Pharmacy followup phone call & Is it still considered 'mild' asthma?

I have just been prescribed Flutiform 125, 2 puffs twice a day as my asthma wasn't sufficiently controlled on the preventer alone (previously 400mcg-800mcg per day of Qvar for the last 3 months or so). We discussed the results of my reversibility testing previously done and also my peak flow readings and then had a discussion regarding which meds I should try next at which strength then what the progression might be if things are still not as good as they should be - all in all a very thorough discussion . I have arranged to either go back or have a follow-up phone consultation in a month to see how I am and if there is any improvement in my symptoms.

When I got the prescription from the pharmacy I had the usual questions of have you used an inhaler before, etc. to which I said yes I have had quite a few different ones now including steriods but have not had this particular one. She then said they wanted to call me in a week to see how I was getting on with it to which I asked why as I had already arrranged to have a follow-up with my asthma nurse. I declined her offer as I prefer to speak to the asthma nurse who I have been building a good relationship with and who understands my symptoms rather than explaining everything to a second person who has no access to my medical records - it just seemed a bit odd to me. Has anyone else had this? Is it useful to have this or not?

Also, I had assumed that I just had mild asthma as I haven't been hospitalised and have only just recently been diagnosed as an adult, although I have had some pretty scary incidents but my reliever has worked well, sometimes requiring a few more puffs though. I've also not really had any symptom free days since long before diagnosis so taking my reliever at least once every day, it has impacted my activity and routine a lot of the time and I don't recall sleeping through the night since the start of the year. I have read that Qvar is quite a strong med (especially at 800mcg per day) and flutiform 125 is generally more for severe / persistant uncontrolled asthma. I was wondering which category my asthma 'fits in to' - should I be worried that it is more serious than I first thought?

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  • That does sound like a very thorough discussion, i've never had that. My asthma wasn't very well controlled last year an i was just basically put on a merry-go-round, try this one and come back in 6 weeks, try this one and come back in 6 weeks.

    A bit like you i always considered my asthma to be mild - i know now it's definitely gone into at least moderate. i'm not sure what the exact definitions are but as i'm now on a combination inhaler i'm pretty sure i can safely say i've 'progressed' into a more serious category. I was diagnosed as a child though and was pretty well controlled for many years.

    Also like you, i was on Qvar 800mcg a day but that became ineffective for me which is why i started the merry-go-round. I'm now on seretide 250, which is the same steroid as flutiform (double the strength of yours) but with an additional long-acting bronchodilator alongside - 4 puffs a day and i think i've got the right one now!

    I once got that thing of pharmacy follow-up too, although despite me agreeing to it they never actually rang me!

  • I was told once (many years ago) that my asthma was mild - and by a consultant. At the time I wasn't sure that he was right (I'd had asthma for twenty years by then) but didn't have the confidence to challenge him (I was in my twenties at the time). Back then there was nothing like the variety of medication available, and I was put on a very lose dose of Becotide (Beclometasone). I ended up in hospital as a result - the only time that has happened in my life. I've never been afraid of querying doctors - even consultants - since then.

    I believe my asthma to be moderate - I'm currently on flixotide 250 (same steroid as flutiform but a stronger version and without the long acting bronchodilator), and this usually controls it very well, although seasonal variation affects the amount of it I need to take. There has been some discussion about changing it with a respiratory consultant as well as one of the GPs at my local medical practice as it is under suspicion of causing problems elsewhere in my body. No change has happened yet. It was agreed that if there was to be a switch it should happen in the summer when my asthma is very stable, but as I am due to undergo a medical procedure (not asthma related) some time this year, no change will be attempted until after that has happened.

    Interesting what you say about the pharmacist. I've never had this happen to me, though to be fair for the past twenty years I've attended a very rural medical practice which has an in-house pharmacy. Very useful!!:-)

  • Thanks for the replies, Jinglefairy - I do feel lucky that after a couple of frustrating consulatations with Doctors I have found a really good asthma nurse. it's really been helping me with what is quite an unsettling time. I have less luck with pharmacies - lots around but a big variation in the meds they stock. A local one within the surgery sounds lovely Maggie. I was initially given Qvar by mistake by one pharmacy were clearly (as was I at the time) unaware that it was double the strength of what I had been prescribed. I often go to one by my work during lunch but it can be a total nightmare as its so busy, on Tuesday it took over half an hour to get my inhalers and I only have a 45 minute lunchbreak in which to get them in. Getting slightly frustrated with the amount of people who choose to go to the pharmacy during lunchtime if they don't have to - I would choose to go at a quieter time if I could! Anyway, rant over.... :-)

