The salmeterol in the Advair is basically a long acting version of your
reliever (assuming the reliver is albuterol or something similar). It makes
sense that you would note less of an incremetal change from your reliever
since with the salmeterol you are starting with a baseline level of drug
rather than from zero. Presumably the height of the response is just as high
and it just feels like less of a change for you (because it is).

Having said that: It is possible that you really are getting less of a total
effect. It has been long known that "standing" (i.e. 'round the clock  -
scheduled) doses of albuterol cause something called "tachyphylaxis" which
means that the medication becomes less effective with time. It is believed
that the mechanism for this is "downregulation" of the beta receptors due to
constant stimulation. The makers of salmeterol claim this does not happen
with their product although the two molecules are so similar that it is hard
to imagine why it wouldn't.

You will just have to look at PFT's and PF's to try to figure that one out.

One effect of steroids, besides calming inflammation, is to "upregulate"
(i.e. increase the numbers of) beta receptors. There is a reserve of beta
receptors stored within the cell so this upregulation requires translocation
rather than synthesis and so can happen within hours.

The exact percentages used to delineate stages in an action plan can (and
should) vary from person to person depending on past history. Many commonly
published plans call for "red" to be considered less than 50% but some use
cut-offs of 80% and 60% for yellow and red respectively. According to these
plans you are not all that far away from red and so the ER may not be
completely unreasonable.

Of course, you will have to work this out with your GP. Like I said, part of
determining what is prudent is to consider the past history of the person.
Most action pans would call PF's in the 60's% of max to be in the yellow
zone and most plans don't call for an ER visit at that point (but again,
please don't substitute this post for the judgment of you or your
physician).

Some examples of things people commonly do in the yellow zone are to
increase the dose of inhaled steroid (difficult to do with Advair - you
would need a separate prescription for Flovent or an increased strength of
Advair), go on oral steroids (some write the prescription in advance to keep
on hand at home), increase the dilators (with either more puffs or go to
nebs), or add another med such as Singulair or Accolate. Since you are
noting incomplete effects from your current reliever it may be worth a try
to add another dilator such as Atrovent (another inhaler available alone or
in combination with albuterol (Combivent) that has a different mechanism of
action) or theophylline.

What is clear is that if you are running in the 60's% you need to intensify
therapy somehow. If you decide not to go to the ER you should arrange a
visit or discussion with your doctor ASAP.

--
CBI, MD

In this case you are no longer a candidate for having your asthma
treated by a GP.  You should ask for a referral to an asthma
specialist.

BTW: You haven't a distant clue what you're talking about.  In fact, you
couldn't get a clue during the clue mating season if you stood in the
middle of a field of horny clues, smeared your body with clue musk and
did the clue mating dance.

.....

Have you looked at Jim Quinlan's web site, http://www.asthmastory.com?
The odds of this being applicable seem to increase for adult-onset
severe asthma.  Unfortunately, getting an MD to take this seriously
can be a major challenge, in my own experience.

Ok, time for a little follow-up.

I decided to get another opinion on the ER being the only other option.  I
found a nice GP who also works for the local University Hospital (cuting
edge place, btw) and she has had experience with her kids being asthmatic.
Needless to say, she's right up on the subject.

Her thoughts were quite similar to mine....that if I am generally well
controlled (and for me, we're talking probably the best control I've ever
had) and if I don't see the need to go to the ER (i.e. peak flows only a
little worse than that I had considered "normal" up to this summer), then
the ER should be avoided.  She inquired about my regular peak flows, the
medications I'm on, the symptoms when I'm having a "bad" day, peak flows
during those times and what sort of things I've been doing to counter
it...very reassuring to have someone ask rather than have to be
told...definitely confirms to me that she's a little more up on the subject.

Anyway, she recommended a second form of medication to help avoid the
problems of the salbutamol (ventolin) and the long acting b2 antagonist in
the Advair giving each other grief.  Basically, it is a non-powder version
of Combivent...it means learning about a different delivery system, but
allows me to do something about my discomfort rather than sit around an ER
and wait (because typical of ER's everywhere, unless I was on my last
wheeze, I'd have to wait to be seen at one of the locarl ERs).

Thanks for all the suggestions and I'll keep you all posted on how things
go. :)

Michael Halliwell

***************************
M. Halliwell
temple2some@shaw.nospam.ca
To reply: remove the "nospam"
***************************

Current asthma management is for the patient to use an
Action Plan to adjust his drugs, depending on symptoms
and peak flows. Typically, when peak flows drop to the
50-80% area, the preventor drug [steroid inhaler] is doubled
and albuterol/salbutamol used as needed.

Advair is a combination drug containing a long acting bronchodilator
and steroid; it can't be doubled because the long acting
bronchodilator drug is already maxed out. Therefore a separate
steroid inhaler like Flovent/Pulmicort may be needed.

See:
--------------------------
http://www.vh.org/Providers/ClinGuide/AsthmaIM/comp1/AssessmentB.html
Periodic Assessment and Monitoring
--------------------------
http://www.lung.ca/asthma/manage/action.html Action Plan ca
"Asthma is a serious disease that can and does change in severity.
Usually, severe episodes are a result of gradual deterioration
over several days. An action plan is a treatment plan for
worsening asthma and every person with asthma should have one.
The action plan adjusts to the severity of symptoms so that
individuals can control their asthma. It is prepared in advance
with your doctor."
---------------------
Ellis