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Medical Forum / Diseases and Disorders / Asthma / March 2005Just Diagnosed
Hi: This week my doctor told me she is "pretty sure" I have asthma. I've had some trouble getting my breath and heart pounding, so thought I was having heart problems. (I'm female, 61). Tests for heart problems were negative. I've also started coughing a lot the last few months, kind of croupy, trying to cough up phlegm, but can't get it up. Tightness in my chest. Trouble swallowing some foods. I also have some bouts of GERD, some allergies too. She had me blow in some kind of a meter, and was not satisfied with the result, and send me for a chest xray. Also prescribed two inhalers, Qvar for every day, once or twice, and Albuterol as needed. Gave me a tube to squirt them through. My problem is that I am reluctant to use steroids, especially after reading the possible side effects. When your doctor is "pretty sure", is that sure enough to believe the diagnosis? I don't know if my condition is bad enough to have to jump right in and use these products. Is there anything else to use that is not a steroid? How did you all start with this? Do you use steroids - especially the ones I have? What kind of effects has it had on you? > Hi: This week my doctor told me she is "pretty sure" I have asthma. I've > had some trouble getting my breath and heart pounding, so thought I was [quoted text clipped - 20 lines] > ones > I have? What kind of effects has it had on you? When you took the breathing test (PFT or pulmonary function test), did the doctor perform a methacholine challenge? That's when breathing tests are performed before and after the doctor has you inhale methacholine, a substance which causes airways to constrict. The differences in response can assess the responsiveness of airways. Here is a link to the test: http://itsa.ucsf.edu/~apflab/methacholinechallenge.html If you do indeed have asthma, then steroidal inhalers are a common way to act as a "preventer". That's a medication that reduces airway inflammation, and is better for long-term control than relying on frequent doses of such a rescue medication as albuterol. There is another newer class of drugs called "leukotriene modifiers" which interfere with the allergic response. This class includes Singular and Accolate, and requires just one pill per day. This drug can work wonders for some, and does nothing for others (like me). It's at least worth asking your doctor about. Here are two links: http://www.singulair.com.pk/secure/impt_of_leukotrienes/impt_of_leuk.html http://www.accolateinfo.com/ Xolair is another new drug that can work very well in cases of moderate to severe asthma, but it is extremely expensive. It is given by subcutaneous (under the skin) injection(s). A link: http://www.xolair.com/index.jsp There can be side-effects to any medication, and one should not take steroids lightly. However, inhaled steroids are much safer than oral steroids, because they are focused directly where they do the most good: the airways. Under that circumstance, there is much less systemic absorption of the steroids, and therefore, less side-effects. It is good that your doctor has given you a spacer (the tube that you mentioned) with which to use your inhaler. It helps to better nebulize the medicine so that more of it reaches the airways, and less is deposited in the mouth. In that regard, it is important to always rinse and gargle with water or your favorite mouthwash right after an inhalation treatment. That will help prevent the incidence of thrush, a fungal infection which can cause mouth and throat sores. If you are skeptical about your doctor's diagnosis, then seek out another opinion, preferably from a pulmonologist or allergist. Good luck. > When you took the breathing test (PFT or pulmonary > function test), [quoted text clipped - 5 lines] > constrict. The differences in response can assess the > responsiveness of airways. Many articles books list the methacholine challenge as the gold standard for diagnosis. It often is not necessary since a difference of 10-20% (dependingon the references used) on pre and post bronchodilator spirometry is also diagnostic of reversible airways disease. This combined with a compatible history is enough to make the diagnosis. The problem with the methacholine challenge is that in the real world it usually can't be done. When ti is ordered the PFT labs will make an apointment for the patient but then when the time comes they can't do it without a pulmonologist present because by definition respiratory distress is induced. Of course, you can't get a pulmonologist to come down tot he lab and hang around