MEDICATION INFORMATION: CONTROLLER MEDICATIONS

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1 FRANK J. TWAROG, M.D., Ph.D. CURTIS T. MOODY, M.D. ADULT AND PEDIATRIC ASTHMA AND ALLERGIES Brookline Concord (617) (978) MEDICATION INFORMATION: CONTROLLER MEDICATIONS Asthma medications can be grouped into two major categories. The first group is considered rescue or reliever medication. These medicines (e.g., albuterol and brand names ProAir, Ventolin, Proventil, and Xopenex HFA) are used to achieve rapid relief of symptoms. They do not, however, improve airway inflammation. The second category is considered controller medication. The purpose of these medicines is to control asthma symptoms by decreasing inflammation or airway irritability when used on a long-term or maintenance schedule. At times, although these are generally used daily, inhaled steroids may at times be taken intermittently preceding allergen exposure or, more commonly, with upper respiratory illnesses in an attempt to prevent occurrence of or increase in asthma symptoms. In some cases with very mild asthma, intermittent use may be sufficient to control symptoms. Beclomethasone (QVAR), budesonide (Pulmicort), ciclesonide (Alvesco), flunisolide (AeroBid and AeroBid-M), fluticasone (Flovent), mometasone (Asmanex), and triamcinolone (Azmacort) are corticosteroid medications taken by inhalation. Advair (fluticasone and salmeterol), Dulera (mometasone and formoterol), and Symbicort (budesonide and formoterol) combine inhaled steroid medications and a long-acting beta agonist. Steroids or corticosteroids are medications which are similar to natural body hormones. They help to relieve the inflammation and swelling in the lungs. Inflammation is now known to be one of the major changes occurring in asthma and causes the symptoms you or your child are experiencing. These include cough, chest tightness, shortness of breath, and wheezing. Inflammation also results in airway irritability or, as physicians call it, reactive airway disease. You may recognize this as cough, shortness of breath, or wheezing after exposure to nonspecific irritants, such as strong odors, tobacco smoke, exercise, or others, as well as after allergen contact in allergic individuals. Inhaled steroid medications are an important addition to the regimen of asthma therapy for those who have persistent asthma symptoms. These medications are recommended as the primary treatment for chronic asthma. In fact, some experts suggest using inhaled steroids even for individuals who have mild, persistent problems. These medications aid in preventing or decreasing the frequency of asthma episodes. They may also interfere with the progression of changes which occur in the airways of some with chronic asthma. Immediate relief of symptoms should not be expected!

2 Page 2 Some of these corticosteroid preparations are dispensed in inhalers similar to those used for other inhaled medications (e.g., Ventolin, Proventil, and ProAir). Although similar in appearance to bronchodilator or reliever medications, the active ingredient in the corticosteroid preparations is different. Some new products are formulated as dry powder inhalers (e.g., Advair, Asmanex, and Pulmicort) because of the international ban on CFCs (chlorofluorocarbons). Others use new substitutes for the CFCs referred to as hydrofluoroalkanes (HFAs). The inhaled steroids work on a chronic basis and should be taken regularly to achieve optimal results. When inhaled properly, these medications usually decrease asthma symptoms markedly, as they reduce the ongoing inflammation present in the airways of the lungs. The irritability of the lungs characteristic of asthma will diminish with time. Maximum benefit may take weeks or even months. In some cases, however, a significant decrease in symptoms may occur within several days. Inhaled corticosteroid medications have now become a mainstay in chronic asthma therapy and are considered one of the most important maintenance asthma medications (controllers). Although usually effective, unfortunately, not all individuals respond to this group of medicines. 1) The effectiveness of inhaled medications is dependent on the proper use and administration of the inhaler. In order to optimize your technique, use of a hand-held metered-dose inhaler (MDI) or powder inhaler device (DPI) will be reviewed by one of our office nurses. When using an MDI, we suggest a spacer to optimize delivery of the medication (e.g., AeroChamber or Vortex). 2) The dose of medication delivered by a metered-dose inhaler is guaranteed only for the specific number of inhalations (actuations) which is noted on the canister. Although more medication may be present in the canister, you may not receive the proper dose if the canister is used for more actuations than is noted on the label. Coincidentally, the control of asthma may begin to deteriorate. One useful tip for estimating when canisters should be replaced is to count the number of inhalations taken per day, calculate the approximate time when your canister should be empty, and note this on your calendar. It would be wise to obtain a new canister several days before your medication will expire. Planning ahead is particularly important for those using mail-order pharmacies requiring 90-day refills. Some inhalers include counters in order to be able to estimate the amount of medicine present, making this estimation simpler.

