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Is it healthy to be taking 4 asthma steroids at once?
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ram2390 posted:
So to combat a recent asthma flare up, my doctor prescribed 4 drugs, Advair, Singulair, Qvar, and Spiriva. Is it okay to be taking all of these drugs at the same time, and if so for how long? He said he wants me on them for at least one month.

Also, is it possible to have a low peak flow meter reading (mine was around 300 and I'm 23 yr old male), but feel just fine with no symptoms of asthma? That's how I've been for the last 7 years.
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sgbl88 responded:
Hi and welcome to the community.

I feel that it is always important to know what your medications are and why you are taking them.

Advair is combination medicine containing an ICS (inhaled corticosteroid - reduces inflamation in the lungs) and an LABA (long acting beta 2 agonist - long acting broncho dilater). One thing to note about LABAs is that asthmatics should not take them alone (without an ICS).

Singulair is a leukotriene modifier. Leukotrienes are generally part of the allergic reation process. They are similar to histemines, but later in the reaction process.

Qvar is another ICS.

Spiriva is an anticholenergic (it limits the amount of mucus your lungs can produes. It also has mild anit-spasmodic properties. Anticholenergics are more recent additions to asthma routines. Historically they are more known for treating COPD. A study released up to two years ago showed that they are useful in treating asthma.

One thing to watch out for is that you are not double dosing a family of medications. It is common however to increase ICS doses when you are in a flare.

Your treatment plan is appropriate.

Peak flow is generally a better way to discern asthma control than how you feel. Sometimes you can adjust to feeling badly and not realize that your asthma is flaring.

I suggest that you stick with the prescribed treatment. You may be surprised by how great you feel afterward.

God bless.

Sonya
Jeremiah 29:11 For I know the thoughts that I think toward you, saith the LORD, thoughts of peace, and not of evil, to give you an expected end... Ye shall seek me, and find [me]
 
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ram2390 replied to sgbl88's response:
Thanks for your response. A friend who is a doctor recommended that given my specific symptoms (more of a tight chest than shortness of breath/lack of air) I should instead take 320mg of Qvar plus two nebulizer treatments (3mg albuterol and .5mg ipratropium bromide) per day, and leave out the other stuff. Does that sound safe to take?
 
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amcate replied to ram2390's response:
There are two components to asthma: inflammation and the muscles around the airway getting tight and closing off the airway. The nebulizer treatment primarily affects the muscles and causes them to relax. Ipratropium bromide is another anticholenergic medicine which is also a bronchodilator. The thought is that by combining albuterol and ipratropium bromide together, the muscles relax more than if you use either one alone. It acts very quicly, usually within 20 min, but only lasts 4-6 hours and then you have to retake it. One thing to consider is whether insurance will pay for the nebulizer unit as mine is now saying that they will pay for asthmatics to go to the emergency room and get a nebulizer treatment, but not for a nebulizer unit to use at home.

Wether or not it is safe depends on how bad it is, but I can't tell that through the internet. In my opinion, the first doctor's plan you mentioned should have some type of rescue medicine, whether it's a nebulizer or a meter dose inhaler. The nebulizer treatment you describe is a rescue medicine. I'm assuming you usually don't take anything. Other than that, both seem reasonable over the internet.

The first doctor's plan contains a lot more controller medicines, which are drugs you take in order to keep asthma under control in the long term. Some doctors will use multiple types of controller medicines in a hope to avoid a flare in the future or prevent a flare from deteriorating into something that needs prednisone, an oral anti inflammatory drug with long term risks.

Both plans are reasonable and it's a matter of trying and seeing which one works for you. If you go with the first doctor's plans, then once you are well controlled you may want to try to get off of some of the controllers to see if you hold steady. The first doctors I went to put me on multiple controllers to avoid using prednisone, but I later went off of some of them and found it made no difference in terms of use of prednisone or number or severity of flares in my case. However, perhaps that approach works well with other individuals to lower or prevent use of prednisone.
 
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sgbl88 replied to ram2390's response:
Hi,
Who is treating your asthma? Are you seeing a primary care or a specialist? You really need to discuss any changes with them.

There is certainly no reason to not layer the Advair and Qvar until this flare as really cleared.

I would the two neb treatments will definitely help. If you can work one more albuterol treatment in per day (NO ipatropium - it will dry you out too much). If you are using ipatropium, I personally would not use the Spiriva. They do the same thing.

Singulair works totally differently. I would definitely keep taking it.

Does that help you any?

Take care and feel better.
Sonya
Jeremiah 29:11 For I know the thoughts that I think toward you, saith the LORD, thoughts of peace, and not of evil, to give you an expected end... Ye shall seek me, and find [me]
 
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amcate replied to ram2390's response:
I just wanted to mention that I am in agreement with Sonya on seeing a doctor to follow up because it's so hard to know over the internet what is happening and then also I'm not a doctor.

The following is what my particular experience was with multiple medicines, but it was all done with a Board Certified Allergy, Asthma, and Immunology person monitoring things to be sure the asthma didn't get out of control. When I first presented to the specialist in Houston, TX (which at the time was in trouble with the EPA for very high ozone levels) she immediately put me on prednisone saying that I sounded absolutely horrible. Then, as she tried to get me off prednisone and noticed how high the controllers had to be and how frequently I kept going into exacerbations, she attempted to rule out reflux disease from my stomach and sinus problems. Even though the imaging showed no signs of reflux, she went ahead and put me on Nexium to be sure as well as Singulair, etc because her hope was that by using these different medicines that together they would control things well enough to get my prednisone usage down. I was even put on theophylline (a very old asthma drug) at one point. However, even after a year I still had symptoms if I took less than 20 mg of prednisone a day. The asthma doctor said that for someone who is 28 years old, that amount was absolutely unacceptable and that I needed to do something drastic about my triggers. Therefore, I moved to a small town where I saw an immediate improvement.

After a few years, I then moved to New Mexico to one of the least polluted cities in the nation. The allergy, asthma, and immunology doctor saw the number of meds I was on and started to order liver function tests every year. He had no concern for short term risks, but was looking at long term risks. Then, he got an IgE level which was normal and looked at the history of allergy test results, which indicated I was not allergic to most allergens in my new city. He mentioned I could become allergic in the future, but said that I was already on high level inhaled corticosteroids, and these other meds (like Singulair) theoretically should only be having a minor impact on the asthma given that I didn't test allergic to the local allergens. So, he decided to take me off of one medicine at a time, and redid spirometry testing every 2 to 3 months and saw my peak flows at home, and asked if I noticed differences in my symptoms or prednisone use. Through this process, he ended up removing a lot of the medicines because he thought they weren't helping my asthma in my particular case (though he does use the medicines for other people) and so why subject me to long term risks of using multiple medicines in terms of the liver? He also tried to lower the dosage on my inhaled corticosteroids, but found the lungs crashed when he did, so now their office just knows they can't lower me off of Advair 500/50 with sometimes adding in FloVent 220 on top of it (another inhaled corticosteroid).

You definitely want to have someone who really knows asthma following up with you, and if you go off of meds, you want to do it with them knowing about it and monitoring things.


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