just in case something bad happens so basically the test doesn't get done. What usually happens is they just do a regular set of PFT's - which usually has already been done and so is useless at that time. My concern is that the office based test may have been just a peak flow or at best a limited office spirogram. In that case she should be referred for a full PFT - pre and post dilators along with DLCO and an ABG or at least pulse oximitry. The chest x-ray is definately needed. If the symptoms are chronic, especially in a 61 year old, then a cardiac evaluation should also be considered (which the OP says was done). If they are acute and have never happened before I would be more inclined to chalk it up to an acute infection and ride it out before diagnosising asthma. She does not mention if she has smoked in the past or been exposed to smoke, asbestos, or other respiratory irritants. The difficulty swallowing is not normally seen in asthma and makes one wonder about reflux. > If you do indeed have asthma, then steroidal inhalers are > a common [quoted text clipped - 3 lines] > relying on > frequent doses of such a rescue medication as albuterol. I would go furthe than saying they are just comon. If she does have astma with persistent symptoms then they are the standard of care with benefits that far outweigh risks at least up to moderate doses. > There is another newer class of drugs called "leukotriene > modifiers" [quoted text clipped - 5 lines] > (like me). It's at least worth asking your doctor about. > Here are two links: I don't think anyone would consider them as an alternative to inhaled steroids at this point. They are more of an alternative as a steroid sparing agent. > Xolair is another new drug that can work very well in > cases of > moderate to severe asthma, but it is extremely expensive. > It is > given by subcutaneous (under the skin) injection(s). A > link: It is also only indicated for people whose asthma is thought to be allergy mediated, poorly controled with conventional meds, and that have very high IgE levels. Even with all that it is often hard to get approved by insurers. > There can be side-effects to any medication, and one > should not take [quoted text clipped - 3 lines] > the most > good: the airways. <snip> I agree with all that. > If you are skeptical about your doctor's diagnosis, then > seek out > another opinion, preferably from a pulmonologist or > allergist. As always.  Signature00doc : > When you took the breathing test (PFT or pulmonary : > function test), [quoted text clipped - 40 lines] : She does not mention if she has smoked in the past or been : exposed to smoke, asbestos, or other respiratory irritants. I did not smoke, but my parents smoked constantly and my husband smoked until we were 44, so I was breathing smoke most of my life. : The difficulty swallowing is not normally seen in asthma and : makes one wonder about reflux. I have had problems with reflux in the past, but don't seem to have much problem with it now. It feels like a narrowing of the esophagus, especially when I try to eat something like bread. I feel like it will choke me. : > If you do indeed have asthma, then steroidal inhalers are : > a common [quoted text clipped - 51 lines] : : As always. Thank you very much. As a newbie to this problem, I didn't understand a lot of what you said, but I printed it out for reference. >> She does not mention if she has smoked in the past or >> been [quoted text clipped - 5 lines] > smoked until we were 44, so I was breathing smoke most of > my life. In some people that is enough to cause emphysema/COPD. >> The difficulty swallowing is not normally seen in asthma >> and >> makes one wonder about reflux. > I have had problems with reflux in the past, but don't > seem to have [quoted text clipped - 3 lines] > bread. I feel > like it will choke me. You may have a stricture of the esophagus. GERD can cause that. Signature00doc <Snipped for brevity> > : The difficulty swallowing is not normally seen in asthma and > : makes one wonder about reflux. > I have had problems with reflux in the past, but don't seem to have much > problem with it now. It feels like a narrowing of the esophagus, especially > when I try to eat something like bread. I feel like it will choke me. I have had that, and for many years thought it was reflux. It got bad enough that I could hardly eat a meal without spitting half of the food back out, and feeling like I was aobut to choke to death. I finally went in and had pictures taken of my esophagus (forgot the actual medical term) Turns out I had a shotsky ring, and they basically stuck a hard piece of tubing down my throat to expand it. Owrked