3 Page 3 The table below should help you in deciding when your usual metered-dose inhaler should be replaced: How Often To Replace Your Metered-Dose Inhaler (Does not apply to dry powder inhalers) # Sprays Sprays Per Day. In Canister days 15 days n/a n/a n/a n/a n/a 100 n/a 25 days 16 days 12 days n/a n/a n/a 104 n/a 26 days 17 days 13 days n/a n/a n/a 112 n/a 28 days 18 days 14 days n/a n/a n/a days 30 days 20 days 15 days n/a n/a n/a 200 n/a 50 days 33 days 25 days 22 days 16 days 12 days 240 n/a 60 days 40 days 30 days 26 days 20 days 15 days *If the medication is taken as prescribed, the canister should be discarded as indicated above. Otherwise, the remaining puffs may not contain sufficient medication. 3) Take the medications regularly according to the prescribed dose at the frequency recommended. Do not arbitrarily increase your dose, as the medication may be absorbed and could cause systemic effects, as can occur with orally administered corticosteroid medications. In the case of viral infections, however, you will often be instructed to increase the dose to 2-4 times the usual baseline for a limited period of time, between 5 and 10 days when you have an asthma episode or with viral infections. Although systemic effects with inhaled corticosteroids are minimized, the possibility of developing adverse or systemic effects is dose-related. This should be kept in mind, particularly with high doses of inhaled corticosteroids. Use of higher-concentration inhaled steroid should be carefully monitored with routine follow-up. As asthma symptoms improve, we will attempt to step down your dose, decreasing to the smallest amount necessary to control asthma. 4) If you are temporarily using an inhaled bronchodilator medication or reliever, this may be taken preceding administration of the inhaled steroid. Use the bronchodilator preparation first and wait 5-10 minutes before taking the inhaled steroid. Some inhaled steroids are more likely to cause cough than others. If cough is a continuing problem, please discuss this with us. 5) Keep the inhaler away from small children. 6) If a dose is missed and you remember within several hours, take the dose which has been omitted. If you miss a dose but do not remember until later in the day, skip this dose and return to your usual schedule.

4 Page 4 7) Serious adverse effects with these medications when used in proper doses are infrequent. Studies have raised the question of possible systemic effects when inhaled steroids are used at higher doses, particularly in children. Some slight growth delay has been shown, though in most cases this would be minimal. Growth should, however, be followed in children on inhaled steroids to monitor the effect. In older patients, particularly postmenopausal females, a loss of bone calcium (osteopenia or osteoporosis) is possible. This may rarely occur even in younger individuals, both male and female. If you are postmenopausal and inhaled steroids are being used, particularly in high doses, calcium and vitamin D replacement should be discussed with your primary physician or gynecologist. Guidelines regarding general dietary calcium replacement are attached to this medication information packet. We often will suggest a bone densitometry study if you are on long-term inhaled steroids. Cataracts and glaucoma have rarely been reported in some patients who are using high-dose inhaled steroids. Because of this, a yearly eye examination for all patients using inhaled steroids and in particular for older patients on regular doses is strongly recommended. The risk of adverse effects, however, appears slight in comparison to those associated with oral corticosteroid medications (e.g., prednisone). There are a few minor side effects which should resolve when you become accustomed to using the medication. These include cough, hoarseness, or sore throat. Notify your doctor if these become uncomfortable or if they are persistent. Use of an extension or spacer device may reduce these side effects when using a metered-dose inhaler (MDI). Furthermore these extension devices often increase the effectiveness of the inhaled steroid by improving deposition of the medication in the lung. 8) Notify your doctor if you develop any persistent or progressive mouth or throat discomfort, hoarseness, or respiratory infection. Use of inhaled steroids is occasionally complicated by the development of oral thrush (a mold infection) similar to that which is seen in small infants. This infection may appear as whitish patches on your tongue, palate, or other mouth surfaces. The use of extension devices minimizes the likelihood of this problem. In order to prevent or minimize development of this infection, rinse your mouth thoroughly with water and expectorate after each use. The use of inhaled steroid before brushing your teeth is also a way of remembering to rinse. 9) In the event of an acute asthma episode, requirement for surgery, or other serious illness, it is important to notify your physician that you are taking inhaled steroids. Although unusual, these medications may cause some depression of your body s ability to adequately respond to stress by producing its own steroids. Because of this, oral or intravenous steroid medications may be required at these times.

