Add on drugs that are usually prescribed by a consultant part 1 (LAMAs, add-on inhalers, theo)

[EmmaF91]

Hi everyone - it’s been a while! Here is the next (probably long awaited 😅) infomercial! Here are some of the drugs commonly prescribed by a local consultant. That being said, GPs can (and do) prescribe a lot of them, but I’d suggest if you’re on one of them and are not under a hospital consultant (and have never seen one) I’d strongly advise getting referred there to make sure you’re on the right drugs for you! So here is PART 2 of asthma add ons (Part 1 - GP add on meds can be seen here; healthunlocked.com/asthmauk... )

LONG ACTING MUSCARINIC ANTAGONISTS (LAMAs) - Spiriva/Braltus/Incruse (usually tiotropium)

Commonly prescribed to COPD patients, it’s been found that some asthmatics benefit from LAMAs. LAMAs are a form of anticholinergic which aims to reduce smooth muscle contraction and reduce mucus secretion in the airways and sub mucosal glands. If you google it (or are into reading about drugs) the term anticholinergic is typically used to refer to antimuscarinics, however technically it doesn’t just cover antimuscarinics. Tiotropium is a preventer drug, not a reliever! However ipratropium (atrovent) which is the same class as tiotropium can be used as a reliever, however you shouldn’t use tiotropium and ipratropium at the same time.

I have not listed all options here just covered the most common devices, so if I’ve missed yours, sorry and please list it below! Spiriva comes in 2 styles - respimat (a MDI style mist) and handihaler (a dpi), however with asthma the respimat is the only one that’s officially licensed 🙄 (or rather this was the case a couple years ago- it may have changed since!). Spiriva Respimat is also licensed for 6+ (at a different dose to adults of course!) who aren’t controlled. Braltus and Incruse are both DPIs. People on a ‘triple’ inhaler (such as Trimbow and trelogy) have a steroid component, LABA component and LAMA component.

Usually it is not advised to use a spacer with the respimat inhaler. It can be done (it will fit etc) but as this is a mist and not a ‘normal’ inhaler, there is a possibility not staying airborne properly. If you do decide you need to use a spacer (or you are advised to), it’s best to try and use it through a smaller compact spacer (like an aero chamber) rather than a volumatic spacer, to make sure that it doesn’t ‘condense’ before it gets into your lungs.

Common side effects include dizziness, palpitations, headache, nausea, drowsiness, constipation, dry mouth/throat, indigestion, flushing, skin reactions, tachycardia, vomiting. It can also cause eye and bladder issues, angiodema and confusion. Like most drugs, the initial side effects usually calm down, however if they are persistent or unbearable contact your GP/consultant!

ADD-ON STEROID INHALER - Alvesco/Qvar/Pulmicort etc

I won’t go into this too much as I think I’ve already covered this in previous posts! For more information about steroid inhalers (well inhalers in general 😅); healthunlocked.com/asthmauk...

Sometimes your doc may think you need more inhaled steroid, but usually the best advice is to have a different steroid to the steroid base of your normal combination inhaler as your lungs will have a limit on how much of each steroid base they’ll absorb. That being said, sometimes doctors use the same base to maximise the steroid dose, without increasing the LABA in someone with a combination inhaler, so if you aren’t sure you can always ask if that’s what they are wanting to do!

Whilst any plain steroid inhaler may be used for this, a special shout out to alvesco. Alvesco can be hard to source, however it has been linked to helping patients get off of oral steroids, then they can then be weaned off of the alvesco!

As will all med changes, this should only be done with doctor approval, to make sure you are having too much of a base steroid etc.

THEOPHYLLINE/AMINOPHYLLINE (Uniphyllin)

The old fashioned ‘wonder drug’ that no doc likes prescribing cause it’s ‘tricky’ 😂. Levels too low (technically under 10, but docs tend to be happy if you’re over 8) you’re untherapeutic, levels too high (over 20) and you’re toxic. Because of this you need blood tests 5 days after you start the drug or change the dose, to make sure you’re therapeutic. This is also a marmite drug - you either love it or hate it!

Signs of untherapeutic levels

From my own experience this seemed to present as ‘asthma flares at weird times’. For me I found that I started to get asthma between 4 and 8 (when I took next tablet) both am and pm, for a few weeks until I thought to get a blood test. Other people might find that they generally have less control as if they weren’t taking the theo at all.

Side effects/Signs of toxicity

Possible side effects of theophylline are;

Agitation, irritability, restlessness, tachycardia, hypotension, rapid breathing, Nausea, vomiting, abdominal pain, headaches, tremors, hallucinations, seizures, hyperglycaemia.

If you have side effect symptoms you should get your levels checked to make sure you haven’t become toxic.

Usually once you start on theo they do a test to see what your levels are and then again if they’ve had to adjust your dose (if your levels were low). Once they are confidence you are therapeutic they won’t retest unless you start getting side effects or asthma starts kicking off for no apparent reason (as these can indicate toxicity, untherapeutic levels or your body not getting along with it any more). If you are side effect and symptom free then there is nothing to worry 😉

That’s all for this one, so I hope you’ve found it useful! Part 2 should cover azithromycin and sodium cromoglicate, but thought this post would get stupidly long if I put them here too 😅😂.

[runcyclexcski]

Thank you, Emma. I have added Qvar to Seretide, thinking that Qvar would deal with the small airways, whereas Seretide would deal with the large ones.

Been thinking to ask about LAMA, too. Funny that most often ideas have to come from the patient, not so much from the GP.

[Wheezycat]

Thank you, Emma! Interesting read! It brings back a memory. Our daughter was diagnosed with asthma when she was five, and regimes tended to be different. At first it was all Ventolin, but that didn't stop night time symptoms, and she had a so called barrel chest, and once collapsed a lobe in her lung, and so on. For me as a young mum it was all scary. She got prescribed theophylline tablets to help with night times. They were HUGE capsules more suited for a horse, and I was really worried if she would choke on them. I vividly recall the first time I gave her one - I just put it on my palm and said here you are, and ......turned away! I literally couldn't watch, and of course I did not want to infect her with my panic. But she just cooly washed it down, and that was that! I was in awe!A few years later she was prescribed sodium crogomlicate, a so called spinhaler. That worked fine - exccept when camping, as the capsules then just tended to collapse rather than pierce. Still we got through it! At the time we were told, I think, that theophylline(?) worked less well for, say, a nine or ten year old, thus the replacement. It all sounds so different now. It was a registrar specialist who prescribed them and she is now 38, still with asthma, but with much fewer asthma problems than those days.

[risabel59]

Hi Emma, good post, just a point about about theophylline, it is sometimes prescribed at a “non therapeutic “ level so you don’t need the blood tests, I have it to address lung “twitchiness” I can be set off by certain things very easily. I know my consultant, and few others prescribe it like this. ( my GP just goes along).

Also for some people it helps to have a LABA/LAMACombination inhaler, so then you can adjust the steroids according to symptoms. However I am not sure any of this would happen via a GP.

Your post was very clear and I think helpful for lots of people

Thank you

R

[djbctla]

Thank you Emma very clear well written informative Bernardine