Autoimmune Diseases Blog

Can I Double My Intake of Flovent During the Cold and Flu Season?

admin — Mon, 05 Oct 2009 07:01:11 +0000

Kathy: I take Flovent and Serevent daily for asthma. I have a problem with all the viruses – cold and flu – come fall and winter, and I would like to get through this year without a flare-up. It has been suggested not to increase the Flovent unless there is a drop in peak flow. Since the drop is hard to stop after it starts dropping, why not double Flovent when I am exposed to those with colds? I understand the need to use the least amount of Flovent as possible, and thus the suggestion to increase the dose only with a corresponding drop in peak flow. But last winter, each drop needed to be jump started with prednisone. In that case, wouldn’t it be better to prevent or minimize the drop in the first place with more Flovent? I use 100 mcg (dry) Flovent, morning and night and I also get flu shots.

Dr. Kraemer: You ask a very good question. How do you prevent worse asthma during the toughest times of the year? You have also described that, without changing anything, you are still going on prednisone with each cold or flu illness. The answer to this question would vary from doctor to doctor. My answer is to give patients a “Plan A” for the daily maintenance medications – in your instance, Flovent and Serevent – and a “Plan B,” which are the medications to use in the event of an exacerbation. It sounds like you have no additional medicines. “Plan B” medications can be inhaled albuterol, nebulizer albuterol, and even possibly a short course of an oral antileukotriene, such as Singulair or Accolate.

When that is not helpful, you will need to use a short course of prednisone. If you still find yourself constantly reaching the prednisone with every URI, then ask your doctor if they feel it would be better to upgrade your “Plan A” medications. Going to a slightly higher dose of Flovent, or even adding the anti-leukotrienes as a daily therapy may be all that is needed.

School and Asthma Medication

admin — Thu, 24 Sep 2009 21:50:59 +0000

Erin:

Well, I would think that they would want to because as I understand it, asthma is the number one reason for school absenteeism, and of course we want these kids in the classroom. We don’t want them to have to stay home because they have asthma.

Nancy:

Absolutely.

Erin:

Do children’s asthma get worse because they transition to school? I mean, does that often happen? Do they often have flare-ups? And how do you handle that medication problem?

Nancy:

Well, the medication problem is a real challenge. In the state of Virginia, we just recently were able to get legislation that permits children to carry their inhalers at school. It was basically a statement reinforcing a federal law that already gives students this right, and it’s called the Americans with Disabilities Act.

Nancy:

And this information is also in our school education packet. Every child with asthma does have a right to carry their inhaler on their person. The schools just need to establish policies that make that safe to do for all students, and so by safe I mean the student must be responsible for keeping their inhaler under control and not sharing it with other students. They must be old enough and trained by their physicians about, how to take their inhaler the correct way and also how to, know when it needs to be refilled.

So, there’s all these intricate stuff that, at first, seem overwhelming when you’re trying to coordinate a child’s care at school.

But as a mother of four children, three of whom have asthma and allergies and other kinds of health problems, I am very encouraged that it can be done.

You just take things one step at a time, and you just don’t try to do too much at one time.

Erin:

Well, and remember that communication with that school nurse, the doctor or the teacher is the key.

Nancy:

Oh, absolutely.

Patient Comment: Impact of Asthma On My Life

admin — Thu, 24 Sep 2009 18:39:38 +0000

Maureen, while you’re with us, may I ask you a question–how has asthma affected you during your life where you need such a lot of medication?
Maureen:: I’ve had some pretty significant asthma. I mean, I’ve only been on these more preventative drugs, the Serevent and the Beclovent for probably the last, I’m going say like the last year maybe. And I was much more heavily dependent on the Albuterol before that, and then I started having some significant problems where the Albuterol just wasn’t working which is a really scary thing, you know, when you take a blast and it doesn’t do anything. So I got on these more preventative types of drugs. But to be honest with you, once I’m on meds, I do whatever the heck I want to do. It has no impact. I mean, I have to be aware of avoiding cats, which is my biggest allergen, but beyond that, I do what I want to, when I want to, where I want to. I just need to stay on the meds. So the drugs have really helped a lot.

Your Child’s Asthma Management Plan at School

admin — Wed, 23 Sep 2009 21:49:48 +0000

Erin:

So, [the asthma management plan] includes triggers, medications, and allergies, I would imagine. Now, then you send your child off to school, and there they are spending their majority of their time now away from you. How can you deal with their asthma management plan? What happens when you take it to school?

