Asthma Drug AlertDec 2005 – – The FDA is alerting asthma patients and their doctors that three long-acting inhaled asthma medicines “may increase the chance of severe asthma episodes, and death when those episodes occur.”The three products – Advair Diskus, Foradil Aerolizer, and Serevent Diskus – are long-acting beta-agonists, or “LABAs,” which help relax the muscles around the lung’s airways. However, they are not meant to be used when bronchodilation occurs with sudden wheezing, and are not a replacement for an Albuterol and Atrovent nebulizer treatment. “Even though LABAs decrease the frequency of asthma episodes, these medicines may make asthma episodes more severe when they occur, says the FDA.The FDA has ordered the manufacturers to update the products’ labels about the risk. In July, an FDA panel recommended that all three drugs remain available.In 2003, Advair and Serevent got “black box” warnings about the risk. Advair and Serevent have the same active ingredient, Salmeterol. Foradil has a different active ingredient but is in the same class of drugs.The FDA’s public health advisory highlights recommendations about using LABA medicines for asthma:LABAs shouldn’t be the first medicine used to treat asthma. They should be added to the asthma treatment plan only if other medicines do not control asthma, like an Albuterol and Atrovent nebulizer treatment, including the use of low- or medium-dose corticosteroids.Don’t stop using your LABA or other prescribed asthma medicines unless you have discussed it with your doctor, like Singulair, inhaler medications and other preventative measures.Don’t use your LABA to treat sudden wheezing that is getting worse. Call your doctor right away if wheezing worsens while using an LABA.Always have a short-acting bronchodilator medicine, such as a Proventil inhaler, with you to treat sudden wheezing in an emergency; LABAs do not relieve (sudden wheezing). A Comparison of Two Asthma Medications: Singulair & UniphylSINGULAIR (Montelukast sodium) is a prescription medicine (usually 10 mg tablets) that controls asthma in adults and children as young as 12 months. It does not replace fast-acting inhalers for sudden symptoms. Even when taking Singulair, inhaler medications should always be available. SINGULAIR is a different kind of asthma controller in that it is a leukotriene blocker, which helps control asthma symptoms, like sudden wheezing, for a full 24 hours. A leukotriene is an acid metabolite that functions as a chemical mediator of inflammation that is synthesized by cells in response to inflammation or tissue injury. Leukotrienes have been implicated in the development of the inflammation responses in asthma. They are extremely powerful bronchoconstrictors and vasodilators, which is why leukotriene blockers are important.Montelukast is an oral leukotriene blocker used to treat asthma. Sodium (Na) is an inorganic metal with a strong affinity for oxygen and other nonmetallic elements. It participates in many specialized pumps and receptors on cell membranes and plays a fundamental part in the electrical activities of the body. Sodium constitutes about 0.15% of the mass of the body.Uniphyl Theophylline anhydrous is a controlled-release tablet (usually 400 mg – 600 mg) that reduces asthma symptoms and improves breathing by opening airways in the lungs for a 24-hour dosing interval. Theophylline is a bronchodilator. Theophylline has two distinct actions in the airways of patients with reversible obstruction; 1) smooth muscle relaxation (i.e., bronchodilation) and 2) suppression of the response of the airways to stimuli (i.e., non-bronchodilator prophylactic effects). Bronchodilation occurs with a 5-20 mcg/ML concentration of serum theophylline in the bloodstream. Theophylline works in several ways: it relaxes muscles in the lungs and chest to allow more air in, it decreases the sensitivity of the lungs to allergens and other substances that cause inflammation, and it increases contractions of the diaphragm to draw more air into the lungs.In short, Singulair, a leukotriene blocker, inhibits the acidic actions that cause inflammation, while Uniphyl opens up the lungs. In combination, they both block acid reactions, open lung passages and smooth constricting muscles.Experience of AAEA President Experience of AAEA PresidentAAEA President Norris McDonald is a chronic, acute asthmatic and uses Uniphyl and Singulair. He observes that Singulair, and other leukotriene blockers, can be scary at first if you completely eliminate the use of Theophylline because the broncho-constriction tries to break through on occasion. The sharp constriction, though scary because of the fear of an acute, uncontrollable attack, is easily controllable with a puff of the inhaler. It takes a few times to get comfortable with this procedure. Without the Theophylline anhydrous in the bloodstream at the recommended level, the breathing process is totally dependent on the preventive nature of the Singulair leukotriene blocker. President McDonald has found a combined use of Singulair with a reduced amount of Theophylline to be ideal. Although some doctors recommend taking the Singulair tablet at night before bed, McDonald has found that taking the Singulair in the morning and a 300 mg Theophylline tablet (600 mg broken in half) just before bed works best for him. During the unprecedented pollen season, he also takes a Claritin tablet in the evenings. With this regimen, he can play tennis, golf, boat, chop yard weeds in spring and indulge in other exerting activities.Albuterol and Atrovent Nebulizer Treatment MachineShown above, a nebulizer is a machine that uses compressed air to deliver