Inhalers and worsening asthma symptoms

Hi,

I am a 60 year old female. Been using inhalers for some years now. I was having combivent and beclametosone - two puffs each twice a day. This was my maintenance dose and needed both as I would have symptoms every day. However, all was good with this. My peak flow was a constant 450 after useage. End of June I had a very heavy cold and my GP thought it wise to give me antibiotics and steroid tablets. At the same time he changed the beclametosone to QVAR. Got over the cold, but did not use QVAR for some weeks as I still had some of the old one left. When I did change my breathing got worse, I had to use the combivent during the day. It got so bad my peak flow dropped to 250 one morning. Saw my Asthma nurse and she gave me a script for the old inhaler. ( I was going on holiday) Got back and it was no better. Peak flow was back up to 450 but could not sustain it during the day. Still needed combivent. Had another visit to Asthma nurse and she has put me on Symbicort 200/6 and Singulair. I have been using this for a week now. I am not too bad. My peak flow will not go above 400 at any time and on a couple of days I have needed combivent because chest has become tight and peak flow dropped to under 350. I ahve to go back to see the nurse but I was wondering if anyne else has had these sort of problem.

9 Replies

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  • As you've told me your age I'll tell you mine, I'm 49 (not that I like to think that my age has anything to do with my asthma (menopausal denial going on ). This is a bit vague but I had a similar thing happen to me. I had worsening asthma over a weekend a few years ago and ended up going to the oncall GP service. I had recently been put on Qvar. The doctor I saw took me off Qvar put me on to Serevent 6/125 (just looked at the box and the steroid in this is fluticasone plus the wonderful ventolin) and also gave steroids plus antibiotics. I continued on the Serevent for a short while, seeing a locum GP at my practice to have things checked: things were not back to my usual, also around 440, I went back to my GP and saw one of the usual ones who was amazeed that I had been existing on such a low dows of steroid. He increased me to Serevent 25/250 2 puffs twice daily. Things improved and came back to normal. Sorry this is a bit vague - at the time I was a bit scared and panicked about my worsening control.

    This is my maintenance dose which I double or put up by 1 puff ie., 3 or 4 puffs twice daily during a virus. My peak flow is usually around the 440 unless ill with viruses or temporarily it will dip by 20 or a bit more if allergic to something or other.

    Dont know if thats any help but basically I hope theSymbicort will work for you - wonder why some drugs work better on individuals - wish I'd had the brains to do research -

    Go back to your GP if you are not happy with your peak flow - or especially if you are not constant around your predicted normal.

    Now 2 questions what is the Symbicort inhaler - is it a combined steroid and reliever?

    What is combivent?

    Bye for now take care

    sandi

  • Hi woodies,

    Welcome to Asthma UK; I'm sorry to hear that you've been having problems recently.

    Reading your story, I'm struggling a little to quite work out the sequence of events. It seems that two things happened around about the time you got worse - you had the heavy cold, treated with antibiotics and steroids, and you were changed from beclomethasone (Becotide or a generic beclomethasone MDI?) to Qvar, which is a brand name inhaler which also contains beclomethasone. Most people should find that Qvar works in the same way for them as any other formulation of beclomethasone, but there will be the odd person who it just doesn't suit for whatever reason. In some cases people don't get on with the delivery device, and find it difficult to inhale the full dose into their lungs, and in other cases, rarely, the propellant used to drive the inhaler may cause problems,

    Having a heavy cold or a chest infection can also cause a deterioration in asthma symptoms for quite some time afterwards, even once the original infection has resolved. Asthma symptoms can also fluctuate in their severity over time for fairly random reasons that aren't fully understood. So there are a number of possible explanations for your deterioration. I am a little concerned that although you say you were well controlled before all this happened, with good peak flows, you do seem to have been using a lot of reliever (Combivent) to achieve this. The goal of asthma treatment, and the management that has been shown to be safest, is to achieve control by increasing preventor medication so that you are not so dependent on relievers.

