Stepping Down Asthma Therapy: Tackling Side-Effects
While it took many trials and years to get my asthma under control, I’ve been on a pretty good mix of inhalers for the last few years. I had a really good breathing stretch in the Fall, although Winter is my worst asthma season. When I saw my respirologist (Canadian for pulmonologist, AKA asthma doctor), whom I refer to as Dr. Awesome, in early December, I—as usual—rocked my PFTs and she decided I could try stepping down my Zenhale (Canadian for Dulera) from 2 puffs in the morning to 1, partly in attempt to curb some of the tachycardia the combination of asthma meds (specifically the formoterol in the Zenhale, and less-frequently Ventolin) and ADHD meds I am on is contributing to.
Now, the step down has been going meh. I do not feel as good as I did on the higher dose, but it is now a week later and I have not “caved” and bumped my Zenhale back up just yet. With that said, the first day, I may have been whining to Dia about how I already felt like I was failing at the step-down, and she imparted some words of wisdom on me along the lines of be patient or give it time or something. You know, things I am not actually good at ;).
The reality is, is that actual Winter and the first cold day hit on the day of my appointment—a massive dumping of snow and icy enough roads that my mom bused to work for two days, and on the third day when she took her car, we encountered a car stuck at the end of the second street we drove down. The bonus to this is that people apparently were ditching asthma clinic, and I got to my appointment early (miraculously), I was one of two people waiting, and Dr. Awesome called me into the office (a miraculous) 20-plus minutes early. We spent a good twenty-plus minutes discussing my asthma control and general health, going over my EKGs and six-minute walk tests, doing spirometry (which she’s hardcore enough to just administer herself), and discussing my meds. By some additional miracle, I was booking my next appointment for May a minute before my scheduled appointment time—when does that happen?!
In Actual Winter, that’s when.
Actual Winter has remained. This—to me—is not an ideal time to decrease my meds. But you know what? When I said that last year, Dr. Awesome agreed with me and told me to try when it was less Wintery out. I did, and it worked. She also told me I could play around with my other meds (granted, she knows I know the limits there!) if I could keep the Zenhale down. I’ve bumped up my Qvar to maintain my same inhaled steroid dose and theoretically, could see if an increased maintenance steroid dose helps. I’ve been taking my Atrovent 3-4 times a day, as opposed to 2-3. Atrovent is an anticholinergic bronchodilator that may have less cardiac effects than formoterol, although the research I looked at was unclear, and most covered ipratropium (Atrovent) combined with albuterol (Salbutamol/Ventolin).
FDA Reports on Adverse Events
With the confusing-ness of the research, here’s what the FDA reports on adverse events say. Less than 2% of adverse event reports for ipratropium (Atrovent) are for palpitations (the awareness of increased/varied heart rate).1 For formoterol, this rate is 1 to 2.5%, combining the terms “tachycardia” and “increased heart rate."2 (I present these as ranges, because doctors use different terms for the same or similar side effects, so I am unsure if a doctor is, say, reporting “palpations” and “tachycardia” as one unit or separately.); and for albuterol (salbutamol/Ventolin), combining the terms “palpitations”, “heart rate increased” and “tachycardia”, we go from 1.45% to 5.05%.3
However, simply all this means is that a patient has found the side effect bothersome enough to report it to a doctor, who then has to report to the FDA. I know that Ventolin specifically causes me to experience heart palpitations, but knew this was a common side-effect and have never mentioned it to a doctor.
Side Effects Are Different From Person to Person
Like everything asthma, side effects are wildly different from person to person. And a side effect that you’re not necessarily bothered by (like my experience) may pop up later and be something your doctor thinks needs addressing. In contrast, you may also experience side effects that your doctor does not feel are important to address. The key here is self-advocacy: sometimes there are not other options, but other times, alternatives may be explored to help you tolerate asthma therapy better—decrease side effects—and maintain asthma control. Since side-effects may make you less adherent to medication (as much as I hate that term!), it’s important to bring these up with your doctor because often they can help you problem solve.
While it hasn’t been too evident yet, hopefully, my step-down in asthma treatment helps me maintain relatively good asthma control while decreasing my heart rate. We’ll see!
Have you experienced a collapsed lung?