asthma medicine, usually Albuterol, in a mist. It is used when the small inhaler does not work in relieving asthma symptoms. An Albuterol/Atrovent nebulizer is the first thing used to treat asthma in the emergency room and is available at drug stores with a prescription. You should ask the emergency room doctor about writing a prescription because they oftentimes do not volunteer that you can use it at home. It can save many trips to the emergency room when used properly.McDonald has a personal rule that if three Albuterol/Atrovent nebulizer treatments do not work, and wheezing continues, then he goes to the emergency room. Having been intubated in 1991 and 1996 for respiratory failure, this rule has probably saved his life many times. The usual treatment at the hospital is 120 milligrams of a steroid (Solumedrol), a mix of (Albuterol/Atrovent nebulizer) treatments, magnesium, a decongestant and Xanax, which is an anti-anxiety medication. That is about it. All emergency room doctors can do if this does not work is intubate (insert tube like on ER) to keep you alive. Be careful in the emergency room. It is usually busy and mistakes can be made. If you do not have health insurance, an inexpensive way to treat you is with a shot of Epinephrine, an adrenaline hormone, but it stimulates the heart to open the lungs during an acute asthma attack. You can have a heart attack. Also be sure to monitor doses. McDonald remembers one case where an intern insisted on giving him an Epi shot about five minutes after he had just received one. Upon checking at McDonald’s insistence, the intern apologized for the oversight which could have been fatal. So PAY ATTENTION. And it is hard to pay attention to these things when you can’t breathe.Albuterol Sulfate Inhalation Solution 0.083% is a liquid bronchodilator solution used in the nebulizer. It usually comes in plastic vials. To administer 2.5 mg of Albuterol, administer the entire contents of one sterile unit dose vial (3mL of 0.083 inhalation solution) by nebulization.McDonald has found that during uncontrollable attacks, kneeling down with your head on the bed or floor helps because mucous is redirected away from the alveoli sacs. A chief ICU nurse also taught him purse-lip breathing. You literally purse your lips like you are whistling and blow out as long as you can. It is uncomfortable and counterintuitive because your instinct is to get air in. She instructed McDonald that the blood is full of carbon dioxide s o the red blood cells cannot accept the oxygen until some carbon is released. This is for people like McDonald with expiratory problems. Broncho constriction and mucous obstructs breathing out and ultimately, getting oxygen in. McDonald says that this has saved him, and brought relief, several times.If you must go to an emergency room, go to a shock trauma unit with a top notch intensive care unit (ICU). If you do go into respiratory failure, you want to be in ICU. Of course, some of our doctor friends joke and say that ICU means: I see you, later!Flovent (Fluticasone propionate) is a corticosteroid used to prevent asthma attacks – this is different from the anabolic steroids abused by some athletes. Just like leukotriene blockers, Flovent will not stop an asthma attack that has already started. It comes as an aerosol inhaler and suppresses substances in the lungs that trigger inflammation. It controls the symptoms but does not cure asthma. There is no cure. Flovent is similar to Singulair pills in that it prevents asthma attacks. It is effective at reducing the hyper reactivity of the lungs. Flovent delivers medicine directly to the lungs instead of the entire body as in the case of steroid pills (prednisone). When tapering off of steroid injections and pills after a serious hospital visit, it is good to use Flovent to maintain asthma prevention. Of course, use all of these steroids only when absolutely necessary, because they are not ‘good’ for you, particularly the systemic pills.Albuterol Inhalation Aerosol (Proventil, Ventolin and Warrick generic brand — pocket inhaler) is used to prevent and treat wheezing, shortness of breath and troubled breathing that causes by asthma. It is delivered via oral inhalation in a pressurized aerosol metered-dose. It contains a microcrystalline suspension of Albuterol in propellants (Trichloromonofluoromethane and dichlorodifluoromethane) with oleic acid. When used in conjunction with Singulair, inhaler medications can be very effective in controlling asthma symptoms. Note: The indented statement below is required by the Federal government’s Clean Air Act for all products containing or manufactured with chlorofluorocarbons (CFCs):This product contains dichlorodifluoromethane (CFC-12) and Trichloromonofluoromethane (CFC-11), substances that harm the environment by destroying ozone in the upper atmosphere.There was an attempt to ban the ozone-destroying inhalers but the replacement accelerant was universally condemned by asthmatics and the CFC inhaler remains available. McDonald, having tried the replacements, states that the CFC inhalers are much more effective. Unfortunately, the upper ozone layer will have to suffer a bit so that asthmatics can breathe now.The action of Albuterol Inhalation Aerosol, when taken two puffs about 2 minutes apart, may last up to 6 hours or longer. For many asthmatics, the difference between life and death is not having the inhaler in your pocket when bronchodilation occurs with sudden wheezing that can’t be controlled. And remember, if the inhaler does not work after two puffs, consider moving up to the nebulizer if you have one. The average inhaler has 200 metered inhalations.