    It sounds like the asthma nurse has acted appropriately in stepping up your treatment in order to try to regain some control. On the combination of Symbicort, Singulair and of course the Combivent, you are on Step 4 of the BTS guidelines for asthma treatment (you can see the guidelines here - brit-thoracic.org.uk/c2/upl... - although there are plenty of other options still to try. A week on these treatments is comparatively early days - obviously, if your peak flow drops more or you become unwell you should seek medical help, but otherwise, you may need to give it a little longer to allow these drugs to take effect. It sounds like your nurse is keeping a close eye on you, anyway.

    The vast majority of people do have asthma that can be controlled on the right combination of medication - but it can sometimes take a while to find this combination. There are other medications you can try if this combination doesn't work for you, and if your GP and asthma nurse are really struggling, there is always the option of referral to a respiratory consultant. A consultant will probably want to do a few more tests to make sure that there is nothing else going on that is contributing to your asthma - such as allergies, postnasal drip or reflux - and will have more experience in some of the less commonly used asthma treatments. It might be worth mentioning this option to your asthma nurse (it is fairly standard to consider referral if there is not a good response to Step 4 treatment). It does sound like you are being treated appropriately, as far as I can judge on what you've told us, though.

    Hope this helps, feel free to ask any more questions you might have.

    Now to clarify some inhaler types:

    Seretide - Sandi, I assume you meant Seretide rather than Serevent? Serevent is salmeterol alone, whereas Seretide is the combination inhaler containing fluticasone (a steroid) and salmeterol (a long acting beta-2 agonist, similar to salbutamol but slower in onset and longer lasting). It is a preventor; it can't be used as a reliever as the salmeterol doesn't work rapidly enough.

    Symbicort - very similar idea to Seretide - it contains budesonide (a steroid) and formoterol (a long acting beta-2 agonist). The only real difference is that although formoterol is long acting, it is also rapid onset, similar in speed to salbutamol. This gives the option of it being used as a combined preventor/reliever as in the Symbicort SMART programme, although it doesn't sound like woodies has been prescribed it to use in this way.

    Combivent is a combination bronchodilator inhaler - a reliever. It contains salbutamol (a beta-2 agonist) and ipratropium (Atrovent - an anticholinergic reliever). It's not very often used in asthma any more, because there's not so much evidence for the regular use of ipratropium in asthma, although it is more commonly prescribed in COPD.

    Hope this helps everyone, anyway,

    Take care all

    Em H

  • Hi Emily H, Apologies for the confusion I am on Seretide 250 - don't think I would be much good on Serevent alone!

    Symbicort sounds appealing - why would seretide be prescribed do you think in preference to Symbicort. The Smart trial way of using the combination inhaler seems a really good idea.

    Sandi

  • I don't know, really, sandi, except to say that some consultants have their individual preferences and that some patients appear to respond better to one steroid than another. The British Thoracic Society do not recommend any one inhaled steroid above the others, considering that there is insufficient evidence that any one is superior.

    The Symbicort SMART regimen certainly sounds good, and initial (manufacturing drug company sponsored) trials do seem to show that asthma control is improved compared to conventional dosing regimens. We will have to wait for the results of independent trials - I know there are some ongoing. The regimen is probably particularly appropriate for certain groups of people - in people who have relatively poor awareness of when their symptoms are deteriorating, or who have compliance issues with inhaled steroids, I can certainly imagine that it will improve control quite a bit. People who like a simple regimen with as few inhalers as possible may also be fans - essentially, three inhalers (steroid, long acting beta agonist and short acting beta agonist) can all be replaced with one.

    It's not suitable for everyone, though - people at the more severe end of the spectrum, whose total daily required dose of beta-2 agonist exceeds the 8 (or 12 with discussion with your doctor) puffs of 6mcg formoterol that the inhaler provides, would have to use another single drug reliever inhaler such as salbutamol or terbutaline to top up. Certainly, for those who are always on the top doses of inhaled steroid and doses of beta agonist in excess of this, the Symbicort SMART regimen would involve no real advantage, as the person would be taking the full amount every day anyway.

    Personally, I'm a Seretide girl, and do remember finding that being on flucticasone as opposed to budesonide or beclomethasone did seem to make coming off long courses of pred easier in the days when I was on and off pred like a yoyo, rather than just on it all the time. These days I take seperate salmeterol and fluticasone accuhalers, a strategy that came about from my desire to alter the dose of salmeterol when I was working, to avoid shaky hands at work. Of course, these days I just stick to the maximum dose of both, but I've stayed on the separate inhalers - I don't really mind one way or the other.