wonders as I can now eat rice and bread and, my favorite, tortillas without choking to death. SignatureKendal Emery MCNGP #19 Now living in the great state of Colorado Permament resident of the State of Confusion : <Snipped for brevity> : [quoted text clipped - 12 lines] : down my throat to expand it. Owrked wonders as I can now eat rice and bread : and, my favorite, tortillas without choking to death. Wow, neither condition sounds like fun. So far it is something I can live with. If it gets worse, I will have to see about it. Lucky you, living in the state of Colorado - God's country. One of my favorite states. > Hi:? This week my doctor told me she is "pretty sure" I have asthma.? I've > had some trouble getting my breath and heart pounding, so thought I was [quoted text clipped - 16 lines] > How did you all start with this?? Do you use steroids - especially the ones > I have?? What kind of effects has it had on you? I'm a female? -? 62? and was experiencing similar problems. Shortness of breath had led me first to the cardiologist to rule out anything there. Then to the asthma allergy doc. He said, "looks like asthma to me". The only diagnostic test was blowing into a spirometer before and after inhaling albuterol. He declared that the six to eight percent improvement after the puff was proof that it was asthma and sent me home with Advair and a rescue inhaler sample. I just didn't believe it so made an appointment with a pal's pulmonologist. He had me tested in the 'body box', which is a much more extensive measure of lung capacity.??? He listened at length for the tell tale wheeze of asthma but couldn't hear it. So i was declared not to have asthma at all, but the shortness of breath was due to extra fat and a sedentary lifestyle.?? The cough? -? no longer present at that visit was said to be a probable result of my many allergies.? I don't have GERD, but be aware that it "can" trigger asthma in some people. Get a second or even third opinion before starting on dangerous drugs and making the pharmaceutical companies even richer. Dorothy ? >He had me tested in the 'body box', which is a much more extensive >measure of lung capacity. What is the "body box"? Was your head inside a container while you were hyperventilating? SignatureAlison Chaiken "From:" address above is valid. (650) 236-2231 [daytime] http://www.wsrcc.com/alison/ "You can't fall down when you're kneeling." -- church sign in Brownwood, TX via Paige M. > >He had me tested in the 'body box', which is a much more extensive > >measure of lung capacity. > > What is the "body box"?? Was your head inside a container while you > were hyperventilating? Nah It's considered a standard test for pulmonary efficacy here. You actually sit in a sealed, Plexiglas chamber and breathe only thru the measuring device after a vacuum is created in the chamber. It takes about an hour and?? -? supposedly? - gives a much clearer picture of how you're ventilating under different conditions. You are directed thru a schedule of breath exercises and every puff is measured.????????? It includes the before and after albuterol part too. I thought it was a piece of cake, but my friend with COPD, (emphysema and asthma) has never been able to make it even half way through. Dorothy ? ? > He said, "looks like asthma to me". > The only diagnostic test was blowing into a spirometer before and after inhaling > albuterol. > He declared that the six to eight percent improvement after the puff was > proof that it was asthma and sent me home with Advair and a rescue inhaler > sample. A friend of mine had just this experience; he went to see doc with a severe cough and shortness of breath and was told he had asthma and prescibed a bronchodilator. He didn't believe it and went to another doctor who diagnosed pleurisy. After a course of antibiotics he made a full recovery and the "asthma" symptoms vanished. -- gumbo Bronchodilators can be a great help in respiratory infections so I have no qualms with the liberal use of them even in people without the diagnosis if asthma. However, I would think it most prudent to hold off making the diagnosis until you have seen them have symptoms not associated with the illness. Signature00doc The good news is that my pharmacist told me QVAR is the absolute lowest-dose steroid inhaler available. My son used it for years. As he got older and his asthma got better, we phased it out. He currently takes Singular, but still has to use albuterol sometimes for exercise-induced asthma. When he was using QVAR, he rarely used albuterol (maybe once a month). -- Mary > Hi: This week my doctor told me she is "pretty sure" I have asthma. I've > had some trouble getting