    Flutiform 125 is not going great so far. Although it doesn't make me cough like the Qvar did and it doesn't have that really foul taste my asthma is exaccerbated lots in the last couple of days since being on it. The long acting broncodilator is great until about mid-afternoon when it clearly wears off and the steriod dose appears not to be enough to stop the inflammation so come about 3pm I'm destined for hours of coughing and struggling for breath for the rest of the day. By the time night comes I'm exhausted and my chest is so irritated that I'm taking lots of my relever to be able to go to sleep. The nurse was torn between precribing the 125 and 250 dose as I had been on quite a high dose of inhaled steriods previously but I opted for the lower dose as I hate taking any/lots of meds and people thinking that I'm sick and weak (personal pride thing here!). I think I probably need to get used to taking lots of things now though... :-( I think this was me just hoping that my asthma is only mild but it clearly is more moderate and very persistant! Going to give it a few more days to settle then give them a call and see if I can up the dose.

  • In terms of whether or not your asthma is mild/moderate/severe/brittle etc it doesn't *really* matter. The only word that really matters is controlled or uncontrolled! Control means you should be able to do your normal activities, sleep through the night, use your reliever three times a week or less, and be able to exercise. If you don't meet those criteria your asthma is uncontrolled (which clearly yours is!) and so treatment should ideally be ""stepped up"". If you had to take a zillion tablets, inhalers and nebulisers but your asthma was controlled then that would probably not be the end of the world, whereas if you're just on a qvar inhaler and unable to function in daily life then that is a big deal.

    Asthma is usually managed step-wise, as I'm sure came up in the discussion you had with the asthma nurse (a good asthma nurse is worth their wieght in gold)

    Step 1= reliever inhaler (usually salbutamol)

    Step 2= +steroid inhaler (beclomathasone, budesonide, fluticasone - fluticasone is usually considered the most 'potent' but has the most systemic effects, whereas qvar, one of the types of beclamethasone, has the finest particles and so is supposed to help at lower doses)

    Step 3= +LABA (long acting reliever, either salmeterol or formeterol - formeterol is both long acting AND rapid onset so some of the combination inahelrs can be used as both a reliever and preventer, usually this is Symbicort SMART or Fostair MART)

    Step 4= +add-on therapy (generally montelukast first which is good for nocternal or allergic asthma, some people with limited response to LABAs havea very pronounced response to montelukast, I think its to do with the specific type of asthma you have. Some GPs like adding in a theophylinne (Uniphylinne, slo-phylinne, phylocontin etc) which is a slightly more old fashioned drug however I think its a good-un, if you're ever in hospital and very ill they sometimes give this as IV aminophylinne, its a bronchodilating drug but has some nasty side effects like nausea, anxiety, tachycardia)

    Step 5 = +long-term oral steroids (this is the point where you definately need to be under a respiratory consultant)

    As with any medication you want to be on the lowest possible 'step' to keep your asthma well controlled, so usually if you're never needing your reliever etc then they'd try stepping you down and if you get poorly then they can always step back up. I guess if you really wanted to discuss severity of asthma then it would be simplest to define it by which step you need to be on to be controlled. Steroids take about 2 weeks to build up in the lungs. As I said, fluticasone is a very potent steroid, and is often very effective, however it will take time to work. If however your struggling at the moment it might be worth going to see the asthma nurse (or GP) again as it is possible that a short course of oral steroids would be useful to help you while the fluticasone builds up. Oral steroids have some evil side effects when used long term, and so GPs are often reluctant to prescribe them however in short courses they're just very effective at treating asthma as they're in such high doses. If you're deteriorating I wouldn't mess about, i'd get to the GP asap to get checked out - you don't want to end up seriously ill and needing emergency treatment!