Nancy:

This is a very traumatizing time for parents. Every fall we get calls in from parents who are just out of their minds because their child’s asthma was so well controlled, and then they send their kid to school, and there’s a class pet such as, in one school there’s this cat that’s allowed to roam through the entire school. In other cases it’s a hamster that’s in the classroom or what have you, or in the cafeteria some children are exquisitely allergic to milk or peanuts, and they will anaphylax – that means their airways will shut down very rapidly – and could die. We have produced a school pack for parents and for school educators to use, and that has been very helpful. That’s also available through the organization at our website. But we also conducted a survey. We’ve heard for 15 years from families every single year about the nightmares that they were having, so we conducted a survey of the schools to find out what are the burning issues, and we found that 61 percent of the schools do recognize that there is an increase in their students with asthma over the past three years.

Erin:

So, [asthma] seems to be on the rise?

Nancy:

Yes, it definitely seems to be on the rise, and they’re taking notice of it. Well, 41 percent of the schools surveyed do not allow children to carry their asthma medications on their person while they’re at school, and these are schools that do not always have a school nurse on staff, so that the child when they go down to the clinic to get their inhaler.

Erin:

This has to do with the zero tolerance policy, no drugs on kids absolutely.

Nancy:

Exactly. And yet in their air at schools as reported by these administrators says, it’s like 56 percent of the schools allow class pets, 76 percent use chemical sprays and pesticides.

Erin:

I would imagine dust and mold is a problem because our schools are aging and the infrastructure has been falling apart for years now.

Nancy:

Well, absolutely, and 36 percent of them say their schools are carpeted, which the carpeting just holds molds and dust and all types of pet dander. So these are all issues that parents are faced with. The good news was that the majority of them did understand that asthma can lead to death. 71 percent of the respondents said they want educational materials for their clinics and for their libraries. They want training for their personnel, and they want to do a good job for our students.

So, what we need to do, [as] parents, teachers, physicians and policy makers, we need to come together to structure healthy learning environments.

And what is healthy as a learning environment for students with asthma is healthy for absolutely everyone.

Managing Asthma and Living a “Normal” Life

admin — Wed, 23 Sep 2009 17:04:36 +0000

I’ve noticed that there are many people with asthma who seek information, but some people are rather complacent about it. As an asthma specialist, are you concerned that some asthmatics may not be doing all they can to manage their illness?
Dr. Shapiro:: Oh, yes, it’s a major problem! As I was saying, people should be able to lead a fairly normal lifestyle. And many people go under-treated because they put up with dysfunction and they don’t really need to. There are very well-tolerated medications these days. Even if you don’t want to get rid of your cat, you shouldn’t just give up and say, “I’m going to have to deal with this.” There are options today, and many people can do better than they’re doing.
Andrew:: Would you please describe the latest drugs and treatment available to people for both management and episodic treatment of asthma?
Dr. Shapiro:: Understanding that asthma is an inflammatory disease, in the last ten years or so, has led to the development of therapies that really hit the inflammation. There are also very good rescue medications today to get you out of a bind when your anti-inflammatory isn’t quite doing everything. We were talking earlier about some of the types of anti-inflammatory medications. There are non-steroidal agents like Cromolyn and Adocramil, and the new leukotrine agents. And then there are inhaled corticosteroids, which are very good for mild disease and also for moderate and severe disease. There are a number of brands available so that people have choices now, between more classic metered dose inhalers, the “puffers” that people see on TV shows and movies, and all over the place. And also dry powder devices, which may be easier for some people to use. There are all sorts of spacers and holding chambers to help people get the medication into their lungs. So there is a wide range of anti-inflammatory therapy. There is also a wide range of bronchodilator therapy. And each patient who has asthma, at least chronic asthma that’s a daily or almost daily problem, should have a daily management plan, and an action plan. So that there are things that they can do right away when things aren’t going well, to keep them from losing sleep and ending up in emergency rooms.
Andrew:: One of the classes of drugs you talked about was an inhaled corticosteroid that could help people with moderate to severe asthma to keep it under control. Is this something that you do routinely–take a couple of puffs when you brush your teeth in the morning and then again at night?
Dr. Shapiro:: That would be a typical sort of program, where it’s very easy to do and would not interfere with your day or your night. And amazingly, something like an inhaled corticosteroid used that way–two puffs morning and night–can make a huge difference. If you could look down with a little telescope into the bronchial tubes you would see that over a week or two or use, swelling would calm down, mucous production would calm down, and you can make an angry airway look very normal with drugs like inhaled steroids.
Andrew:: I understand that there are national guidelines suggesting that patients with ongoing asthma have a plan to manage their illness. How is a plan formed–for example, is it written?
Dr. Shapiro:: It would be a good idea for you to tell your doctor–or, your doctor may come up with it spontaneously–that you would like to have something that you can hold on to, something that you can refer to in the future, that refreshes you on what you should be doing every day to maintain good health, and then what you should do when you start to see things going downhill. So that you can catch things early and not have an emergency.
Andrew:: Is there sort of an overriding take-home message you’d like to leave with our audience?
Dr. Shapiro:: I think the message all along is that people can be managed well so that they can have a normal lifestyle, and that preventive therapy on a regular, ongoing basis with these anti-inflammatory medications is very important to maintaining that sort of good lifestyle we want for everyone.
Andrew:: Well, that’s a good message and I think one that’s very comforting to people to know that they can go on and not suffer with asthma.

