Posts Tagged ‘reliever’

Generic Name
Carbamazepine (car-bam-A-zuh-pene)
Brand Names
Atretol    Tegretol
Carbatrol    Tegretol-XR
Epitol    Teril Equetro
Type of Drug
Anticonvulsant.
Prescribed For
Seizure disorders as well as other neuralgias; also  severe pain; psychiatric disorders including depression, bipolar disorder, intermittent explosive disorder, borderline personality disorder, post-traumatic stress disorder, psychotic disorders, and schizophrenia; withdrawal from alcohol, cocaine, or benzodiazepine-type drugs; restless leg syndrome; hereditary and non-hereditary chorea in children; and diabetes insipidus.
General Information
Carbamazepine was first approved for relief of the severe pain of trigeminal neuralgia. Over the years, it has gained wide use in seizure control, especially in people whose seizures are uncontrolled with phenytoin, phenobarbital, or primidone, or who have suffered severe side effects from these drugs. Carbamazepine is not a simple pain reliever and should not be taken for everyday aches and pains. It is associated with potentially fatal side effects.
Cautions and Warnings
Carbamazepine should not be used if you are allergic or sensitive to any of its ingredients or to any tricyclic antidepressant.
Carbamazepine should not be used if you have had bone marrow depression.
Carbamazepine may cause severe, possibly life-threatening blood reactions. People who have had blood reactions to other drugs are at particular risk for another reaction with carbarnazepine. Your doctor should have a complete blood count done before you start taking this drug and repeat these tests weekly during the first 3 months of treatment, and then every month for the next 2-3 years. Unexplained fever or infection may be a sign of a blood reaction.
Monoamine oxidase inhibitor (MA01) antidepressants should be discontinued 2 weeks before starting carbamazepine.
Rarely, severe, possibly fatal skin reactions can develop in a few people taking carbamazepine. Asians are 10 times more likely to develop these reactions than non-Asians.
Carbamazepine may aggravate glaucoma and should be used with caution by people with this condition. This drug may activate underlying psychosis, and, in older adults, confusion or agitation.
This drug is not for the relief of minor aches or pains.
Possible Side Effects
V Most common: dizziness, drowsiness, unsteadiness, nausea, and vomiting. Other common side effects are blurred W double vision, confusion, hostility, headache, and severe water retention.
♦ Less common: mood and behavioral changes, especially in children. Hives, itching, rash, and other allergic reactions may also occur.
your breathing, speech,function, and many
Drug Interactions
•    Carbamazepine blood levels may be increased by azoles (e.g. ketoconazole), acetazolamide, cimetidine, dalfopristin, danazol, delavirdine, diltiazem, haloperidol, isoniazid, propoxyphene, erythromycin-type antibiotics (except azithromycin), fluoxetine, fluvoxamine, loratadine, levetiracetam, macrolides, MAOls, nefazodone, niacinamide, nicotinamide, protease inhibitors, quinine, quinupristin, terfenadine, tricyclic antidepressants, valproate, verapamil, or zileuton, leading to possible carbamazepine toxicity.
•    Carbamazepine may reduce the effectiveness of contraceptive drugs and cause breakthrough bleeding.
•    Charcoal tablets or powder, clozapine, methsuximide phenobarbital and other barbiturates, phenytoin, primidone and theophylline may decrease the absorption of carbamazepine. Levels of phenobarbital, a breakdown product of primidone, may be increased by combining primidone and carbamazepine.
•    Carbamazepine reduces the effects of acetaminophen, the anticoagulant (blood thinner) warfarin, and theophylline (prescribed for asthma). Increased dosage of these drugs may be necessary. Other drugs counteracted by carbamazepine are antipsychotics (e.g. aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone), benzodiazepines (e.g. diazepam and lorazepam), bupropion, cyclosporine, digitalis drugs, doxycycline, felodipine, lamotrigine, levothyroxine, methadone, mirtazapine, certain muscle relaxants, oxcarbazepine,  slatin drugs, tiagibine, topiramate, tramadol, and zonisamide.
•    Combining carbamazepine and other antiseizure drugs, including felbamate, hydantoins, succinimides, and valproic acid, may cause unpredictable results. Combination treatments to control seizures must be customized to each person.
Possible Side Effects (continued)
♦ Rare: Rare side effects can affect
liver function, urinary    other
parts of the body. Contact you    you any side effect not listed above.
•    Combining carbamazepine and lithium may increase nervous system side effectssuch as muscular twitching or im-
paired consciousness.
•    Carbamazepine suspension should not be combined with
other liquid medicines or diluents.
Food Interactions
Take carbamazepine with food if it causes stomach upset. Avoid taking carbamazepine with grapefruit products.
Usual Dose
Adult and Child (age 13 and over): 400-1200 mg a day, depending on the condition. Usual maintenance dose is 400-800 mg a day in 2 divided doses.
Child (age 6-12): 200-1000 mg a day, or 22-24 mg per lb. of body weight 2-3 times a day for suspension or 4 times a day for tablets. Do not exceed 1000 mg a day.
Child (under age 6): 22-24 mg per lb. of body weight 2-3 times a day for suspension or 4 times a day for tablets; dosage should not exceed 77 mg per 1b. of body weight a day.
Dosage varies according to form. Liquid carbamazepine must be taken 3 times a day, regular carbamazepine tablets twice a day, and sustained-release tablets once daily. Never change your dosage schedule without first checking with your doctor.
Overdosage
Carbamazepine is a potentially lethal drug. Overdose symptoms appear in 1-3 hours. These include irregularity or difficulty in breathing, rapid heartbeat, changes in blood pressure, shock, loss of consciousness or coma, convulsions, muscle twitching, restlessness, uncontrolled body movements, drooping eyelids, psychotic mood changes, nausea, vomiting, and reduced urination. Induce vomiting right away with ipecac syrup—available at any pharmacy. Then take the victim to a hospital emergency room. ALWAYS bring the prescription bottle or container.
Mormation
Carbamazepine may cause dizziness and drowsiness. Take care while driving or doing any task that requires concentration.
