Wednesday, July 13, 2016

My thoughts on Advair

If you've been reading my blog the past month or so I've mentioned Advair quite a bit. Here I would like to give you my unadulterated opinion of it. Here goes. 

So, the two ingredients in Advair are salmeterol and fluticasone. Salmeterol is a long acting bronchodilator and fluticasone is a inhaled corticosteroid. Let me tell you about these.

Salmeterol: It was approved by the FDA in 1994. It was in a little green inhaler called Serevent, a little shorter than the albuterol inhaler. Dr. Oliver prescribed this inhaler for me, telling me to take two puffs two times a day, once in the morning and once at night. He said it's basically the long acting version of albuterol. 

Back then my asthma wasn't as controlled as it is today. This was mainly because the inhaled steroid I was on at the time was Azmacort, and it was not very strong, and needed to be taken as four puffs four times a day. So, needless to say, that wasn't possible for a busy 24 year old. 

Most of the time I used it as instructed, but there were times I would use it instead of albuterol as a rescue inhaler. I didn't really do this intentionally, but I remember one night I was having trouble, and I puffed on my inhaler frequently during the night. Then in the morning I realized the inhaler I was using was Serevent. Needless to say, I did not die. 

So this is how I discovered that salmeterol does not kill, as one theory suggests. You know that some asthmatics died clutching a Serevent inhalaler. So, rather than blame the asthma, the inhaler gets blamed. So that's how a black box warning got on long acting bronchodilators like Serevent. 

Now you have warnings on these: "Do not use more than twice a day. Do not use more than instructed." I am fine with this. However, if you go to Canada, they use the Symbicort inhaler as a rescue medicine. It's a program called Symbicort Smart. So, apparently, it's only in the U.S. that LABAs kill. 

My point here is you should not be afraid to use Advair and Symbicort. They are very effective for helping asthmatics obtain ideal asthma control. I'm not saying you should use them more than prescribed. 

I do not like Symbicort or Dulera or Breo. Formoterol makes me too jittery. It is the active LABA in Symbicort and Dulera. Vilanterol, which is in Breo, is also the same. Only salmeterol like me. The disadvantage of salmeterol is it takes 15-20 minutes to open airways, unlike the other LABAs that work immediately. But this is fine with me, because I don't like to feel jittery and shaky. 

Now, I am going to say something that you should never do without talking with your asthma doctor. That is my disclaimer. That said, I have not taken formoterol and vilanterol enough to know if they are safe to use more frequently than most American doctors suggest. Obviously, based on the Symbicort Smart program, Symbicort probably is. but I know from my own personal experience that salmeterol is safe. 

Think of it this way, as my doctor said long ago, all salmeterol is is a long acting version of albuterol, and side effects of albuterol are negligible. It might give you the tremors, but it won't kill you. The same is true of salmeterol. If you need to take an extra puff to end a severe asthma attack, go for it. 

No. Don't go for it if you didn't talk to your doctor. Actually, I personally have never discussed this with my doctor. And this is because I rarely do it. In fact, I have only done it one time in the past five years. One night I was at hunting camp, having a severe allergy/asthma attack, and that extra puff of Advair pulled me out of it.  It took about a half hour, but all of a sudden I could take a deep breath. 

Would I make a habit of doing this. NO. Would I take many puffs of it. NO. Not intentionally, anyway. But the inhaler is not going to kill you. Now, as other experts have noted, the people who die with an Advair or Serevent inhaler in their grasps are those who relied overly on their inhalers when they should have sought for help. So, seek help when you need it! 

I have had this disease for 44 years. I know what works for me. I know that my asthma attacks are not going to kill me. I know an extra puff of Advair will pull me out of my attacks. If they didn't, well then I would seek help. But they almost always do. Plus, because I use it regularly as instructed, my asthma attacks, when they do occur, are relatively mild and easily controlled. 

So, there, that is my personal opinion of Advair. My doctor has this bug up his butt about getting me on something different. So I tried all the other combination inhalers, and they all made me jittery and nervous. So, I am back on Advair, and I will forever be on it -- lacking a cure of course. 

Again, do not use your inhalers the way I do. I just do it the way I do because I am a professional asthmatic. I do not get arrogant and cocky with my medicine. I used to, but that wasn't smart. It wasn't smart to take many puffs on serevent back in 1994. 

Friday, July 08, 2016

What do allergic asthmatics do to pass the time?

A question I pondered this morning was this: "What do people with allergies do to get through the day?" Well, you all know I write. But what do you do when the writing is done for the day? 

Okay, so there are kids to play with. There is a wife to hang out with. There are people to see, and work to be done. Well, when I say work I say that lightly too, as much of the regular "guy" duties are not done by me. They all involve dust and other allergens. So, that said, what do people with allergies do?

I, for one, played with baseball cards when I was a kid. Most of the cards I had were new. I sorted them out. I opened packs. I traded with my friends. I went to flee markets and bought old ones. I had quite a collection. Okay, so this occupied a lot of my time. When my brothers and dad were out doing guy things, and my asthma prevented me from going, my baseball cards occupied me.

So, after I met my wife in 2000 I put my baseball cards aside. Fifteen years later I brought them out. I bought a nice collection at a yard sale. This was going to be a hobby brought back to life. But then the allergies hit.  