How to Educate School Personnel When Your Child Has Asthma

admin — Tue, 22 Sep 2009 21:48:56 +0000

Andrew:: You’ve mentioned about other people who work with a child – teachers and school nurses and others. Let’s talk about that for just a second. So, the parent and the child get comfortable with a treatment plan, and recognize that asthma can be under control. But certainly there are asthma flare-ups, and there are things that happen and needs sometimes for higher levels of medication. It could happen within the school day, perhaps. So what is the responsibility of the parent, and maybe the child themselves if they’re a little bit older, as far as helping educate school personnel, for example, so that they can be part of the team?
Dr. Gower:: Well, I always try to discuss, first of all with the patient, even if it’s a four, five, six-year-old youngster, because, the younger the child is, the more control the parent has over the care and nurturing of that youngster. But, as they grow older, all children exert some independence. So the kid has to buy into this. The teachers need to buy into it and be educated. I send literature to them, I write them notes and letters, answer their questions, and write out some sort of asthma management plan to the teachers, the athletic directors, the principal, any nurses that might be in the school, so they understand that the youngster with the asthma is not just trying to get out of exercise and P.E., or trying to use this as an excuse not to participate in planned activities. And with that education, I find most parents, most youngsters, most relatives, and most schoolteachers are very compliant and, by using all these different resources, utilize their different talents and different slants on life and different problems to come up with, I think, a more compliant patient and better results.

Goals for Treatment of Asthma

admin — Tue, 22 Sep 2009 17:02:59 +0000

Dr. Stempel, can you talk a bit about what doctors hope to achieve in the treatment of asthma?
Dr. Stempel:: We know of asthma and we talk about asthma as being an inflammatory condition in which there is swelling in the airways, and we have very specific drugs that we use to treat this inflammatory component. So when we talk about patients who have persistent asthma, be it mildly persistent asthma, but people who are affected more days of the week than not with their asthma, then we start using drugs that we call anti-inflammatories. These are preventative drugs. They are drugs like inhaled corticosteroids.Asthma is a disease that for many people comes and goes. And I know it’s very hard for a patient with asthma to say, “I feel well, why should I be using the medication?” But it is of ultimate importance that they use these every day, and this will get us to the point of really improving the underlying asthma condition, really being able to achieve the goals that we want to, which is really enjoying life, being able to be out with your family, your friends, and being able to be physically active.
Dr. Redding:: One of the ways that I describe the different treatments for asthma to parents and to adults is, if you have a cough or a wheeze, you use a certain medication that we call a bronchodilator, as a way to alleviate those symptoms, whether they be cough, wheeze or shortness of breath. And that’s the manifestation or the outward presentation of asthma. In contrast to that, when Dr. Stempel talks about anti-inflammatory drugs, he’s really talking about the drugs that treat the process of asthma. And you can treat the symptoms forever, but if you don’t treat the process, you really don’t get to the underlying reason why you’re sick.

Can Asthma-Related Symptoms Develop Into Asthma?

admin — Mon, 21 Sep 2009 21:47:29 +0000

Andrew:

Joining us now, Dr. Gower, is Colleen from Norwich, New York. Colleen, thank you for being with us.

Colleen:

Hello.

Andrew:

I understand you have a 3-year-old child, and you’ve been told that your child has asthma-related symptoms. Tell us a little bit about that and then your question for Dr. Gower.

Colleen:

Okay. When he was a year old, he was hospitalized. He had pneumonia. And they diagnosed him there. They said he had asthma-related symptoms, that it wasn’t asthma, and they put him on Intal and Azmacort and albuterol when he got a cold. And he’s had that now for about two years, and he doesn’t wheeze when he runs. He doesn’t have any problems that you ever associate with asthma, except when he gets sick. When he gets a cold, it’s always worse. It turns to a sinus infection or an ear infection or bronchitis. And the inhalers have really done a lot of good keeping it under control, but I was just wondering, is that something that’s going to turn into asthma when he gets older? Is it really asthma now? Or, is that something that maybe I can do something now to prevent it from changing to something worse?