Call your doctor at once if you experience yellowing of the skin or whites of the eyes, unusual bleeding or bruising, abdominal pain, pale stools, dark urine, impotence, mood changes, nervous system symptoms, swelling, fever, chills, sore throat, or mouth sores. These may be signs of a potentially fatal drug reaction.
If you forget a dose, skip it and go back to your regular schedule. it you miss more than I dose in a day, call your doctor. Do not stop taking this drug without first consulting your doctor.
Special Populations
Pregnancy/Breast-feeding: Carbamazepine caused birth defects in animal studies. Seizure disorder itself also increases the risk of birth defects. Pregnant women should take carbamazepine only after discussing with their doctors its potential benefits and risks.
Carbamazepine passes into breast milk. Nursing mothers who must take carbamazepine should use infant formula.
Seniors: Seniors taking this drug are more likely to develop heart Problems, confusion, or agitation.

Let’s hope it never happens - but if it does, knowing what to do could make the difference between surviving and not surviving. The sensible thing is to read these pages - or whichever parts are relevant to you or your child - before you encounter an emergency. It is often helpful to rehearse the procedure in your mind and actually imagine yourself going through the actions described here.
Find out in advance what the local ambulance service is like, and ask your GP for advice about who to contact in an emergency. (If you have latex allergy, check in advance that all local ambulances carry a latex-free kit.) These are the options:
• Call your GP.If the doctor is nearby and the hospital or ambulance station a long way off, this may be the best decision. Doctors in rural areas may have supplies of adrenaline for emergency treatment, and oxygen for those suffering a severe asthma attack.
• Call an ambulance. Where the local ambulance service is dependable, this is always the best option. The ambulance crew will have adrenaline and oxygen.
• Go by car or taxi to the nearest hospital
emergency department. This is not usually a
good plan, because your condition may quick-
ly get worse, and you have no emergency
treatment available. But there may be situa-
tions where it is a sensible decision. Emergencies can occur when you are away on holiday or business. Never stay anywhere without a phone – check that it is working as soon as you arrive. Make sure you have the number of a local doctor and know where the nearest hospital is. A remote holiday cottage can be a dangerous place to suffer an asthma attack or anaphylactic shock.
Anaphylactic shock
This is an extremely serious emergency, requiring immediate medical help. The signs of anaphylactic shock are listed on p.58. In the case of food allergy, there are additional signs in the mouth, lips and throat (see p. 62). Use adrenaline (epinephrine) straight away if you have it – but get emergency medical help as well. With injectable adrenaline (an EpiPen or Anapen – see p. 150), remove the cap and jab firmly into the outer thigh, going straight through any clothing. Never inject into any other part of the body – this can be dangerous.
If you have an adrenaline inhaler (see pp. 155-6) you can use this first to treat symptoms in the mouth, throat and airways, and then use the injector if you still have symptoms. (Improvise a spacer – see p. 100 – if there is difficulty in inhaling the adrenaline.) Anyone whose reactions tend to be severe should use the injector first and follow up with the inhaler if necessary. Overdosing with adrenaline is possible, and can be fatal, but using the inhaler as well as the injector is safe as long as you don’t have a heart condition (see pp. 155-6).
If you do not improve after using the injector, a second one can be used, 10-15 minutes later.
In situations where medical help is not yet available and the symptoms are not abating, another shot of adrenaline can be given every 15-20 minutes. But the maximum number of shots recommended by your doctor should never be exceeded. Keep count of how many you’ve had, and tell medical staff.
An asthmatic who does not have an adrenaline inhaler can use a beta-2 reliever inhaler such as Ventolin (see p. 152) as well as the adrenaline injection, although it probably won’t help very much.
Suppose you know for sure that you have encountered your allergen, but you don’t have any symptoms yet? In Britain, the usual advice is to wait for symptoms, but doctors in the United States say go ahead and use the adrenaline injector if you have reacted very badly in the past. In general, for people with no other health problems, it is better to give an adrenaline injection which isn’t needed than to delay giving one that is needed. Delaying the use of the injector may mean that the reaction gets out of control. Some people put off using the injector because they think it should be saved for when they ‘really need it’. In fact the adrenaline works just as well if you have used it on previous occasions.
Following anaphylactic shock, you should be kept in hospital for 6-12 hours even when everything seems fine. Attacks have recurred as much as eight hours later. Corticosteroids reduce the chance of this happening – ask if these have been given. If you are discharged early and it is a long journey home, consider waiting in the hospital, or nearby, until eight hours after the original reaction.
First aid for anaphylactic shock
A badly swollen tongue or throat can cause suffocation. If there is visible swelling and the person is unconscious or turning blue, try to keep the top of the trachea (the main airway leading from the throat) open. Use the handle of a spoon – one that has very smooth edges. Slide it carefully over the top of the tongue and into the throat. Press down gently but firmly to open the airway.
Someone who is feeling faint or dizzy, or losing consciousness, or (in the case of a child) becoming very pale and floppy, may be suffering from a dangerous drop in blood pressure. He or she is more at risk of a fatal collapse if in an upright position, because not enough blood is reaching the heart. The worst thing is to stand up suddenly, or to move (or be moved) quickly from a lying to a sitting position –death can follow within seconds. The best thing is to lie down, preferably with the legs resting on cushions or a stool so that they are above the torso, and with the arms raised above the chest. Adrenaline can be given while in this position. A stretcher should be used to get the patient to an ambulance.
Latex allergy and emergency treatment
If you have anaphylaxis due to latex allergy, going to hospital can be alarming, as you may suffer further reactions to latex gloves or equipment. Some patients with latex allergy have had such bad experiences in ambulances and hospitals that they become fearful of using their adrenaline injector, since this means they must go to the hospital afterwards. They delay using the injector, which makes the situation worse. Some doctors are now giving such patients all the medicines and training they need to manage their anaphylactic shock themselves, so that they don’t need to attend hospital.
A person who has lost consciousness should be lying down on their side in case they are sick (this reduces the chance of them inhaling their vomit). The same goes for anyone who feels nauseous.
On the other hand, if the major problem at the outset is difficulty in breathing (as it generally is in children) a sitting position is better.
