Contemplating Winter–in Summer
I had my biannual asthma clinic visit the last Tuesday in June. The respiratory outpatient clinic was shockingly calm, and Dr. Smartypants spent a good chunk of time with me. I always appreciate getting a good amount of time with her, because she is freaking smart, she is hip, and I am generally inquisitive about all things lungs and asthma!
Contemplating treatment changes – six months out
My treatment has been much the same most of the time I’ve seen Dr. Smartypants, which is I think about six years now (!!). We swapped one inhaled steroid for another, and one combo inhaler for another, and re-added Singulair for my rhinitis six months ago (and it’s working surprisingly awesome), but those are pretty minor changes–and evidence of the advances clearly needed in asthma treatment!
The cool-but-not-cold seasons, Fall and Spring, are my best seasons, Winter my worst, and Summer in-between. Winter is what needs the most solving for, though, given it takes up a disproportionate 5.5 months of the year here on average. We’re still working to reduce my inhaled steroid dose overall. We’ve been successful in the past, but I’ve found, thanks to Winter in significant part, often I get my dose down but my asthma control worsens and I have little to do but re-up it. I wondered if this might be psychosomatic, but it also happens every so often when I don’t realize my Qvar is empty, and after sucking back nothing but propellant from my add-on steroid for days, so, yeah, I do need at least some extra steroid to what I get in my Zenhale (Dulera in the US).
However, the inhaled steroid, of course, handles inflammation, not constriction. As Dr. Smartypants studied the chart of available inhalers in Canada (and we discussed the lovely pink metered dose inhaler in the UK that seems to be a made-for-me combo of formoterol-the long-acting bronchodilator from Symbicort/Dulera-and beclomethasone-the inhaled steroid of Qvar!), she considered a new plan for Winter to revisit at my November visit.
The possible plan for winter
At some point between now and November, I’ll get a letter from the clinic somewhat inefficiently telling me when to come back in. I’ll probably have PFTs, and go for another hopefully great chat with Dr. Smartypants, and come out with a new plan to try.
Her thought process at present is that my cold-air induced asthma in Winter is likely a constrictive response, not an inflammatory one. I hadn’t considered this, but it makes total sense. “You do well on Atrovent,” she noted, in regard to the short-acting anti-cholinergic I take two-to-four times a day, a different type of bronchodilator to the usual salbutamol(/albuterol). Anticholinergics are approved for asthma, but they’re not a first line treatment. (For anyone curious, I just messaged John and told him to writethatarticle, by the way!)
Which brought us to the contemplations of the new plan.
We’ve always opted to keep me on Atrovent versus a long-acting anticholinergic (the best known is Spiriva) because in most seasons, I take Atrovent morning-and-night with the occasional midday dose. I could tell in each discussion we’ve had around any anti-cholinergic switches she was hedging-and I alongside her, since our goal is to keep me on the lowest possible medication doses, and though less convenient, Atrovent allows me to modulate my doses as needed. This discussion was much the same.
‘I think’ she told me, gazing at the medication chart on the desk in front of her, “We should consider adding something like Spiriva”- she pointed to the Respimat on the chart, given our earlier discussion about my preference for non-dry powder inhalers – “When I see you again in the Fall and try that out for Winter, to see if we can manage your symptoms while keeping your inhaled steroid dose down over winter.”
I’m not excited about the worsening of my asthma that comes with Wintry sub-zero (or sub-10*C) temperatures. I am very excited that we have a new plan to try, because I know the inhaled steroids still weren’t adequately controlling my asthma in Wintertime, anyways.
Maybe, just maybe, thanks to Dr. Smartypants being smart, I won’t have that same Winter asthma experience I’ve had for the last 9.5 Winters with asthma.
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