Andrew:

Good question. We were told that too, with our young child. It was – I forget what they called it, but restrictive airway syndrome, or something like that.

Dr. Gower:

Reversible airway disease. Bronchiolitis, bronchitis, respiratory syncytial virus. There are lots of terms.

Andrew:

So when is it asthma?

Dr. Gower:

Well, that’s a real gray zone. Is there a family history of allergy or asthma, Colleen?

Colleen:

I guess in my husband’s family there’s asthma.

Dr. Gower:

Okay. So there would be certainly a chance that your, is this a boy or a girl?

Colleen:

Boy.

Dr. Gower:

That he could develop into asthma or allergies or both. Allergies and asthma are related, and they’re hereditary. There’s certainly not a guarantee that he will have this, but if these symptoms appear at this age with that family history, the son has a higher than normal – across-the-board statistically – chance of getting asthma. At this point, upper respiratory infections are the trigger factor as I understand it, right?

Colleen:

Yes.

Dr. Gower:

Okay. How many times a year does this occur, approximately?

Colleen:

Well, they had him on the Intal at a lower dose, and it occurred a lot. It was every probably three weeks we were taking him to the doctor with some kind of infection. But since they raised it up to what it should be, it hasn’t been that much. It’s been like maybe once every two months or so.

Dr. Gower:

So, he’s taking it four times a day?

Colleen:

He’s taking it two times a day, four puffs a day.

Dr. Gower:

Four puffs, so that’s another way to do it. It probably doesn’t work quite as well, but he’s getting a full dose in. It’s not really a twelve-hour medicine, but that still is going to be a nice compromise, and it’s very difficult to get any medicine in four times a day. So, that’s great. I would do that. He’s doing that on a regular basis?

Colleen:

Every day, yeah.

Dr. Gower:

Okay. And Azmacort also, or not?

Colleen:

Azmacort when it starts turning into something, before it turns into an infection.

Dr. Gower:

Okay. So whether they’re calling it asthma now or not, they’re using the Intal on an every day basis, right?

Colleen:

Yes.

Dr. Gower:

Okay. So they’re really treating it as if it’s asthma or irritable lung disease right now, and there’s not a safer medicine out there than Intal, so I would suggest that you’re doing exactly the right thing. They’re hedging on the diagnosis because it’s very difficult at that age to make the diagnosis because you really can’t measure the lung function, and they’re doing everything right by getting more and more aggressive, depending upon if the previous treatment was adequate enough. I would suggest that you stay the course, and if not doing well, then start thinking about adding another thing, and that would be, again, as I mentioned, Singulair, which is a leukotriene modifier down to age two. And certainly, he’s three now, so it would be a different way to control the inflammation. Azmacort is an excellent anti-inflammatory cortisone, [it] doesn’t work real great if you use it acutely for emergencies because it just takes days to weeks to really reach full benefit.

But it doesn’t absorb into the bloodstream as much as prednisone or other systemic steroids do.

Andrew:

Dr. Gower at what age would Colleen, as a parent, know whether in fact this is asthma and would need to be managed long term.

Dr. Gower:

Generally, depending upon the personality of the youngster, it’s around four to five or four to six years of age when you could adequately measure the lung function to see if they have reversible airways disease, and can do a good pulmonary function test to show that it’s asthma or not. When in doubt, they’re doing exactly the right thing, and that’s treating it as if it’s asthma, but it’s not being called that at this point. One other thing, before I forget it, I would consider having somebody check a blood gamma globulin level, because you mentioned that he’s had pneumonia and sinus infections and ear infections. Now, we all get these occasionally. Certainly, youngsters get ear infections and sometimes sinus infections, and pneumonia certainly is there – if you have bronchospasm and asthma attacks you can also get a lot of mucus from the respiratory infection, but asthma itself produces a lot of mucus and then predisposes you to pneumonia.

So, if he’s had these things, one would wonder, is it just the twitchiness of the airways and the inflammation and the viruses that are triggering this, or does he have perhaps a low IgA or a low IgG antibody in his blood? So that’s an easy test to check.

Andrew:

Now, just so we understand the significance of that, if they check that and it is low, is that easily controlled? Or what happens then?