my breath and heart pounding, so thought I was [quoted text clipped - 16 lines] > How did you all start with this? Do you use steroids - especially the ones > I have? What kind of effects has it had on you? QVAR was the med of choice from my doctor at Mayo. He explained that its much smaller particulate size allowed for better airway penetration. That's very good to know - in my wandering around the net, I couldn't find anything about that. : The good news is that my pharmacist told me QVAR is the absolute : lowest-dose steroid inhaler available. My son used it for years. As he [quoted text clipped - 23 lines] : > How did you all start with this? Do you use steroids - especially the ones : > I have? What kind of effects has it had on you? Here is a link that discusses that: http://www.docguide.com/dg.nsf/PrintPrint/8392057424B5267B852568F1006D5415 > Here is a link that discusses that: > http://www.docguide.com/dg.nsf/PrintPrint/8392057424B5267B852568F1006D5415 Presumably the point of the link is the discussion of the particle size of Qvar (beclomethasone proprionate) and its relation to dose-response. I searched PubMed on this topic (beclomethasone proprionate particle) and came up with the following: Pulm Pharmacol Ther. 2005;18(2):151-3. Epub 2004 Dec 20. In vitro comparison of nebulised budesonide (Pulmicort Respules) and beclomethasone dipropionate (Clenil per Aerosol). Vaghi A, Berg E, Liljedahl S, Svensson JO. Azienda Ospedaliera "G. Salvini", Garbagnate, Italy. This study compared the in vitro performance of two inhaled corticosteroid products for nebulisation, Pulmicort Respules(budesonide 0.5 mg/mL) and Clenil) per Aerosol (beclomethasone dipropionate (BDP) 0.4 mg/mL). Each product was used in combination with three different nebulisers (2 mL/test, 5 min run time) and the dose to the lungs was determined according to standard methods. The shape of the suspended particles in each product was studied using scanning electron microscopy (SEM). Overall, a higher fine particle dose was achieved with Pulmicort Respules versus Clenil per Aerosol, with estimated dose to the lungs of 8-14 and 3-6% of nominal dose, respectively. SEM showed that budesonide particles were small, typically approximately 2-3 microm in diameter, whereas those of BDP were needle-shaped and up to approximately 10 microm long. The more favourable particle shape and size of suspended budesonide may explain the higher fine particle dose with Pulmicort Respules versus Clenil per Aerosol. Obviously this paper isn't too favorable towards Qvar. OTOH this paper http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstra ct&list_uids=15198549 says that Qvar does in fact have fine particles. There are 66 hits for the search I did. From what I can by scanning a few of them, the evidence that the finer particles of Qvar cause a benefit is unclear. YMMV. SignatureAlison Chaiken "From:" address above is valid. (650) 236-2231 [daytime] http://www.wsrcc.com/alison/ "You can't fall down when you're kneeling." -- church sign in Brownwood, TX via Paige M. >> Here is a link that discusses that: >> http://www.docguide.com/dg.nsf/PrintPrint/8392057424B5267B852568F1006D5415 > > Presumably the point of the link is the discussion of the particle > size of Qvar (beclomethasone proprionate) and its relation to > dose-response. Yes, that's what I took it to mean as well. I searched PubMed on this topic (beclomethasone > proprionate particle) and came up with the following: > [quoted text clipped - 35 lines] > few of them, the evidence that the finer particles of Qvar cause a > benefit is unclear. YMMV. As with many medications there are advocates and detractors. This is from the American Thoracic Society: http://www.cmecorner.com/macmcm/ats/ats2003_02.htm wherein they claim a benefit in distal small airways, and attribute that to smaller particle size (3- to 4-fold over Beclovent) . This is likely to be a matter of debate for some time. Well yeah - who says distal deposition is better? Drug companies do this all the time. They claim a reason for superiority and hope no one notices that the underlying assumption is unproved. If it turns out that the distal airways are the site of action of the steroids then this may be a good thing. Of course, one could surmise with a high degree of certaintly that the systemic absorption is increased as well. If it turns out that the site of action is in the more proximal airways then the whole thing is a wash. Asthma typically affects the medium size airways. Where this falls on the proximal/distal scale I am not sure but it does give me reason to have some doubts. Signature00doc I didn't get the information from a drug company; it was from a researcher at Mayo Clinic in Rochester. As you say, it has been traditionally thought that asthma was mainly expressed in the medium airways, but some of that view has been formed by limitations in visualizing the small airways, and their involvement in asthma. Here are some references that discuss the impact of the small-airways, and that it appears to be more significant than previously thought: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=64806 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1 2221892&dopt=Abstract http://www.inhalation.net/pathophysiology_asthma.htm http://www.thoracic.org/ic/ic2002/pgeve14.asp http://www.cmecorner.com/macmcm/accpchest/accp2003_04.