5 Page 5 10) Although some differences of opinion exist, children using inhaled steroids who develop chicken pox may need to receive a medication (acyclovir) to decrease the possibility of a more severe case. 11) Instructions for proper use of HFA metered-dose inhalers are as follows: Inhalers are best taken using an extension device (e.g., AeroChamber or Vortex). Exhale to a normal level. Begin a slow inhalation, then activate the canister. Inhale slowly over 5-6 seconds. Hold breath for a count of 10. Breathe normally and repeat sequence for the next dose. The technique for using the dry powder inhalers is quite different and requires rapid inhalation. Use should be reviewed with our nurses. 12) When is your asthma inhaler empty? It is difficult to judge when an MDI is no longer providing the dose of medication that is expected. Inhalers are designed to provide accurate doses only for the number of actuations listed on the label. Floating the inhaler in water will not give a reliable estimate of how much medication is left, and approaches that rely on changes in pressure or taste are also unreliable. In fact, the only accurate method is to count the number of doses used and to compare this with the number on the canister label. Currently, many MDIs have counters, simplifying this issue. In the case of dry-powder inhalers, the number of actuations is either listed on the device or a counter will notify you how many actuations are left. It may seem easy enough to keep track of the doses used, but this is not always true. For those who use the medications regularly, we recommend that you simply calculate the number of doses and mark on your calendar when the device is likely to be empty. If you are not sure how much is left in your inhaler, it is safest to obtain a new inhaler. 13) If your asthma is sufficiently severe to warrant use of inhaled steroids, we feel it is important to schedule regular follow-up visits to monitor your asthma. Even if you feel well, these routine visits allow us to better evaluate your progress and, importantly, to try to reduce or step down the dose of your medication if, in fact, the asthma is stable and breathing tests are normal. Published guidelines suggest a regular, six-month follow-up for anybody on inhaled steroids and more frequent if asthma is poorly controlled. 14) These are general guidelines. Other side effects occasionally occur. Always notify your doctor if you are experiencing adverse effects which seem to correlate with taking the medications, if you are not responding as expected to the treatment, or if you are pregnant, breastfeeding, or develop a new medical condition.

6 DIETARY CALCIUM Recent studies suggest that calcium replacement is best achieved through natural food products. Although data remains debatable, several studies have suggested a possible increase in cardiovascular problems using calcium supplements. In view of this, you should attempt to achieve daily calcium requirements through food products unless recommended by your primary physician. In order for calcium to be properly absorbed, vitamin D is also necessary. A number of investigations have found low vitamin D levels, particularly in the Northeast, where sun exposure is limited throughout a significant portion of the year. Poor asthma control has been associated with low vitamin D levels as well. Whether or not replacement of this vitamin will improve control remains uncertain. If appropriate, vitamin D levels should be obtained and supplementary doses guided based on this level. Daily Calcium Requirement Age Minimum intake Maximum intake Up to 6 months 210 mg/day not determined 6-12 months 270 mg/day not determined 1-3 years 500 mg/day 2,500 mg/day 4-8 years 800 mg/day 2,500 mg/day 9-18 years 1,300 mg/day 2,500 mg/day years 1,000 mg/day 2,500 mg/day 51 plus years 1,200 mg/day 2,500 mg/day Special considerations Pregnant/lactating women: Under age 19 1,300 mg/day 2,500 mg/day Ages ,000 mg/day 2,500 mg/day Calcium Content Milk 300 mg per 8 oz. Yogurt 350 mg per 8 oz. Cottage cheese 77 mg per 4 oz. Processed cheese 174 mg per 4 oz. Cheddar cheese 191 mg per 1 oz. Ricotta 337 mg per 4 oz. Ice cream 88 mg per 1/2 cup Pudding 133 mg per 4 oz. Corn bread 94 mg per serving Oatmeal 154 mg per 6 oz Pancakes 116 mg per two 4 Waffles 179 mg per one 7 Enriched wheat flour 303 mg per 8 oz. Oranges 96 mg per one lg. Blackstrap molasses 579 mg per 3-1/2 oz. Maple syrup 180 mg per 3-1/2 oz. Broccoli 132 mg per 1 cup Dried beans, cooked 144 mg per 1/2 cup Tofu 145 mg per 4 oz. Cheese pizza (1/4 pie) 332 mg Macaroni and cheese (1/2 cup) 181 mg Cream of tomato soup (1 cup) 168 mg Beef taco 174 mg Chili with beans (1 cup) 82 mg

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