It is unusual for both faintness and severe breathing problems to be present at once. If this occurs, the patient should lie down, and if there is swelling in the throat, a spoon should be used (see left) to keep the airways open.
Insect-sting allergy
If you don’t have an adrenaline injector, get medical help immediately.
If you’ve had a cutaneous systemic reaction (see p. 60) in the past, use the adrenaline injector if there is any difficulty in breathing, hoarseness, stomach cramps, diarrhoea, nausea, faintness, dizziness or confusion. If you are unsure, remember that, unless you have a heart condition, it is usually better to overreact (i.e. use the adrenaline unnecessarily) than under-react.
If you’ve had a severe systemic reaction (i.e. anaphylactic shock) in the past, use an adrenaline injector at the first sign of any reaction other than immediately around the sting.
If there is a honeybee stinger left in the skin, scrape or flick it out sideways using a fingernail, knife blade or credit card – the venom sac is attached and will go on injecting venom for up to 10 minutes if you leave it there.
Don’t try to pull the stinger out – this squeezes the venom sac and pumps more venom into the skin.
Get emergency medical help, and follow the other measures for dealing with anaphylactic shock (see left).
Don’t go alone
If you suffer vomiting or diarrhoea during anaphylaxis, and have to go to the toilet, tell someone to call an ambulance and take someone else with youto the toilet. Do not go in alone and lock the door, in case you collapse.
Asthma attacks
Even those with mild asthma, who have never had a serious attack before, can quite suddenly get into difficulties and require emergency treatment. Don’t be over-anxious about this, because it is unlikely to happen – but do be prepared. Not having your reliever inhaler with you when a severe attack starts is a recipe for disaster – always take it, wherever you go.
Deal with an attack promptly. The sooner you act, the fewer drugs you’ll need in the long run to control the attack. Most asthmatics wait too long and then under-treat their asthma.
The important thing is recognising an asthma attack, and knowing when it is getting out of control. Not all attacks are the same – some come on fast, some come on slowly.
Rapid asthma attacks come on in a matter of hours. You may have been fine all day, but then start to feel very breathless and wheezy, or begin coughing badly. Less than an hour later, despite using the reliever, the breathlessness is worse and it is a struggle to speak or walk across the room. This is a severe attack: don’t delay in getting medical help.
Slow asthma attacks come on over a period of days. At first you are more breathless and wheezy than usual, and your reliever inhaler is not helping much. Asthma wakes you up at night, and you are far more breathless than usual in the morning. This could be the beginning of a severe attack, so don’t delay in getting medical help. If you get to the point where your asthma is disturbing your sleep every night, and in the morning you have difficulty in speaking or walking about, this is a very serious situation – you must see your doctor or go to the hospital now.
A few asthmatics have great difficulty recognising when they are increasingly breathless, and for them, using a peak-flow meter (see p. 97) every day is essential. Indeed, most asthmatics find
Recognising an asthma attack in a very young child
With a young child, these signs indicate a severe asthma attack:
• the nostrils are flared
• the shoulders are unusually high
• the child can say only one or two words between breaths
• the ribs are pushed out, and the spaces between the ribs, and below the chest cage, are sucked in during breathing
• you can hear wheezing (a whistling noise)
• the lips, tongue or fingernails are blue.
If wheezing stops, without any other apparent improvement, this is a very bad sign — it may mean that the airways are now so narrow that no air is passing through them. This is called a ’silent chest’, and indicates an urgent need for medical attention.
that monitoring peak flow is a valuable way of spotting attacks in advance. However, if your peak flow seems normal, and yet you feel breathless and have a tight feeling in your chest, pay attention to your symptoms and get medical help.
Your response to your reliever inhaler is another helpful sign assessing asthma attacks. Things are serious if:
• the reliever inhaler does not seem to be working at all within 10 minutes of taking a puff
• it does not work as well as usual
• it works, but the effect wears off in less than three hours. If you have an asthmatic child, give everyone who normally takes care of the child detailed written instructions for recognising and dealing with an asthma attack. People forget verbal instructions especially in an emergency. A child who is exhausted or upset c. an attack should always be given medical care.
Taking action
If your reliever inhaler is not working well (see above), take another puff to open up your airways – and then take further action. as described below.
If you seem to be in the early stages of a slow asthma attack check your management plan, and if your peak flow has fallen below the recommended level, double the dose of inhaled steroids (twice as many puffs each time) now. Add any other medicines (e.g. steroid tablets) as recommended by the management plan.
Those who don’t have a peak-flow meter or management plan should double the dose of inhaled steroids and make an urgent appointment to see the doctor.
If you are suffering a rapid attack, or a slow attack that has got out of control, you need emergency medical help. Ring for an ambulance, ring your doctor, or go to the hospital – the ideal course of action will vary, depending on where you live (see p. 98).
Use your reliever inhaler until medical help arrives. You can take a puff every 5-10 minutes if needed, but keep a count of how many puffs you’ve had and stop after 30. Some doctors suggest taking up to 30 puffs all at once. (If you have a heart condition, this dose might be dangerous: follow your doctor’s advice.)
If it is difficult to inhale, use a spacer – this can make all the difference, especially for children.
You can improvise a spacer from a plastic cup, a plastic bottle, or a paper bag. Make a hole in the bottom of the cup or bottle, or in one corner of the paper bag, and insert the mouthpiece of the inhaler here. The open end of the cup, bottle or bag goes in or over the mouth – with the bag, you have to bunch it up and hold it around the mouth. Squirt the inhaler repeatedly into the improvised spacer, while breathing steadily in and out.
The six golden rules for asthma attacks
• Breathe as slowly as possible and concentrate on breathing out, not on breathing in. Exhale as fully as you can and your in-breath will follow automatically.
• Never panic – if you do, you may start hyperventilating, and this makes matters much worse (see p. 226). Panicky parents are the worst possible thing for an asthmatic child during an attack.