    Do you have a spacer? Spacers are very important in making sure you're getting the absolute maximum amount of medication into your lungs, if you dont have one you should be able to ring up the GP surgery and just ask the receptionist to ask a doctor to prescribe one - it shouldn't be a problem. Your pharmacist will be able to show you how to use it. The follow-up call is a reasonable system they have set up for individuals like you who have been on a fairly low level of treatment. It sounds like your asthma nurse is fantastic, and so for you the service is much less useful (and if I were you i'd have probably declined as well) but many people are simply given an inhaler and sent on their way, and often they get the impression that acombination inhaler is basically the 'top level' treatment and so if they continue to get symptoms then they just need to get on with it, so a pharmacist contacting them to see how they are getting on is a good way of ensuring that the medication is actually working for them! Pharmacists are a very under-used resourse, they are great at what they do and really know how to get the best out of medication. Use of spacers is one way of making sure youre getting your inhalers properly and either pharmacist or asthma nurse would be able to tell you how to use one properly. Pharmacists are also good at checking your inhaler technique (a surprising number of people are incredibly bad at using their inhalers properly - the number of people I see in hospital who press the butter and inhale a good few seconds later nearly gives me a heart attack) and helping you to monitor your asthma, many now do asthma check-ups. You should also make sure that you rince and gargle after using your inhaler to stop it trashing the inside of your mouth.

    Another good idea is to monitor your peak flows - again, if you don't have a peak flow meter then your GP should be able to prescribe one - to see the trend. Basically big zig-zags are a sign your not well controlled. You should always know your best peak flow (there are online tools to predict best peak flows based on height and age however these are only useful as a guideline until you have gathered enough data to know your personal best ever peak flow) and use that as a tool to monitor how your breathing is. Generally 75% or higher is considered acceptable, 50-75% is considered 'symptomatic' and below 50% is an attack, you should always go on symptoms and how you feel as a priority, but peak flows can help back up your symptoms with more objective numbers. Usually if you're struggling to get out of the middle, yellow, zone then that might be a time to go to GP and step-up treatment or add in some oral steroids, and generally if you're not able to get out of the bottom, red, zone you should be getting emergency treament. Monitoring peak flows can help show general trends and help identofy tirggers. Most people montior two or three times a day and you can order peak flow diaries from asthma UK.

    I'm sure the asthma nurse explained a lot of that to you, but I have exam revision to avoid so I have spare time :-P Hope you're feeling better soon!!

  • Wow, comprehensive response - thanks Soph! Yes I have a spacer and peak flow device although I've only really taken readings before and after taking my reliever to prove it is asthma so I don't have a normal value yet to compare against as I haven't had my asthma under control since diagnosis. I'm pretty tall though, very active and wasn't a prem baby (in fact well overdue and a whopper at over 10lbs) so would expect my peak flow to be higher than It is once the asthma is under control. Just living on my relievers at the moment but will definitely go back to the docs if I can't manage until the steroid change kicks in. I just hoped it wouldn't take as long, although the nurse said it would, but I thought as I was already on a different type of steroid the new one would sort of take over from it - wishful thinking perhaps!

    I saw on another of your posts that you're struggling with uni exams and illness - sorry to hear that. I can't imagine how hard it is with asthma hospitalisation, but I had plueracy pretty bad in my last year at uni and missed loads of lectures because of it - I went from on course for a 2:1 or first to a 2:2 in the end, was barely able to get to any lectures for 3 months. The worst thing I did was suffer in silence and just tried to carry on. I never returned to the doctors after diagnosis when looking back I think I actually had asthma triggered by it and a few asthma attacks during that time, although I blamed the plueracy at the time. In hindsight I should have said I was struggling and asked for extensions. I just didn't want to have to repeat a year and stay another year without all my friends and have another year of debt - does that sound familiar? So anyway, I do hope you feel better soon and don't be afraid to let people know you're struggling. Also, try to take some time out for yourself if you can, have a girly pamper session, anything that helps you relax. Good luck with your exams.

  • What was your 'after' number like? Thats often a good starting point for establishing a personal best as it'd hopefully be when your lungs are more open (although obviously this wont deal with the inflammation so it will be a clearer reading once things are more settled). It will at least give you a range of values to worry about, although as your personal best increases you'll have more worrying numbers. I have a very high personal best (600) and frankly its a bit of a PIA in A&E as a peak flow of, say, 300, sounds pretty good, but for me thats only 50% so is much more significant than it sounds. It sounds like you might have a high peak flow, but I know someone who runs marathons and has a peak flow of 200, no asthma or anything, just really useless peak flows :-P I think some of it is technique for a lot of people (I think flute playing has boosted mine) and some is just 'one of those things' so dont be weirded out if you do have a low PF. I would start monitoring it (at least morning and night) for a week or two - you should be able to print off a chart. It'll just give you a good indication of which way things are heading with the new medication.

