Dual Inhaled-Steroid Madness

"So, I have a note here," the pharmacy assistant says, unclipping a blue paper from the top of the folded paper pharmacy bag, and proceeding to reach in. He extracts the Zenhale (Dulera) and Qvar, "that-"
"Yes," I interrupt, somewhat laughing and as polite as I can possibly interject and save him some time, "Those both contain an inhaled steroid. I'm aware."
"Okay, good! Someone flagged this so I just had to make sure!"
"No problem," I told him as he replaced the boxed inhalers back in the bag. "It seems to pop up or get flagged in the system every year or two."
"Often one of our pharmacists will just notice it because of the overlap, and then they'll make a note of it."
I laugh, "Yep, been there before, I've been on this combo for probably 5 years now."

He scans the labels on the bag, prints, and staples the receipt to the re-folded over top. "I'll put a note in your file, hopefully, that'll help!"
The pharmacy assistant hands me my bag, and I head out of the pharmacy thinking a) why did they not just make a note before? and b) I kind of wish I'd gotten the other pharmacy assistant, not because the dude wasn't nice, but because she always asks when I am going to California next, and I had news to tell her that I may be going in May. Alas, I will have to wait until I go for Nasonex I suppose!

Ah yes… another steroid.

Dual-inhaled steroids: What gives?

My dual-inhaled corticosteroid journey started when I was on a ridiculous 9 puffs of Symbicort a day. Yes, that is technically over what they are supposed to prescribe. My then-allergist and I worked to decrease my Symbicort by adding Pulmicort, the theory being I needed more inhaled steroid for the inflammation, but not as much long acting bronchodilator as I was getting-which was, indeed, a lot.

Just before I switched to my current respirologist, AKA Dr. Smartypants, I swapped Pulmi for Qvar, and then when it became available in 2011, Symbicort for Dulera. 1 This has been my best combination, and I've since been able to decrease my Zenhale further, possibly due to the smaller particle size of Qvar getting into my tinier airways 2-hooray!

Sometimes, patients respond better to one steroid over another. In my case, budesonide (in Pulmicort/Symbicort) does not work as well for me as Qvar (beclometasone) does in tandem with Symbicort, and similarly, Qvar in tandem with mometasone (in Zenhale). It's a weird world of trial and error, and it should go without saying that your experience may vary! For me, I think the smaller particle size of Qvar might matter.
I'm also, thanks to the add-on steroid of course, on a lower amount of long acting bronchodilator (LABA)-which is good given I already take a stimulant med for ADHD, and I really don't want too much more heart-rate increasing LABA on board. Fortunately, the extra steroids seem to do me well!

Decreasing the inhaled steroids: More trial and error

Dr. Smartypants and I revisit the discussion of decreasing my inhaled steroids and my ICS regularly. Every Spring/Summer I attempt to decrease my meds, with a few intermittent increases when needed, and every Winter, my lungs start sucking more again and as the temperatures decrease, my meds have to increase. As I am able, I constantly play with titrating my own doses-as recommended by my doctors-while trying to keep things decently in control at the same time. Finding the optimal dose is tricky, but having a good doctor helps!

Now, hopefully, my pharmacists aren't again confused by my route to optimal dosing… at least perhaps not for the next year or so!

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