• Adopt a position that makes breathing as easy as possible. Propping your arms up at about shoulder height can help – for example, sit back-to-front on a dining chair, with your arms folded and resting on the back. Or put pillows on a table, sit in an upright chair, and rest your head and arms on the pillows. Don’t lie down, as this makes matters worse. Open a window, as long as the air outside is not cold, polluted or loaded with pollen.
• Avoid factors that can make an asthma attack worse, for example, vigorous activity, cold air, irritants and allergens.
• Drink plenty of water, fruit juice or other liquids as a lot of water is lost through the surface of the airways during an asthma attack, and you can become dehydrated.
• Don’t take anything to help you sleep, even herbal pills. If your asthma gets worse during the night, you need to wake up so that you can get more air.
After an attack
Asthmatics who have suffered a severe attack are occasionally sent home from hospital before they are completely better. A few people have died as a result of being discharged too soon. So if you feel breathless or otherwise unwell after you leave hospital, don’t hesitate to go back – or seek other medical help.
See your GP or specialist within a few days of any emergency treatment. Don’t be over-confident just after a severe attack – this can be a very vulnerable time. Take more rest than usual and drink plenty of fluids, as you may be dehydrated. Keep taking your preventer inhaler at the increased dose – reducing the dose now could lead to another severe, possibly fatal, attack. Keep taking steroid tablets if you have been given them.
If you produced a lot of mucus during the attack, try to clear it, but without violent coughing. Mucus can sometimes form solid plugs which block small airways. Treatment by a physiotherapist would help, and expectorants – drugs which help loosen mucus –can also be useful (ask your pharmacist about these). Don’t take ordinary cough medicine (see box on p. 163). There are also some breathing exercises which can help to clear mucus (see p. 231).
An asthma attack represents a chance to learn more about preventing asthma – so think about what went wrong. Had you forgotten to take your preventer inhaler regularly? How long is it since you had your medicines reviewed by the doctor or asthma clinic? Have you been using your peak-flow meter daily? Were you exposed to a high dose of allergen or an irritant?
A reaction to aspirin-like drugs
Aspirin sensitivity can begin quite suddenly in someone who has previously taken aspirin without trouble. If you have unexplained chronic urticaria, or polyps in the nose, plus asthma and/or rhinitis, the development of aspirin sensitivity at some time in the future is a distinct possibility (see p. 151).
A sensitivity reaction to aspirin or aspirin-like drugs usually begins between 30 minutes and two hours after the drug is taken. You will have some or all of these symptoms:
• a runny or badly blocked nose, and red eyes
• a feeling of warmth, flushing and sweating
• a general rash
• a sensation of tightness in the chest, a dry cough, increasing breathlessness
• malaise and exhaustion
• vomiting or diarrhoea
• swelling (angioedema) and/or nettle rash (urticaria). If you have such symptoms get emergency medical help immediately because the reaction can quickly develop into severe asthma, shock, collapse and unconsciousness.
If you have asthma, use your reliever inhaler as much as required (up to 30 puffs) until medical help arrives. Anyone who has an adrenaline (epinephrine) auto-injector, or an adrenaline inhaler, can use this as well – up to 30 puffs of the inhaler, or whatever maximum dose is given in the instructions. Tell the ambulance crew and doctors exactly what you have taken.

Using inhalers
The value of using an inhaler rather than taking tablets or syrup is explained on p. 141 for steroids. The same principle applies to all drugs.
The oldest type of inhaler is the ‘puffer’ or aerosol inhaler, properly called a ‘pressurised metered-dose inhaler’ or MDI. It delivers the drug as a fine, moist, spray. In addition, there are now many devices that deliver drugs in dry-powder form.
If you or your child find the aerosol inhalers difficult, you may do better with a dry-powder inhaler. Your doctor should have several different inhalers available for you to try out, to see which one suits you best.
When you are given an inhaler you must be shown how to use it by a doctor or asthma nurse. A great many asthma patients have a ‘poor inhaler technique’, and get too little of the drug as a result. This often leads to their asthma getting out of control. The advice given here for using inhalers is no substitute for proper training, and should only be used to supplement what your doctor or asthma nurse has told you.
When using an aerosol inhaler or MDI, remember to shake the inhaler well or you will not get the right dose. Your in-breath must coincide exactly with pressing the canister down: this is the part that many people find difficult. You must breathe in slowly and deeply, otherwise you do not get much of the drug into your airways.
Many asthmatics stop inhaling the moment the
spray from the aerosol inhaler hits the back of the
throat. The spray contains a propellant, which
makes it very cold, and there is a natural reflex
response to this cold liquid which stops inhalation.
This response may be impossible to control. If so,
you need a dry-powder inhaler (see right), or a
spacer to use with your aerosol inhaler (see p. 162).
Breath-operated aerosol inhalers such as the
Autohaler can be useful for those who find ordinary
aerosol inhalers too hard to use. With these devices, you do not have to push the canister down because your in-breath triggers the release of the drug. Take care not to block the air-intake holes with your hands and don’t stop breathing when you hear the inhaler click. (If there is no click, start again and breathe in more forcefully this time.)
One hazard with aerosol inhalers is that, when almost empty, they produce no drug – just the propellant. Although they still ‘puff’ normally, they are not effective. It may be hard to tell when your inhaler is running low. Ask your doctor or asthma nurse for advice about this.
Many asthmatics find dry-powder inhalers such as the Spinhaler, Rotahaler, Diskhaler, Accuhaler, Clickhaler and Turbohaler are the easiest to use. They have no aerosol device, so none of the problems associated with the coldness of the propellant.
On the other hand, nothing pushes the drug into your mouth and lungs with a dry-powder inhaler: you have to do all the work yourself. This means you have to breathe in quite hard and fast. During a severe asthma attack you may not be able to breathe in hard enough to get a good dose of the drug. Some asthmatics have an aerosol inhaler as well, often combined with a spacer (see p. 162), for use during severe attacks.
For the parents of asthmatics, who want to keep an eye on how much of a drug is being used, most of the dry-powder inhalers allow you to do so.
Arthritis and inhalers
Those who suffer from arthritis in their hands often find inhalers difficult to use. There are several aids now available to help with this problem – ask your doctor or asthma nurse about these.
