Add on drugs that are usually prescribed by GP; montelukast, LABAs, combination inhalers and steroids!

[EmmaF91]

Hi everyone

As I think I’ve mentioned before this post is going to go into some of the add ons medications for asthma. As there are so many, I’ve decided to split it into 4 posts; those typically prescribed by GPs, those prescribed by secondary cons, those typically prescribed by tertiary cons and those prescribed for the common comorbidities. If something isn’t on this list it may well be on the next! So this is the follow on from “Inhalers; what to take and when!” ( healthunlocked.com/asthmauk... ). I’ll try to avoid repeating info 😉. I’ve also tried to do it in the way they are most commonly added 😅. So on with the infomercial 😉😂

LONG ACTING BETA 2 AGONISTS (LABAs) - salmeterol/formoterol inhalers

For a lot of people a steroid inhaler is not enough to control their asthma, so your GP may try giving you a 3rd inhaler (on top of the steroid and reliever inhalers). This inhaler aims to have a long lasting bronchodilation effect, allowing the airways to stay open for longer. You may be offered this is they believe you have ‘exercised induced’ asthma, that is to say your only remaining trigger on the steroid inhaler is exercise. Personally when I was like that, I was told to take it on the days I trained but that I didn’t have to take it on the days I didn’t. This was over 10 years ago tho so things may have changed! The most common side effects specific to LABAs (and not inhalers in general) are tremors, nervousness/anxiety and palpitations/tachycardia, but usually calm over time!

COMBINED INHALERS

If you find the LABA helps, or if your GP has decided you will need the LABA daily they may offer you a combined inhaler. This is basically a mix of steroid and LABA. Like I said on the inhaler post it takes time to kick in fully, and will take time to identify he right inhaler for you (there are LOTS available 😅). Side effects wise it tends to be very similar to LABA inhalers or plain steroid inhalers. Sore throat/thrush, headaches, tremors, palpitations, tachycardia, nervousness and anxiety etc etc. If it’s too much, doesn’t settle or you don’t feel the benefits outweighs the side effects see your GP and try another mix/inhaler style etc.

LEUKOTRIENE RECEPTOR ANTAGONISTS (LTRAs) - Montelukast/Singulair tablets

Licensed for both adult and children, this is one of the most common add ons but equally one of the ones that causes the most concern for people. People on LTRAs often find they either really help or they do nothing 😅. Those more likely to benefit are from the allergic phenotype, or who have ‘exercise induced’ asthma (EIA) and works to reduce inflammation in the airways. They may take up to 6 weeks to kick in, but if by then you’ve not noticed a difference your GP will likely discontinue it.

Typically people are instructed to take this at night, but those with EIA or those who get bad sleep based side effects might be told to take it in the mornings. Speaking of side effects, this is the one where people get the most concerned. But first please realise that under 15s should be on half the adult dose or less. So adults take 10mg typically, whilst teens and younger are on 5mg.

There have been some instances of a LTRA triggering anxiety/depression/irritability and, very rarely, suicidal ideation (usually in teens), so it now comes with a warning- this is what concerns most people. The lower dose still carries warnings for these effects, but most of the issues were in children and teens taking the 10mg dose, which, as previously stated, shouldn’t be given to those under 15 anymore. My advice to any parents with kids on this drug is to warn them if this. Speak to them, let them know that it’s to help their breathing but it MAY cause them to feel really sad/down/depressed/ideation (whatever term you feel is suitable) so if that happens they should let you know straight away. The risk of this happening is very low (esp compared to the benefits it give) which is why it gets prescribed, however warning them will hopefully help them connect the feeling to the drug. If you/your child has an mood change that you associate with the LTRA, then one - it’s easier to control/ignore that feeling, and 2 - you can stop the drug and book an emergency asthma review with the GP to inform them of what happened and find an alternative ‘add on’. More commonly, the side effects are ‘whacky’ dreams 😅; vivid dreams, lucid dreams, nightmares, sleepwalking and/or insomnia. Personally I used to ‘rewatch’ what I had watched on TV before bed, knowing it was a repeat and a dream - it was really weird! 😂 Most people manage this by switching to taking it in the morning (after informing/discussing it with their doc of course 😉), but for some people the side effects are too much and so they stop - just like with any drug! Also don’t forget that often side effects can reduce the long you take something, so it’s worth trying to stick it out if you can. Personally I went from weird dreams every night, to about once a week, and eventually just once in a blue moon.