Dr. Gower:

Well, there are five different classes of antibodies. The IgE allergic antibody, which is frequently related to the allergic asthma or allergies or hives or food allergies; there’s the IgD, which we don’t really understand much about; and then there’s three classes that we typically measure under these circumstances when there’s a lot of infections. IgA, which protects the eyes, mucus membranes, respiratory tract, and the bowels. IgG and IgM which protect the interior of the body against bacteria. The IgA is really pretty commonly deficient, low, and it’s like one in 250 people who have allergies. Across the board, it’s about a hundred – one in 600 or 700 nationwide. You can’t really replace the IgA, but you’re more prone, and to give antibiotics if you have an IgA deficiency because you just don’t have enough defense out there to prevent the viral infections. You’re also more prone to push the person onto prophylactic medicines like the Intal on a regular basis and perhaps get flu shots and so on. The IgG can be replaced, so the one thing that you’re really looking for that you can really totally turn around is an IgG deficiency, because we can give infusions, injections, of the IgG to replace a deficient blood system.

Andrew:

Okay. So, Colleen, it’s just something worth looking into.

Is it Necessary to Use Medication Long-term for Asthma?

admin — Mon, 21 Sep 2009 17:01:01 +0000

Gina:: The goal for a parent often seems to be, in any kind of medical issue, to not have to do any medication. With asthma, is there any reason to avoid medication if it’s working, and is it really necessary to stay on it long-term?
Dr. Redding:: The hardest concept that people and families deal with is the fact that asthma is chronic and that it has to be controlled, that there is no cure for asthma as we know right now. Hopefully, that will change in the future, but right now asthma has to be prevented, and it has to be controlled. In order for it to be controlled, someone usually needs to be on medicine at least daily. That’s a very tall order, particularly when a child or a person feels well. They may not be normal in terms of lung function, but they feel well. They’re able to function daily as they would expect to do. In that circumstance, they tend not to take their medicines, so it’s very common for us to prescribe medicines and even more common for people to forget them.
Gina:: And it’s important — I think we discussed this. You need to be very honest with your doctor about whether you’ve been taking the medicine or not so the doctor doesn’t have to over-prescribe?
Dr. Redding:: The goal of asthma management should be doable to the family. There are families that are truly challenged by the chaos in their lives, the disruptions in their lives, the number of children they have, their income. A whole number of things go into how families survive daily life and its challenges. To add on top of that the layer of a chronic illness in a child that requires daily monitoring or daily therapy is a large order. Part of that is convincing people that indeed the therapy does improve the clinical condition of their child. Part of it is trying to develop a daily routine that allows for asthma management thatisn’t terribly inconvenient, isn’t terribly complex, and is very effective.

Aggressive Asthma Treatment Needed – to Prevent Airway Remodeling

admin — Sun, 20 Sep 2009 21:45:57 +0000

Andrew:

There are many people who avoid taking medications when they don’t have active symptoms and feel that they are better off. I understand you experts now say that my not be necessarily true.

Dr. Lanier:

We used to think when people had asthma but weren’t wheezing, that they were okay, that asthma was just a problem of muscle spasm. We’ve learned differently through the years. What we’ve learned is that the body responds to swelling in the lungs, so-called inflammation – not infection, now, inflammation – by a process of scarring. So, basically what happens to people over a goodly period of time if they have asthma that’s poorly treated is they get the same sort of scarring that people do when they do bad things, like smoke. It’s not exactly the same place, but there is problems associated with people who have long-term asthma that’s not treated. We think that children especially need aggressive treatment in the first two or three years they have asthma in order not to let this process begin.

Now, the scarring has lots of names. I think the most genteel name for it is “remodeling,” but a lot of the women physicians have pointed out to us that remodeling to women is a good thing. You know? That the end product of remodeling is something better than they had before, and that’s certainly not the case with asthma. The remodeling process in asthma really is scarring, and that’s not a good thing.

And the way you prevent that is to control the asthma better, use medicines that don’t have inflammatory elements built into them like the older albuterol compounds, and you use inhaled corticosteroids, drugs that really reduce that swelling, and sometimes leukotriene modifiers. That makes a difference in some segment of children, and to the point that you can keep this swelling and inflammation down, and when you do that, kids can go into adult life with basically normal lungs.

All doctors have seen patients in their 40’s who have very poor lung function, and we always sort of thought maybe they were smoking and didn’t tell us. But now we’ve realized in retrospect that asthma can scar lungs, and people do lose lung function. And they lose it at an accelerated rate when the asthma is not under control. So, it’s really important to get proper treatment for asthma.