Do hold your breath
Whichever type of inhaler you use, it is important to give the drugs a chance to do their work. After inhaling, and when your lungs are full, you should hold your breath for at least ten seconds. Then breathe out, but wait at least another 30 seconds before breathing in again.
Side effects from non-drug ingredients
There are other ingredients in inhalers, besides the drug, and they occasionally cause side effects.
Aerosol inhalers are the worst offenders. They can contain up to five non-drug ingredients, such as propellants and surfactants. Some asthmatics are sensitive to one of these, and respond with coughing or bronchospasm when they inhale them.
If inhaled in large amounts, the propellants in aerosol inhalers can give a mild ‘high’, and asthmatic teenagers and their friends may - very rarely - begin abusing inhaled beta-2 relievers. Parents should be alert for the possibility of such problems, but not worry unduly.
Dry-powder inhalers do not need propellants or surfactants, so they are suitable for anyone who develops a sensitivity to these. However, they may contain lactose, or milk sugar, in addition to the drug. Enough lactose is deposited in the mouth and swallowed to provoke symptoms, such as diarrhoea and wind, in people who suffer from severe lactose intolerance (see box on p. 79). Trace amounts of milk proteins in the lactose may be a problem for people with severe milk allergy.
CFCs and inhalers
Aerosol inhalers have long contained CFCs, which are very inert gases (at ground level) and perfectly safe to inhale. Unfortunately, they cause serious damage when they reach the ozone layer high above the earth, so they are being phased out in asthma inhalers, as they are in all aerosols. Other propellants, called hydrofluoroalkanes (HFAs), are being introduced to take their place. The spray from an HFA inhaler may taste and feel different, but it should do exactly the same job as a CFC inhaler: the drug it contains remains the same. Research suggests that these new propellants are very safe, but tell your doctor if your reaction to your inhaler seems to change suddenly.
These new propellants deliver medication more efficiently into the lungs, so that usually only half the previous dose is required. Unlike CFC-type inhalers, they will deliver a constant dose until empty. In addition, they are not affected as much by below-freezing temperatures.
Inhale - then clean your teeth
Asthmatic children are more prone to dental decay than other children, and inhalers are suspected of causing the problem. No one knows, as yet, exactly which ingredient of the inhalers is the culprit - it could be a drug, or a non-drug additive such as a propellant. Alternatively, the fact that the spray from some inhalers is slightly acidic could explain this side effect. Brushing the teeth after using the inhaler, or just rinsing out the mouth with water, is recommended as a preventive measure.
Using spacers
A spacer is a large empty chamber that can be fitted to an aerosol inhaler (a puffer or MIDI). to make it more effective and easier to use. The aerosol spray goes into one end of the spacer, and the asthmatic breathes it in from the other end.
When using a spacer, you can breathe normally: you don’t have to take all the drug in at once. or hold your breath after you’ve inhaled. But you should try to breathe as deeply as possible, and hold your breath for up to ten seconds if you can.
Note that spacers are for use with aerosol inhalers only. Spacers allow the aerosol propellant (see p. 161) to evaporate, leaving tiny airborne droplets of the drug to be inhaled. Once the propellant has evaporated, these droplets are no longer cold, so the reflex response that stops inhalation is avoided.
During an asthma attack, spacers are immensely valuable because they allow you to get some of the drug into your airways even though you are unable to take a deep breath. There is a collapsible spacer, called the E-Z Spacer, which folds up into a plastic case small enough to be slipped into a pocket. In a severe asthma attack, having such a spacer could save your life.
In an emergency, if no spacer is available, you can improvise one (see p. 100).
Babies and small children, who cannot yet coordinate the in-breath with pushing the aerosol canister down, need spacers for everyday use. There are spacers designed for children under two years, with masks that fit over the nose and mouth.
When using a spacer, shake the inhaler and then spray it into the spacer once only. Inhale within five seconds. During an asthma attack, you can add another dose from the inhaler every ten seconds, until the attack begins to subside, but keep a count of how many puffs you use (see p. 100).
For a young child, shake the inhaler well, and fit it to the spacer. Put the mouthpiece into the child’s mouth, or put the mask on. Tell the child to breathe in and out steadily. Listen for the clicking of the valve on the spacer - this shows that it is opening and closing. When the child’s breathing is regular, puff a single dose into the spacer. The child should breathe in and out 5-8 times.
Priming a spacer
Prime a new spacer, or one that has been washed, by firing the inhaler into it about five times. Do this before you actually need to use the spacer.
The drug will coat the spacer walls, due to an electrostatic charge on the plastic. You won’t be able to see the drug as it forms a very thin coating.
When you come to use the spacer, no more of the drug will stick to the spacer walls, because they are already coated, so the full dose will be available for you or your child to inhale.
Priming new spacers is particularly important when the asthmatic is a young child, because there may be some delay between firing the inhaler and the child actually getting a proper lungful of the drug. The longer the delay, the more chance the drug has to stick to the unprimed spacer walls.
A spacer can be used on a baby while it is asleep, which may make life easier for you both. If you need to use the spacer while the baby or toddler is awake, stroke the mask against the child’s cheek first. Keep smiling and talking so that the situation doesn’t seem so frightening. If the baby does start to cry, keep the mask in place: crying will bring on a deep in-breath which is just what is needed.
For an older child, decorating the spacer with coloured stickers can make it appear less daunting. Try to make using the spacer seem like a game. If this fails, don’t get into a battle with the child – leave it a while and try again later.
Playing with the spacer when feeling well will help the child to see it as something familiar, not as a frightening piece of equipment associated with asthma attacks.
Nebulisers
A nebuliser delivers high doses of asthma drugs in an easily inhaled form. It is generally used for severe asthma only, or in an emergency to relieve asthma attacks.
A nebuliser can be attached to an oxygen cylinder, which enriches the air–drug mixture with oxygen. This is useful in severe asthma.
The only people who need to have a nebuliser at home for emergencies are those with brittle asthma, whose condition can deteriorate very suddenly and sharply.
