Kevin Huang, BSc Pharm Student
Patients with asthma know how frustrating this condition can be. From dealing with wheezing to breathlessness, asthma can be unpredictable and easily limit your everyday lifestyle. Without the proper use of medications, patients will often struggle to catch their breath.
Many physicians will prescribe their patients inhalers to combat these symptoms. More often than not, patients go for years on these same inhalers. However, to properly manage the condition, it may be necessary to modify your inhaler therapy to specifically address your needs.
Types of Inhalers
You may be wondering why you would need to change your therapy in the first place. For most, the rescue inhaler works great to treat any asthmatic attacks. While this is true, it’s ideal to get your asthma well-controlled (no nightly awakening & exacerbations, <2 uses of the rescue inhaler per week, and near normal lung function). In order to do this, choosing the correct inhaler is important. Each medication has its specific use and addresses different characteristics of the disease. Thus, in choosing the medications, one can use these treatments to improve their quality of life.
Short-Acting “Rescue” Inhalers (Bronchodilators e.g. salbutamol, also known as Ventolin®)
Most people who know someone with asthma, or have asthma themselves, will be familiar with the small, blue, L-shaped inhaler commonly known as Ventolin®. Clinicians often refer to Ventolin® as the rescue inhaler since it contains a fast-acting ingredient that relaxes the airways during any kind of asthma flare-up or reaction. Ventolin® is a must-have for anyone with respiratory issues as it acts within minutes, and it should always be kept close-by in case of emergency. That said, despite being effective during emergencies, the effects of Ventolin® don’t last very long, and it doesn’t do much to prevent inflammation in individuals with problematic asthma. Thus, if anyone finds themselves frequently relying on their rescue inhaler, it’s a sign they should start using long-acting medications.
Long-Acting Medications (Corticosteroids e.g. Fluticasone, also known as Flovent®)
Long-acting inhalers used in asthma often contain inhalable corticosteroid medications. Inhalable steroids are ideal as they manage airway inflammation over a 24-hour period. When used daily (or twice-daily), steroids prevent inflammation instead of just treating it, which means individuals can go on with their daily lives knowing their asthma’s being controlled long-term. This means fewer night-time awakenings from shortness of breath, fewer asthma attacks or flare-ups, and fewer episodes of shortness of breath and coughing throughout the day. Ideally, someone with well-controlled asthma should almost never have to use their rescue inhaler.
There are several “downsides” that have notoriously surrounded the use of inhaled steroids (ICS). The first is that using ICS medications increase the risk of developing thrush, a (minor) fungal infection of the mouth. The chance of this happening is very rare, but clinicians recommend rinsing out your mouth after each use of your inhaler for prevention. The second rumour is that steroids cause weight gain and stunted growth in children. The fact of the matter is that inhaled medications are only active in the lungs, and do not affect the body on a systemic level – therefore, weight gain is extremely unlikely and cases are few and far between. With respect to stunted growth, studies have shown that there is very little chance that steroids may slow growth, but they don’t limit it. In other words, children susceptible to this effect almost always end up growing to their expected height later-on in life. On the other hand, the effects of poorly controlled asthma on the growth and development of a young adult are far worse than the possible (and unlikely) side effects of ICS medications.1-3
Combination Inhalers – (ICS/Long-acting Bronchodilators e.g. Symbicort®)
Sometimes, an ICS alone isn’t enough, and it may be necessary to introduce additional medications. Combination inhalers include both an inhaled corticosteroid and a long-acting bronchodilator, which is typically a longer-lasting version of Ventolin®. Altogether, these inhalers are the next step to minimize inflammation and keep airways open for individuals with highly-reactive asthma. Similar to ICS therapy, these medications should be used regularly throughout the day, and mouth rinses are recommended after each use.
The Rule of Two
This leads to the big question: How do you know when you should be on long-acting medications? How often is too often when talking about your Ventolin® use? The Rule of Two is a series of questions used to determine if your asthma is well-controlled. Answering yes to any of these questions indicates your asthma is only partially controlled, and that you may benefit from new treatments (note that albuterol is the formal term for your rescue inhaler):
1 – Do you need to use your rescue inhaler more than twice per week?
2 – Are you experiencing nightly episodes more than twice per month?
3 – Are you refilling your rescue inhaler more than twice per year?
Managing asthma can be a strenuous process of dealing with medications and symptoms. However, by collaborating with your health care team, it’s possible to get your asthma on track. So, don’t be afraid to talk to your team to get the care that you need!
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- 2018 GINA Report: Global Strategy for Asthma Management and Prevention [Internet]. Global Initiative for Asthma – GINA. 2018 [cited 14 September 2018]. Available from: https://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-prevention/
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