    In terms of relievers, do bear in mind that they really should be lasting about 4hrs, and if you're not finding them lasting 4hrs then it is significant and probably should warrant getting checked out. Remember that vsalbutamol only deals with the bronchodilaiton, not the inflammation, and if the inflammation goes unchecked for too long then it wont matter how much salbutamol you use, you wont be able to breathe. Its common for people to 'soldier on' for as long as possible before getting help, but asthma can and does kill, and the worse you are when you get treatment, the more treatment you're going to need! Remember that you can ring 111 anytime (but usually if your GP practice is open they'll just reffer you back to them) to get advice - but more importantly thats how you can access GP appts out-of-hours. Better to get seen when you only need a GP appointment rather than waiting till you need an ambulachariot (far fancier than an ambulance).

    These two ICU admissions in a row have really exhausted me. My breathing has just been getting so bad and it just wears me out!! The first admission I ended up on BIPAP (don't know how much you know about that kind of thing but basically a mask that blows air into your lungs to take away some of the work of breathing) coz I was so exhausted my co2 levels were getting really high. And because I also have severe, chronic joint pain, which has been worse while i've been poorly, as well as the pain in all my breathing muscles, I'm currently on a high-ish dose of morphine (not high in the grand scheme of things but faaar more than i've ever been having before) and that zonks your brain as well. I have no idea how i'm going to do in these exams because trying to revise feels like dragging my brain through mud!! The not wanting to stay an extra year thing - yup - 100% my life right now!! So badly just want to be finished and be like everyone else - although a few of my closest friends are doing masters so at least I wouldn't be alone. I am keeping my department as up to date as possible, I think they know how hard I try to work (nurse in ICU said I should get a first just for making the effort to revise in ICU) and keep up. I've had about 9 or 10 hospital admission during this academic year alone as well as lots and lots of time at home when I was very anaemic, or had kidney infections which were trying to kill me or when they missed the appendicitis, as well as obviously lots of chest infections etc. and so was unable to function like a real human. I've already missed one exam, which i'll be taking during resit week in August, but I'm desperately hoping to get as many as possible done 'on time' so that resit week isn't evil. Last year I basically did all my revision and all my exams during resit week (6 exams in 5 days) but thats a risky strategy as I could sooo easily be poorly during the week and then thats it for another year. I just so want to be done with it and finished and know what I got and do well. I'm never going to get the grade I could have got had I not been so ill these past three years, but I want to get an ok grade. I'll be gutted if I miss out on this.Everyone says how well i've done just to keep going, and that no matter how I come out of it it's an impressive achievement, but to me thats not enough. I know I under-estimate how hard it is to have all this stuff going on with my health but I feel like i dont want to use it as an excuse - silly i'm sure, but its how I feel.

    Went to see the lecturer today and he was AWFUL. Bearing in mind I've not been able to go to the revision sessions (where they went through the 2014 exams) due to being in hospital and yet he refused to give me a written version of the marks because its against departments policy to give them out - even though technically everyone else got the answers when he went through the paper!! And then when I asked him a question and he found out I hadnt gone through all the workshop questions before asking him it he refused to help me!! Said I should be trying to work it out myself. I was so upset because I'm trying sooo hard, but not only am I exhausted and trying to revise while I feel like death, but I've also got a load less time to revise than I should have had because of how much time I spend in hospital!! I'm just asking for a little bit of help to make this huuuge task a bit less impossible. Sigh!

    Think next weekend i'm going to get my housemates to do a movie and takeaway night as a treat. Next week is my worst week of exams and so I'll need cheering up! Thanks for 'getting it' :-) nice to feel less alone with it!

  • Hi Soph,

    You sound as though you've been having a very bad time of it.

    I don't know which university you're at, but do you have a director of studies, or tutor who can help out when it comes to dealing with unsympathetic lecturers. My younger son (another asthmatic, though his condition is mild now) had a bad spell in his final year (he studied architecture) and his director of studies did sort out one or two issues for him when lecturers and studio people got difficult.

  • All asthma needs to be kept under control. So called mild asthmatics are also at risk of attacks.

    I was switched to Qvar from regular beclometasone. Was told it is stronger but take a lower dose of it. Was also told the particles in it are smaller and so suit some asthmatics better.I seem to be doing well on it. Taking less ventolin. I also take montelukast which works well for me but I know it does not suit everyone.

  • Also ,see previous reply, I take 400 qvar daily( divided I to two doses) and have been told I am a moderate asthmatic.

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