For routine use, only a very small minority of asthmatics require a nebuliser. They include:
• Those with such severe asthma that they depend on large doses of drugs to control their symptoms
• Very small children or elderly people with severe asthma, who have difficulty using inhalers. For them, a nebuliser may be the easiest way to take their drugs.
The fact that the hospital’s nebuliser is so effective in an emergency gives it a special mystique for many people, who assume that nebulisers are a magical cure for asthma. Nebulisers are widely advertised in specialist publications for asthmatics and, while they are expensive, they can look like the answer to a prayer. Many asthmatics, or their parents, mistakenly believe that owning a nebuliser would be the answer to all their problems. In fact the nebuliser only works so well because it delivers a much higher dose of the reliever drug – a dose which also carries a higher risk of side effects. This high-dose treatment should not be used on a regular basis unless it is absolutely essential. No one should buy a nebuliser without first discussing the matter with their doctor.
Asthmatics who own a nebuliser should have detailed written instructions from a doctor about when and how to use it, and how much of the drug to put in. One hazard of owning a nebuliser is that it may give you a false sense of security during emergencies, and delay you from getting expert medical help when you need it. If the nebuliser is for emergency use you should be told the exact signs that indicate a need to use it and – no less important – the signs that show the attack is out of control and needs hospital treatment.
Take care, when using a nebuliser, not to allow the mist to escape and settle on the face or eyes. Regular exposure to steroid mist can cause cataracts in the eyes, and thinning of the skin on the face. Anti-cholinergics (see p. 156) can cause glaucoma if they come into contact with the eye. The mask must fit very tightly. As an additional precaution, place a scarf around the upper edge of the mask to cover any gaps. Wash the face after using the nebuliser for steroids.
Keep off the cough mixture
Coughing can be a useful reaction in asthma, evicting mucus from the lungs. But in some asthmatics the cough does not produce mucus and seems to be no more than a reflex reaction to the airway inflammation. This type of cough can be debilitating, but it is not a good idea to treat it with cough mixture which has no benefit and may mask the seriousness of the asthma. Tackling the airway inflammation with preventer drugs such as steroids is the best course. Simple expectorants, which loosen mucus, may be of value – ask your pharmacist about these.

Drugs for Asthma
The drug treatment of asthma is far more complex than for any other allergic disease. Drugs prescribed for asthma fall into two basic categories: those that open up the airways by relaxing the airway muscles, called relievers, and those that treat the inflammation in the lining of the airways, called preventers. The former offer a ‘quick fix’ - like taking an aspirin when you have a headache. Just as the actual cause of the headache is not treated by an aspirin, so the actual cause of the asthma attack is not addressed by relievers. Preventers, on the other hand, tackle the basic problem - the inflammation that triggers the contraction of the airway muscles (see p. 36).
In the past ten years, there has been a quiet revolution in asthma treatment, with far more people being given preventer inhalers, usually low-dose steroids. The aim is to get the airways in better condition, with the inflammation thoroughly damped down, so that the airway muscles don’t go into spasm. The ultimate objective is to make people far less reliant on reliever inhalers, because the potential hazards of over-using them are now realised.
The details of modern asthma management, and the different approaches used, are described on p. 160, following the discussion of the main types of drug used for asthma treatment.
Beta-2 relievers (beta-agonists)
Our airways open up when we produce adrenaline. This is the body’s natural response to feeling angry or frightened. The adrenaline widens the airways so that we can run faster or fight more vigorously.
Adrenaline (epinephrine), given as a drug, was among the earliest treatments for asthma. However, it also stimulates the heart to beat faster and raises
the blood pressure. While it is useful for emergency treatment (see p. 155) the side effects make it too hazardous for routine use.
The beta-2 relievers work by mimicking adrenaline – they bind to the same receptors in the airways, the beta-2 receptors. Binding to these receptors stimulates the airway muscles to relax, so that the airways open up.
In other respects, the beta-2 relievers are not like adrenaline. Clever chemical manipulation has made them sufficiently different from adrenaline to have little effect on the heart and other organs, when taken at normal doses.
Beta-2 relievers are best taken by inhalation. Although tablets and syrup are available these are far more likely to bring on side effects, because the dose needed is so much bigger.
Inhaled beta-2 relievers target the drug directly on the airways, so the dose can be smaller. They also have the great advantage of taking effect soon after being inhaled, and giving full relief from airway narrowing within 10-15 minutes.
There are two different kinds of beta-2 relievers:
•    the traditional short-acting beta-2 relievers whose effects last for 3-6 hours (usually about four). The modern consensus is that these should be used only when needed, not taken routinely.
•    the newer long-acting beta-2 relievers, which last up to 12 hours. These drugs are prescribed for more severe forms of asthma (see p. 154), and are generally used routinely, twice a day.
A key question for asthma sufferers is: How often can short-acting beta-2 relievers be used? Ideas about this have changed considerably over the last 20 years, and no doctor would now want to have patients using a Ventolin inhaler five, six or more times a day - something that was quite common in the past. This level of need for beta-2 relievers indicates that the asthma is poorly controlled and requires treatment with a preventer, to quell the inflammation in the airways.
Detailed policy on beta-2 relievers still varies from one part of the world to another. British guidelines state that anyone who needs to use a short-acting beta-2 reliever more than once a day, or who suffers from nocturnal asthma, should be given a preventer as well. The international guideline is more stringent: if a short-acting beta-2 reliever is needed more than three times a week, a preventer should also be prescribed.
How safe are these drugs in the long term? The cause of the big re-think on beta-2 relievers was an epidemic of asthma-related deaths in New Zealand between 1976 and 1988. The death rate from severe asthma attacks was 2-4 times its previous level for a while, and over a thousand New Zealanders died in the epidemic.
There has been a huge controversy over what exactly caused these deaths. Most researchers now agree that the main cause was a new brand of inhaler that delivered a double dose of the drug fenoterol, a short-acting beta-2 reliever with a very powerful effect on the airways and quite high levels of side effects involving the heart. The same brand of inhaler may have been linked to increased death rates in Canada and Germany.