STEROIDS

As you’ve probably seen, I’ve already done a post about them here; healthunlocked.com/asthmauk... which should cover everything. But basically if you’re constantly on pred you should be escalating your maintenance treatment regime, and being referred onwards to try and reduce/remove steroids as a daily meds.

So there you have it. Part 1 of the add on posts! And for me that’s a relatively short post 🤣. As I said at the start of the drug you’re looking for isn’t here, hopefully it’ll be covered in the next few 😅. And yes I feel super productive doing both the steroid post and this one in 1 day - making the best of my last day of being 28 I suppose 🤣

[HungryHufflepuff]

Thanks for the info as always 👍Happy birthday for tomorrow 🎂

[EmmaF91 Community Ambassador in reply to HungryHufflepuff]

Welcome. And thanks! 😊

[Celie1]

Hi thanks for the info. I take a combined inhaler, Duoresp Spiromax. The thing that concerns me is I have to take 2 puffs twice a day. , whereas in the past one puff used to be enough to control my asthma. When I try to reduce it I start to get breathless, but I’m concerned about the long term effects of taking such a high dose on a permanent basis. This might be a silly question but how can I get back to taking less?

[EmmaF91 Community Ambassador in reply to Celie1]

If that’s the dose you need right now to be controlled that’s what you need. You may find that once winters over you need less again. It’s not uncommon for people to increase/decrease inhalers seasonally. And if it helps, long term side effects from inhalers are very rare, to the point most doctors don’t think of them unless they actually crop up! (Whereas when they prescribe steroid tablets they tend to think of these a lot more). The actual benefit you get now from controlling your asthma (ie not needing hospital, not becoming a statistic etc), far outweigh the very minimal risk of long term side effects.

I think usually doctors are happy to downgrade/reduce meds after at least 3-6 months of good control. They want you on as little as possible as well!

The other thing to think about is if there are any untreated triggers that you can control. Doesn’t work for everyone, but some people find that helps

For more information about inhalers; healthunlocked.com/asthmauk...

And for more about steroids in general; healthunlocked.com/asthmauk...

Hope this helps

[Celie1 in reply to EmmaF91]

Thanks Emma,I’ve been on this dose a few years now. It used to be that I would increase the dose from one puff to two, if I had a cold/infection, because that’s always a major trigger for my exacerbations. Then after a month or so I could reduce it back down, but I don’t seem to be able to do that now and when I feel like my asthma is beginning to get worse I don’t have any add on. I always end up on 7 days of 8 a day prednisolone, usually followed by another 7 days (one week of is never enough I don’t know why). Then a weaning off period. Is it usual for asthma to worsen as you get older? I’m 63 and started with asthma about 15 years ago.

[EmmaF91 Community Ambassador in reply to Celie1]

Asthma changes over time. For some people it ‘disappears’ for others it gets worse. It is very rare for people to not have ‘severity’ fluctuations over their lifetime.

However if you frequently find you have to use prednisolone, it’s definitely worth querying if the doctor thinks an add on would work for you!

You may also benefit from giving the AUK helpline a call. The nurses are great and will be able to give you more advice. They can be reached on 0300 2225800 M-F 9-5. Alternatively their WhatsApp service is 07378 606728.

Hope this helps

[Celie1 in reply to EmmaF91]

Thanks very much Emma. It helps to ‘talk’ to someone who knows about asthma and makes the time to help people make sense of it. 🤗

[Wheezycat]

Hi Emma, Thank for all that info! I intend to copy and save. Regarding Montelukast my experience is slightly different. I don’t think I have allergic asthma, though I do have the odd allergy expressed in other ways. After a year or more needing Prednisolone several times whenever I got a respiratory virus, my asthma nurses were super keen that I also took Montelukast, and the GP agreed. Side effects wise I was fine, just dreams felt incredibly busy, like watching a crowded street scene on speed. My quality sleep didn’t seem quite as good, but no major worries.

Anyway, I haven’t noticed any difference to my daily asthma experience, but over time my asthma has been much more stable. Unusually I have had just one cold in 12 months, and I sailed through that one not needing to seek help. Since Covid, of course, I have been so careful that my chances of picking up anything at all is virtually non existent, so it has not tested my respiratory infection resistance hardly at all. So I don’t know if I really need it.....but on the other hand I haven’t had any bad episodes. It is something I intend to discuss in a review when I get one.