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=njclib&db=PubMed&cmd=Retri eve&list_uids=12197566&dopt=abstract Also, here is an article specifically targeted to QVAR. The disclosures indicate that the authors are involved in various pharmaceutical companies (including 3M, maker of QVAR), so caveat emptor: http://www.medscape.com/viewarticle/456358_1 > I didn't get the information from a drug company; it was from a > researcher at Mayo Clinic in Rochester. As you say, it has been [quoted text clipped - 5 lines] > > http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=64806 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1 2221892&dopt=Abstract > http://www.inhalation.net/pathophysiology_asthma.htm > > http://www.thoracic.org/ic/ic2002/pgeve14.asp > > http://www.cmecorner.com/macmcm/accpchest/accp2003_04.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=njclib&db=PubMed&cmd=Retri eve&list_uids=12197566&dopt=abstract > Also, here is an article specifically targeted to QVAR. The disclosures > indicate that the authors are involved in various pharmaceutical > companies (including 3M, maker of QVAR), so caveat emptor: > > http://www.medscape.com/viewarticle/456358_1 I have been wondering. Did they help you at Mayo? Joy > I didn't get the information from a drug company; it was > from a [quoted text clipped - 6 lines] > visualizing the small airways, and their involvement in > asthma. I think it mostly comes from looking at spirometry curves. It is thought hat when you look at the downslope of the curve the larger airways empty first and then on it goes in order of airway size. In normal people this part of the line is flat but in a symptomatic asthmatic the middle bows down which has been taken to reflect an obstruction primarily in the medium sized airways. > Here > are some references that discuss the impact of the > small-airways, and > that it appears to be more significant than previously > thought: I'l have to look at them later. The problem is that even if one accepts and increased role for the small irways it still does not necessarily prove that higher distal deposition is better. The onus is on the drug company making the claim (I and the drug company does make this claim) to prove it is true. > Also, here is an article specifically targeted to QVAR. > The [quoted text clipped - 5 lines] > > http://www.medscape.com/viewarticle/456358_1 I'll have to thank you for that. Something like 60 or so slides spread out over 25 pages consisting of a rambling talk where he presents a lot of data - none of it clinical outcomes data. The reader really never needs to go past the first page where he states that increased peripheral deposition MAY be beneficial. At one point he was getting into the tired old stuff about CFC's being bad for the ozone layer. To me it smacked of a sales pitch (more like an infomercial) more than an unbiased report. Like I said. There is a lot of theory to support the idea. However, the proof is in the pudding and QVar has not done the necessary studies to claim superiority = especially when the price is considered. Signature00doc >> I didn't get the information from a drug company; it was from a >> researcher at Mayo Clinic in Rochester. As you say, it has been [quoted text clipped - 8 lines] > down which has been taken to reflect an obstruction primarily in the > medium sized airways. In that regard: "Small airway inflammation in asthma Meri K Tulic, Pota Christodoulopoulos, and Qutayba Hamid Meakins-Christie Laboratories, McGill University, Montreal, Canada. Most of our knowledge of lung function in asthmatic persons comes from spirometric and plethysmographic measurements made during bronchoprovocation, and these are dominated by large airway responsiveness. Because the volume and surface area of the lungs increases with increasing airway generations, the contribution of peripheral resistance to the total lung resistance was originally believed to be minimal. Research conducted over