Research suggests that the problem was greatest in New Zealand because sales of the new inhaler were highest there, and because many patients got their inhalers through repeat prescriptions. As a result, people whose asthma was deteriorating badly were not seen by a doctor and were using large amounts of beta-2 reliever, rather than taking preventer drugs. This is now believed to be a major cause of asthma deaths. There are three separate factors involved:
•    The beta-2 reliever covers up the effects of the severe inflammation of the airways. People feel reasonably well, because the reliever is opening up their airways, and don’t realise just how bad their asthma really is. The untreated inflammation in the airways can eventually lead to a very serious, and potentially fatal, asthma attack.
•    The short-acting beta-2 reliever, used regularly, makes the airways more sensitive to exercise, and to allergens such as dust mite or pollen. This means that an asthmatic who is already allergic to these allergens reacts to them at much lower levels in the air.
•    The airways become less and less responsive to the beta-2 reliever itself, so that when a serious attack occurs, requiring hospital treatment, huge doses of beta-2 reliever are needed to open up the airways. These massive doses carry a risk of serious side effects involving the heart.
The details of the New Zealand epidemic still evoke controversy. Was fenoterol itself, which is stronger than other beta-2 relievers, the cause of the deaths? Or was it just that the inhaler delivered a double dose - would any short-acting beta-2 reliever be dangerous at twice the normal dose? Or was it over-use of all beta-2 relievers and lack of preventer drugs?
Some common brand names
Common brand names include:
short-acting beta-2 relievers in inhalers - Aerolin, Airomir, Bricanyl, Ventolin short-acting beta-2 relievers in tablets - Bambec, Bricanyl, Volmax short-acting beta-2 relievers in syrup - Monovent, Ventolin
long-acting beta-2 relievers in inhalers - Bambec, Foradil, Oxis, Serevent
Until this is resolved, safety-conscious asthmatics may want to assume that any of these possibilities could be correct. An ultra-cautious approach would include:
•    Avoiding fenoterol (it is no longer available in Britain, except in the Duovent inhaler, combined with an anti -choli nerg ic drug)
•    Not using double-dose inhalers of any beta-2 reliever (i.e. inhalers that deliver 200mcg/ micrograms per puff)
•    Not routinely taking two puffs of a single-dose inhaler (check with your doctor if you have been told to take two puffs)
•    Using any short-acting beta-2 reliever only I as needed’ – which should be once a day or less according to British guidelines. Note that, with this level of use, there is absolutely no risk from these drugs: it is only regular over-use that is damaging and dangerous.
•    Using a peak-flow meter and ensuring that you are assessed regularly by your doctor
•    Always taking your preventer medication as prescribed.
Since about 1990, the death rate from asthma has been falling, particularly in countries with a policy of reducing use of beta-2 relievers, and increasing inhaled steroids. The death rate in New Zealand is now the lowest it has been for 50 years, and at the same level as in other Western countries.
Unnecessary alarm
While investigating the causes of the New Zealand epidemic, medical researchers discovered that patients inhaling a short-acting beta-2 reliever four times a day had more irritable airways after just two weeks. Their airways were also less responsive to the drug, even after this brief period of use.
Some researchers began to ask if the asthma epidemic itself – the increasing number of cases of asthma – could actually be due to these drugs. Maybe children with mild wheezing, which might have cleared up if left untreated (and which would have gone untreated in the past) were becoming full-blown asthmatics because they were now using beta-2 inhalers?
Many doctors became very concerned about these questions, and a leading medical journal
published an article with the provocative title: ‘Worldwide worsening wheezing – is the cure the cause?’ That was in 1992. Since then, much more research has been done, and it is clear that this particular fear about beta-2 relievers was unfounded.
Unfortunately, there are a few books and other publications around that are spreading unnecessary alarm about these drugs by reporting the debate as it was in 1992. They have taken up that question ‘Is the cure the cause?’, assumed that the answer is ‘yes’, and ignored all the subsequent research, which shows the opposite.
Beta-2 relievers in severe asthma
A few patients with severe asthma remain breathless and wheezy, even though they are inhaling moderate doses of a steroid preventer every day. Increasing the dose of inhaled steroids does not make a huge difference to their symptoms, and it substantially raises the risk of steroid side effects.
Taking a long-acting beta-2 reliever often works wonders for such patients. These relatively new drugs relax the airway muscles, and go on working for 12 hours or more.
There has obviously been concern about long-acting beta-2 relievers having the same sort of insidious side effects as their short-acting colleagues (see p. 153), and so increasing the likelihood of deaths from asthma. However, studies of people taking these drugs suggest that the risks are minimal. Certainly, long-acting drugs taken twice a day are very much safer than short-acting drugs taken four times a day.
Other studies show that the chemical differences of the long-acting drugs, as well as prolonging their effects, also give them a more complex set of actions in the body. For example, they improve the effect of steroids in calming inflammation, and may even have some small anti-inflammatory effect of their own.
Doctors believe that, for patients with troublesome asthma, the benefits of long-acting beta-2 relievers greatly outweigh the risks. But they should only be used in combination with inhaled steroids. Various other options, such as allergen avoidance and the new anti - leukotriene drugs (see p. 159), should probably be investigated as well.
If you are taking long-acting beta-2 relievers, do use them regularly, once every 12 hours – the good effect gradually builds up with consistent use.
Generally speaking, you should not take additional doses in between. These are not intended for use if you have a sudden asthma attack – your doctor will prescribe a short-acting beta-2 reliever for this. This limitation on the use of long-acting beta-2 relievers is certainly appropriate for salmeterol (which was the first of the long-acting beta-2 relievers to be developed) because it is very slow to take effect on the airways. However, one of the newer long-acting beta-2 relievers, called formoterol, begins to work just as quickly as a short-acting beta-2 reliever. Formoterol could, in theory, be used on an ‘as-needed’ basis to combat asthma attacks. You may want to discuss this possibility with your doctor.
Finally, don’t stop taking your preventer drug (e.g. inhaled steroid or cromoglycate), even if you feel a lot better. Long-acting beta-2 relievers are not a substitute for preventers.