    Em

  • worsening asthma

    Hi Em,

    Thank you for your response. I probably did not fully explain myself or give all the facts. Before I changed over to QVAR I had recovered from the heavy cold and even whilst I was poorly my breathing did not get too bad at all. My symptoms are always the same - I get a very tight chest and it's like breathing through a straw. I don't cough or wheeze. I do have food intolerances, colourings and preservatives can cause migraines or sick headaches with blurred vision etc.

    Food stuffs such as dairy, bread and wine affect my breathing. I cannot use aspirin or ibrobrufin. I try to manage my eating and eliminate as much as I can, but you can guarantee there is always something hidden away that causes me problems. I was diagnosed with asthma after having flu and bronchitis. MY GP suspects I had it all my life but the flu etc made it worse. I have had tests for COPD and that has been ruled out. I have had symptoms every day since. tightening of the chest and a peak flow first thing in the morning of around 350. The inhalers have made my life so much easier. As I said previously my dose first thing in the morning and then last thing at night kept my breathing on an even keel. It was only after I had changed over to QVAR that everything went wrong. How long will it take for the symbicort and the singulair to take over? At the moment the highest my peak flow will go is 400. It makes my chest ache. this could of course be attributable to the fact I am using my peak flow monitor more!!

    But many thanks for all the info.

    woodies.

  • Hi Woodies, I'm going to reply on Em's behalf as she's not around this afternoon.

    People vary in how fast they respond to both Singulair and Symbicort. You might notice some benefit from the Symbicort pretty quickly, because - as Em explained below - it is composed of two medications - budesonide, a steroid, which might take some weeks to take full effect - and formoterol, a long-acting beta agonist (LABA), which is a bit like the salbutamol component of Combivent - but it last about 12 hours instead of about 4 hours. The steroids can take some time to fully exert their anti-inflammatory effect, perhaps up to 4-6 weeks. Contrasted to that, with the LABAs you may notice a pretty instant effect as their onset of action is within about 5-30 minutes. So you may feel the benefits of symbicort within a day or so of starting using it, but it will take some weeks to have full effect - so hang on in there.

    With Singulair it's a similar story - everyone is different but again you're probably looking at a few weeks to notice full effects. When I started on it I would say I noticed a difference within the first week, but others I know haven't noticed any effects until a couple of weeks later. The most important thing is to try to remember to take it regularly (it's most effective when taken at night) and to persevere with it to give it some time to do its job.

    Hope this helps.

    CathBear

  • Worsening symptoms

    Hi CathBear or Em,

    Many thanks for all the help. I am using the symbicort and singulair exactly as prescribed and have been for over a week now. Would you expect it to last the 12 hours - because it does not. After around 7 hours my chest starts to go tight and peak flow drops to around 350. If I take one puff of combivent peak flow rises to around 480. Surely, even after a week symbicort should be lasting longer than this!

    Woodies.

  • Hi woodies, I'm sorry you're still struggling. The formoterol component of Symbicort should be working by now and probably should be lasting pretty much the full 12 hours, but the budesonide (steroid component) probably won't have kicked in to its full effect if it's only been not much over a week. The Singulair might not have kicked in to full effect either. Obviously, if your symptoms are very troublesome, your PF is dropping, or you are getting less response to the Combivent, or you are worried in any other way, you should seek emergency medical advice. Otherwise, I'm afraid it's just a case of hanging in there and being patient - these things can take time, but there's no reason to think that you won't have good control once the drugs start to work properly. Hope this helpsEm H

  • Hi woodies, I'm sorry you're still struggling. The formoterol component of Symbicort should be working by now and probably should be lasting pretty much the full 12 hours, but the budesonide (steroid component) probably won't have kicked in to its full effect if it's only been not much over a week. The Singulair might not have kicked in to full effect either. Obviously, if your symptoms are very troublesome, your PF is dropping, or you are getting less response to the Combivent, or you are worried in any other way, you should seek emergency medical advice. Otherwise, I'm afraid it's just a case of hanging in there and being patient - these things can take time, but there's no reason to think that you won't have good control once the drugs start to work properly. Hope this helpsEm H

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