three decades ago, using a retrograde catheter technique in animal models , demonstrated that the small airways are pathways of small resistance, contributing less than 10% of the total resistance to airflow in the lung. Hence, Mead et al. originally described the small airways as the 'quiet zone' of the lungs in 1970. Since then, more sophisticated frequency-dependent measurements of small airways function have been developed. Invasive studies in mongrel dogs using alveolar capsules or the forced oscillation technique have demonstrated that both airway and parenchymal compartments contribute to airway hyper-responsiveness........................" "More recently peripheral airways, including lung tissue, have been recognized as a predominant site of airflow obstruction in asthmatic persons . Wagner et al. showed that, in mild asthmatic persons with normal spirometry, peripheral airway resistance was increased up to sevenfold when compared with control individuals, and these measurements correlated with responsiveness to methacholine. In addition, computational analyses based on quantitative histology have shown the peripheral airways to account for the majority of airway hyper-responsiveness among asthmatic persons . Noninvasive methodologies for separating airway and parenchymal mechanics have been developed using the low-frequency forced oscillation technique in animals and in humans . With this technique, Hall et al. demonstrated that inhaled methacholine alters both airway and parenchymal mechanics in infants, and that infants with a history of wheeze have significantly increased parenchymal responses to methacholine when compared with control children. These studies further consolidate the contribution of the small airways to the total lung resistance." >> Here >> are some references that discuss the impact of the small-airways, and [quoted text clipped - 3 lines] > and increased role for the small irways it still does not necessarily > prove that higher distal deposition is better. When you decide to look at them, you will see that this is one of the things that they are postulating. >> Also, here is an article specifically targeted to QVAR. The >> disclosures indicate that the authors are involved in various [quoted text clipped - 10 lines] > old stuff about CFC's being bad for the ozone layer. To me it smacked of a > sales pitch (more like an infomercial) more than an unbiased report. That's why I prefaced it with the disclosures and the declaration of obvious bias. Of all the links that I made reference to, this is the one that you selected to critique as being (surprise) biased. It does make it easier to dismiss the entire premise. > When you decide to look at them, you will see that this is > one of the > things that they are postulating. The key word being "postulating." > That's why I prefaced it with the disclosures and the > declaration of [quoted text clipped - 3 lines] > biased. It > does make it easier to dismiss the entire premise. I looked at that one because you seemed to be setting it apart and saying it was more germain than the others. I have not dismissed the premise. It is based on a lot of seemingly sound theory. However, people need to keep in mind that conjecture and thoery are not the same as proof. Doctors have to make clinical decisions based on uncertain evidence all the time. Often theory is all there to go on. So I would not fault a clinician for going on a good theory when there is no better evidence - I do it all the time. So I do not criticize the Mayo docs for liking Qvar. I certainly don't have a strong argument that anything else is better. Personally, I tend to use Pulmicort when I am not using Serevent and Advair when I am. That is based largely on cost considerations and compliance issues. I treat a realtively poor and non-compliant population and they seem to have trouble with spacers (getting them, keeping them, remebering to use them, etc) and technique so the dry powder inhalers seem to do better for several reasons. Also, in my thinking, Qvar is much more expensive than Pulmicort and so they really do need to show superiority in order to justify the price. Due to the price I find that there are a lot of formulary issues with it as well. When the prescription is not immediately filled at the pharmacy many of my patients will just not get it rather than call me to switch or get it authorized so it is a big deal. That is not to say that I wouldn't keep Qvar in mind and give it a try if the person is not doing well with other meds. While making a decision on theory alone in the absence of proof is perfectly fine for a clinician treating a patient (and needing to make