Some patients with very severe asthma need to take regular doses of short-acting beta-2 relievers as well as long-acting beta-2 relievers. You should obviously follow the advice of your asthma specialist closely if you are on this kind of drug regime, and not change anything without approval. However, it might be worth discussing other options, such as anti -leukotriene drugs. In addition, do all you can to combat your asthma in other ways – by reducing allergen exposure, avoiding asthma triggers (see p. 39), and employing various other self-help measures (see p. 41).
Immediate side effects of beta-2 relievers
Minor immediate side effects of these drugs include:
•    headache
•    nervousness, trembling, restlessness, anxiety; children may become more excitable, and some are badly behaved or even aggressive.
•    flushing
•    dry mouth
•    muscle cramps.
These side effects – all of which are due to the resemblance of beta-2 relievers to adrenaline – usually wear off relatively quickly. Some long-acting beta-2 relievers may cause nausea and vomiting.
A pounding heart is usually a relatively minor side effect, but it can be more serious, and should be reported to your doctor.
A few asthmatics find that their airways tighten up when these drugs are inhaled, rather than opening. This is called paradoxical bronchoconstriction. If this happens, stop using the inhaler and see your doctor as soon as you can.
Even more rarely, asthmatics can develop allergic reactions to the drugs, or suffer hallucinations or seizures. Obviously you should stop using the inhaler immediately if you experience side effects of this kind, and should see your doctor.
There can be an interaction between beta-2 relievers and other drugs or medical conditions. Should you need a diuretic, tell the doctor or pharmacist that you are also taking a beta-2 reliever, and ask which diuretics are safe. If you have high blood pressure, a heart problem, or a thyroid condition, make sure the doctor remembers this when prescribing beta-2 relievers.
Adrenaline inhalers
Adrenaline inhalers are for use in emergencies. Technically, they are not available in Britain, but they can be imported under special licence, and your doctor may be persuaded to obtain one for you if he or she thinks it might be useful. They are given to people who have asthma and have sometimes had attacks of anaphylaxis (see p. 58), for example in reaction to food, latex or an insect sting. The inhaler provides prompt emergency treatment for the kind of severe asthma attack that you may experience during anaphylaxis.
You should probably be carrying an adrenaline auto-injector as well, as you may need to use both (see p. 98). Those who usually have fairly mild reactions to their allergen can use the inhaler first, to treat symptoms in the mouth, throat and airways. If other symptoms develop, such as faintness or widespread nettle rash,
Asthma alert
If you ever find that your short-acting beta-2 reliever has no effect within ten minutes, or is needed more than once every four hours, this indicates a serious asthma attack and you need urgent medical help (see p. 100).
During a severe asthma attack, while getting to hospital or waiting for a doctor to arrive, up to 30 puffs of a short-acting beta-2 reliever should be taken as an emergency treatment, to get the airways open. There is a risk of death if you don’t use the reliever fully in this situation. (This emergency dose is safe for almost everyone, but there may be risks if you have a heart condition – get detailed advice from your doctor in advance.)
then the adrenaline injector can be used. Those with a history of more severe reactions should start with the adrenaline injector and then use the inhaler if there are still symptoms in the mouth or airways.
Don’t exceed the maximum number of puffs stated on the canister, as the propellant can cause problems. If you have a heart condition, your doctor will advise you about using this kind of treatment safely - adrenaline can affect the heart.
Ephedrine
Ephedrine and orciprenaline (brand name Alupent) belong to the previous generation of reliever drugs. They are chemically very similar to adrenaline and therefore cause a lot of side effects, especially involving the heart.
These drugs are no longer recommended, and will soon be phased out completely. Some older asthmatics may still be using them, just because they have been on them for years and no one has reviewed their treatment.
If you are taking such drugs, ask your doctor about switching to a newer form of reliever - it will be more effective in treating your asthma, as well as having fewer side effects.
Anti -cho linerg ics
These drugs, also known as anti-muscarinics, are relievers. However, they work in a completely different way from the beta-2 relievers. They block the action of the parasympathetic nervous system, a set of nerves that are the biological equivalent of auto-pilot - working without the intervention of conscious thought. The parasympathetic nervous system has many effects on the body, including keeping the airway muscles nicely toned (see box on p. 235). By blocking the parasympathetic, anticholinergics help the airway muscles to relax.
Anti-cholinergics are taken by inhaler, and require 30-90 minutes to achieve their full effects. They should continue working for 3-6 hours.
Some common brand names
Common brand names of anti-cholinergics include: inhalers – Atrovent, Oxivent
nasal spray - Rinatec
For most asthmatics, especially those with a strong allergic component to their asthma, anti-cholinergics are generally less effective than beta-2 relievers. But they are useful to children under one year, who may not respond to beta-2 relievers. They also have a role where asthma is combined with chronic bronchitis -here the anti -choli nerg ics can sometimes be more effective than beta-2 relievers - and they are particularly useful for asthma with a lot of mucus, because blocking the parasympathetic tends to reduce mucus production. For severe asthmatics, anticholinergics may be combined with beta-2 relievers.
Anti -choli nerg ics should be taken only when needed, not regularly several times a day. If used regularly, they can make the airways more sensitive, just as short-acting beta-2 relievers can (see p. 153).
Side effects
Minor side effects of anti-cholinergics may include a dry mouth, blurred vision, constipation, and irritation of the mouth and throat. A few people suffer nausea or difficulty in passing urine.
Serious side effects are rare. Any increase in the stickiness of the sputum coughed up may be a cause for concern, especially in children. If there is an increase in wheezing or coughing, stop taking the drug and see your doctor.
If you already have glaucoma or prostate problems you should be monitored carefully by your doctor, as these conditions can get worse with anti -choli nerg ic drugs.
When anti -choli nerg ics are used in a nebuliser, it is vital that the mask fits well (see p. 163).
Anti-cholinergics for the nose
Another use for anti-cholinergics is in nasal sprays, for the treatment of vasomotor rhinitis, a non-allergic condition that is frequently mistaken for allergic rhinitis (see p. 29). In this disorder, the constant flow of mucus is caused by a malfunction of the parasympathetic nervous system, which is why anti-cholinergics work well.