scary for me, and very scary for my wife.

Under the mart regime I am allowed to go up to 8 doses a day, so I do this after a major attack. I then get better, with minor issues, so I go back to 4 doses, then a couples of days later I deteriorate etc, which culminates in a major attack.

I am off to see the asthma nurse next week at the hospital.

What am I expecting her to be saying? Is the above normal.

I am only with her temporarily, so a little concerned she will send me back to the gp asthma nurse.

Also concerned Re triggers, the last attack took me from 630 to 331 really quickly, but I don't know the cause. I just woke up, did my readings, took my meds and went downstairs to the kitchen.

[Troilus]

I’m no expert Homely, I have only learned through my own experiences and what I have learned here and from my clinic.

So, that said, I would say that your asthma is not controlled. As I understand it, the aim of the game is to have zero attacks and very limited use of the blue inhaler. Now, this is not always possible, but from where you are now it may be or at the very least things could be a lot better for you.

I started on Fostair 100/6 but still had attacks as soon as the beneficial effects of prednisone wore off and so I was increased to 200/6.

Along the way I have had various other things added into the mix. Maybe this is something to discuss with the clinic nurse while you have her. If you are still experiencing a lot of attacks I would suggest your current regimen isn’t working for you.

[Poobah]

The aim is to keep asthma symptoms at bay with use of a preventer inhaler, such as Fostair, and maybe additional meds like Montelukast. Ideally, Ventolin use is maybe 2 or 3 doses a week.

It sounds as though you're currently like a pin ball machine, lurching from alot of treatment to control attacks, to low treatment, which leads to uncontrolled symptoms and more attacks.

If you're seeing the clinic nurse I would prepare a table of symptoms, peak flow results and meds taken on each day for the last month at least, 6 weeks if possible. It will be easier for the nurse to see the erratic nature of your treatment and resulting symptoms/attacks. I would also stress that you find jumping between high and low doses aren't working for you and would appreciate help in achieving more tailored treatment that keeps symptoms in check.

I'm currently on Fostair 200/6, 2 doses twice a day, so twice your Fostair steroid dose of 100 x 2 x 2. My asthma nurse says my dose is moderate, which suggests your dose is at the bottom of the range. That's just an observation.

The UK uses the Asthma Stepwise Management approach and you can Google this to see how doctors are supposed to increase treatment on a step by step basis in order to control a patient's asthma symptoms. Only when control has been maintained for a decent period of time should treatment be scaled back, one step at a time.

Good luck.

[Lysistrata Administrator Community Ambassador in reply to Poobah]

Agreed in general - it sounds like something more needs adding, because this regimen isn't working. MART isn't for everyone and it sounds like it isn't working, as your asthma really doesn't seem controlled Homely2.

I would say though Poobah that your asthma nurse isn't correct about Fostair dose levels. 800 micrograms total daily dose (ie 200/6 two puffs twice daily) usually is a moderate dose of inhaled steroid, but for ultrafine particle inhalers like Fostair you need less drug to get the same effect, so the cutoffs are different. I checked as I'd been told my dose was high (I'm the same dose as you, 200/6 2 puffs twice daily) - and for Fostair it is considered high (see link here, scroll down to Combination inhalers:

cks.nice.org.uk/topics/asth...

So 100/6 two puffs of Fostair twice a day is moderate, and Homely2's max dose is the 'high' dose for Fostair. Which sounds like it's just not enough! It sounds like something more is needed, and there definitely are other options Homely2 that you can discuss.

These posts might help to give an overview of what else is out there as an option: healthunlocked.com/asthmauk...

 healthunlocked.com/asthmauk...

If you haven't already, it's worth calling the asthma nurses to chat through your options to ask the nurse about: 0300 2225800 or WhatsApp [phone] Monday-Friday 0915-5pm

[Chip_y2kuk]

Your asthma is not controlled and unfortunately in the world of respiratory problems they (doctors) like us to fit in a box and have a normal behaving condition and quite alot do but there are also quite alot that don't

So if your on fostair as mart there are a number of options really

1. Increase to the 200/6 (but you can still only take 800mcg of beclomethasone so 4 puffs a day... so this isn't normally used in mart) and you would also need a ventolin/salbutamol for as and when needed (which you should have even on mart)

2. Add another therapy... montelukast, spiriva being the obvious two next ones to try

3. A short sharp blast of prednisolone... quite often does the trick the prednisolone works quick to fight back any inflammation allowing the fostair to keep it that way

works for some not for others and prednisolone isn't that nice a medication, it has lots of side effects and potentialtial issues... but not being able to breathe is a pretty big issue too

4. Decide that fostair just isn't working and you are going to need to try a different combination inhaler (their are tons of different ones)

5. Allergy testing .... sounds daft but you can be allergic to "airborne allergens" and keep coming into contact with them without knowing and they will just cause respiratory issues a quick IGE test will tell you if that's the case ... if its high they then use the same sample for testing a specific set of allergens (normally dust, pet dander, specific pollens etc)

If The the above is the case montelukast is known to be useful for people with allergies and asthma(but is like marmite... you either love it or hate it) .. but an antihistamine of some sort will at least help (avoidance is best but in the real world you can't always avoid them)

Also how long do you take 8 puffs for? .... it takes about 36-48 hours for any change to start to have an effect.... yes the formoterol works in minutes but the steroid takes a little longer to "do it's thing" ... so you may need a sustained burst of 8 puffs

I once was going through the fostair 100 every 2 weeks @8 puffs a day ... this lasted for 3 months before I ended up in absolute bother

[Homely2 Administrator in reply to Chip_y2kuk]

Thank you for this.My asthma is quite allergy based, dust mites and pollen per the ige tests. Also hates mould, and the present cold air. I live by the coast, so a good easterly gale can be interesting.

Might try an air filter.

Montelukast sounds interesting.

[Chip_y2kuk in reply to Homely2]

Dust at this time of the year is horrific especially as it loves warm moist environments and central heating blows it everywhere ... we've got an air purifier and small dehumidifier . ... the air purifier gets the most use

Chip

[Homely2 Administrator in reply to Chip_y2kuk]

Your options were pretty spot on.The hospital asthma nurse put me on fostair 200 and Montelukast. She also said she was sending my notes to the consultant to check.

My only issue is that she has sent a note to the gp asking them to actually prescribe the revised drugs. So it may all take a while.

In the meantime I have just got a chesty cough, which I have never combined with a period of uncontrolled asthma before. So it is a new, rather unpleasant experience.

[Chip_y2kuk in reply to Homely2]

Glad they where a help

They tell me that from hospital to GP "stuff" test results/ doctor telling GP what to prescribe etc etc can take up to 5 weeks.... now from experience it is measured in weeks but I've never had it be 5

Chip

[Jollygood]

hi Homely

Excellent advice above but I just wanted to add that fostair doesn’t work for everyone. I was exactly like you (weekly attacks and ongoing symptoms) whilst on fostair 200/6. Eventually I was changed onto relvar & I’m now much better controlled. It may be you need a different inhaler. Good luck & let us know how you get on.

[eleanordigby]

Apologies if you’ve mentioned this in another post, but have you been considered for biologics?