some decision based on something) it is quite another for a drug company, or even a doc, to claim that one product is superior to another. For that you need proof - not just theories - no matter how good they may be. The last thing that gives me pause is the lack of head to head studies. I know how these companies work. If a hot new drug comes out and they are planning to market it as better (and charge a correspondingly higher price for it) it helps immensely to have head to head studies. I find it difficult to believe that 3M hasn't done at least some small pilot studies. But where are they? I suspect that the reason it is not out there, and they are instead spreading lovely little radiolabelled deposition studiy pictures far and wide, is because it belies the expectations of some very good theories. As an aside - this is why there is currently a push to have all studies involving humans, no matter how small, be registered an the results made available. Wouldn't it be nice to KNOW if there had been a pilot study and what the results were for a fact rather than just a suspicion? Hopefully, that will be starting in the next few years. Signature00doc >> When you decide to look at them, you will see that this is one of the >> things that they are postulating. > > The key word being "postulating." Well, "postulating" is my term. Some of the studies have demonstrated that smaller particulates that can reach the small airways have measurable benefit, and provide that data. Although the links that I provided were not full-text, the PMID will get you to that. >> That's why I prefaced it with the disclosures and the declaration of >> obvious bias. Of all the links that I made reference to, this is the [quoted text clipped - 3 lines] > I looked at that one because you seemed to be setting it apart and saying > it was more germain than the others. I was setting it apart as a counterbalance to the preceding articles. It was obviously an advocacy piece, and I mentioned it. > I have not dismissed the premise. It is based on a lot of seemingly sound > theory. However, people need to keep in mind that conjecture and thoery > are not the same as proof. That's why these peer-reviewed trials were done. Please take a look at them in full-text, and if you find flaws in their methodology or conclusions, please say why. > Doctors have to make clinical decisions based on uncertain evidence all > the time. Often theory is all there to go on. So I would not fault a > clinician for going on a good theory when there is no better evidence - I > do it all the time. So I do not criticize the Mayo docs for liking Qvar. I > certainly don't have a strong argument that anything else is better. I believe that there is no universal "better", but that in selected circumstances it can be beneficial where there is small airway involvement. It would appear from the studies that I have read that the incidence of distal airway influence on asthma is more significant that previous diagnostics were capable of disclosing. I think it is all well and good to talk about particle size and patterns of lung deposition but there isn't much, if any, direct clinical evidence of an advantage to QVar. I think if docs say "I use it because there are theoreticala dvantages that I find compelling" then it is hard to argue - other than arguing what the theory really means. If the doc says something to the effect that Qvar is superior or is the drug of choice then I think they wouldbe challenged to hold that end up in a debate. Signature00doc -- 00doc It's funny that this discussion became a talk about particle size and the advantages of QVAR. I certainly haven't said that it's the best asthma drug out there. I was just addressing a concern about using inhaled steroids. My son used QVAR for a long time because, while he did need inhaled steroids to control his asthma, he didn't need very much. No other inhaler gives such a low dose. My husband uses Pulmicort and Serevent. Azmacort and QVAR didn't work for him--he had to keep increasing the puffs and still kept using albuterol. -- Mary > I think it is all well and good to talk about particle size and > patterns of lung deposition but there isn't much, if any, direct [quoted text clipped - 7 lines] > drug of choice then I think they wouldbe challenged to hold that end up > in a debate. That's what is interesting about inhaled steroids--if one looks over the archives a bit, one will see that there is no one med that works for everyone. Some swear by Pulmicort--others by Flovent, Advair, etc. Regarding the particle discussion, I don't have a horse in that race one way or the other (nor any stock in 3M), it's just academically interesting to me that researchers continue to find more sensitive ways of implmenting imaging and spirometry. OO Doc writes <<< I think if docs say "I use it because there are theoretical advantages that I find compelling" then it is hard to argue - other than arguing what the theory really means. If the doc says something to the effect that Qvar is superior or is the drug of choice then I think they wouldbe challenged to hold that end up in a debate.>>> Thank you doctor. In the five years before I discovered Pulmicort (in this newsgroup) I used all the topical corticosteroids available here in the USA, including beclomethazone MDI. All of 'em except for fluticasone, which I suspect should be the "other" drug of choice. Can't understand why anyone should have to try Q-var or Aerobid or any of the others. Not before trying Pulmicort and Flovent. Pulmicort really turned me around and that's been some years ago.---Jack > The good news is that my pharmacist told me QVAR is the absolute > lowest-dose steroid inhaler available. My son used it for years. As he > got older and his asthma got better, we phased it out. He currently > takes Singular, but still has to use albuterol sometimes for > exercise-induced asthma. When he was using QVAR, he rarely used > albuterol (maybe once a month). -- Mary I'm not medically qualified, however my understanding (based on conversations with my specialist who is a researcher in a internationally recognised asthma research group) is that it is considered better to take inhaled steroids and reduce brochodilator use to the minimum rather than stop taking inhaled steroids and increase use of brochodilators. The reason for this is that the steroids actively improve the disease condition over extended periods of time (eg partially reversing airways remodelling) whereas reliance on bronchodilators while excluding steroids does not have this beneficial effect, with the result that the illness usually worsens over time. If he's having to use albuterol at all regularly, I'd go back onto low dose qvar and get the albuterol use back down to once a month (which is an excellent result). This approach should lead to the best outcome for him over the longer term. -- gumbo >> The good news is that my pharmacist told me QVAR is the absolute >> lowest-dose steroid inhaler available. My son used it for years. As he [quoted text clipped - 24 lines] > > -- gumbo That's my understanding as well: to use the inhaled steroids as a long-term preventer and to reserve the bronchodilator for acute exacerbations. Properly applied, inhaled steroids appear to have minimal risk when compared to their benefits. >>>The good news is that my pharmacist told me QVAR is the absolute >>>lowest-dose steroid inhaler available. My son used it for years. As he [quoted text clipped - 29 lines] > Properly applied, inhaled steroids appear to have minimal risk when compared > to their benefits. Yeah, I know that. We slowly phased him off steroids because he's just a kid, had been using inhaled steroids for eight years, and his asthma was in great control. Even now that he's off the steroid inhaler, he doesn't use albuterol more than once a week. It would probably be more often if we hadn't added Singular. Singular makes sense when your asthma triggers are primarily allergic reactions. -- Mary >>>>The good news is that my pharmacist told me QVAR is the absolute >>>>lowest-dose steroid inhaler available. My son used it for years. As he [quoted text clipped - 36 lines] > hadn't added Singular. Singular makes sense when your asthma triggers are > primarily allergic reactions. -- Mary Out of curiosity, did you notice any significant side-effects (growth delay, etc.) from your son's use of the inhalers? I know that when Flovent was first out, there were concerns about pediatric usage. >>>>>The good news is that my pharmacist told me QVAR is the absolute >>>>>lowest-dose steroid inhaler available. My son used it for years. As he [quoted text clipped - 40 lines] > etc.) from your son's use of the inhalers? I know that when Flovent was > first out, there were concerns about pediatric usage. Only time will tell. Most studies show that any slowing in growth is made up within a year of stopping steroids. He has only been off it for a few months, and he was on a very low dose (but he was taking it for a very long time, and started at a much higher dose when his asthma was more severe and volatile). He is 11, and is short for his age...but, of course, that doesn't always mean anything. His brother was a shrimp in middle school, but then went from 5'2" to 5'9" in the blink of an eye! --Mary |
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