Just to give you an example. It was very slow today at work. So, I decided to bring my baseball cards in. They are 1980s Topps baseball cards. They belonged to my brother. I managed to sort them out earlier in groups such as the following: 1-99, 100-199, 200-299, 300-399, 400-499, 500-599, 600-699, and 7-726. 

Today's job was to finish sorting them out. So, I started with an easy job: 7-726. That got done really fast. Note that I am breathing fine. I am on 500mcg of Advair, so I should breathe easy. Not so fast. 

I managed to sort through the 600s without much of a problem. But by the time I got to the 500 my chest started to burn. Those little bugs were in my lungs. They were in there already by the 700s. It took my immune system that long to register an immune response. My airways seem to be quite twitchy, despite 500mcg twice a day of fluticasone. 

See my point. So, I ask: What do allergic asthmatics do to pass the time?

You know, it's really neat that I get to run. When I was a kid I couldn't do that. I can run as much as I want and I have no asthma symptoms. I can take the kids about anywhere. I can go for walks in the woods. I can go on dates. I can do pretty much any of that. 

So, what can't I do? Well, obviously I can't (or shouldn't) go to my dad's cabin. I obviously can't (or shouldn't) play with my baseball cards. But I will. I know I'll go to my dad's cabin again. It's just too fun. I will just have to figure out what to do at night, when others are sleeping. I will also play with my cards again. I want to right now. But I better not. (Chest is starting to feel somewhat better. The longer I stay away from those cards, the better it will feel, even if I don't treat it).

Look, I just love baseball cards. I would love to open up a little online shop. But, I'm pretty sure that goal might be dashed. No. It won't.  Only, most of the time I limit myself to 30 minutes. I went way past my limit today, like four hours past. I violated my own rule. In the future, which will probably be tomorrow, I will have to limit myself.

Or, I might be able to wear a mask. But I tried that before, and those little buggers still managed to get into my airway somehow. 

Still, I had to be at work for eight hours today, and there literally is nothing to do. I wanted to take a break from writing, but here I am. I am only writing here because my twitchy, burning airways told me to quit. 

It's kind of neat that I have had this disease so long, and I don't let it stop me from doing anything. But, that's not necessarily true. I mean, I cleaned my bedroom the other day, even cleaned in the closet, but I did it fast while holding my breath. Today, I did not hold my breath. I breathed normally while enjoying my collection. I even enjoyed the smell of the cards, that dusty smell of cardboard, not the new, fresh smell of Bazooka Bubble Gum. 

Don't get me wrong, I'm not feeling sorry for myself. This is just what I have been dealt.

I'm kind of nonchalant about it. I've always been that way about my asthma. Ironically, I'm not sniffling or sneezing, it's just the chest tightness today. I wonder why that is. Usually the dust mites give me both allergies and asthma symptoms. Usually they make my eyes itch long before my lungs, but my eyes seem to be fine right now. Go figure. 

And, also interesting, I'm not really short of breath, it's just the chest tightness. And I know it's my airways spasming, mainly because this is the same every time I inhale little critters. Okay, so I'm a little short of breath, but so far not horribly bad. Just bad enough I know I need to quit. 

It almost feels as though someone has feathers in my chest, millions of them (hmmm, how about millions of little legs from dust mites crawling all over my airways), rubbing them on the walls of my airways. And so my immune system attacks them, causing my airways to spasm (twitch), and mucus to increase (causing the itch). 

As I've written before, the symptoms I feel right now are more annoying than they are deadly. I know I'm not going to die from dust mites. I might die of boredom (well, not really, because I just moved on to the next assignment). 

Which is also interesting. I have also written before that I never feel sorry for myself, just learn to cope. You have to realize I've had this disease for 16,987 days. So, that's long enough to learn how to cope. When there's something I can no longer do, I just move on. That's the way you deal with a chronic disease. 

Actually, I am starting to feel tight now. I have taken three breathing treatments so far.

You know what is going to hit tonight, or what might? That late phase reaction. Those late phase reactions are usually the worse. It might hit around midnight, or it might hit around 2 a.m.  It's pretty bad I've had this so long I know what's going to happen later. Pretty cool, hey? I don't regret it though, as I had fun sorting through those cards. Just wish I could have finished the project (which brings me to tomorrows post, finishing projects with allergic asthma).

The late phase reaction. I could write a post on that too. I will probably wake up sometime tonight feeling very dyspneic. Or, it might just be a severe allergic reaction. It will hit like a mack truck. It won't kill me, just make fee feel very uncomfortable. When it hits, I'll take a Benadryl, and wait it out. I might fall asleep propped up. I like Benadryl because it acts sort of like a sedative, taking the edge off, allowing me to fall back asleep. 

But, I think my motive right now is to find another hobby. Something besides writing that I can do. This brings me back to that original question. Now that I shouldn't (but still will) sort through my baseball cards (or at least the time doing this will be severely limited from now on) what will I start doing (besides writing, considering I already do that) to pass the time? Hmmmm.

Thursday, July 07, 2016

A letter from my health insurance

I received a letter from my insurance company that said, as of July 1, they will no longer be paying for my Advair or Breo. The letter said, "If you tried Symbicort and Dulera within the past year, and this insurance paid for it, you do not have to do anything. Otherwise, you will have to have your doctor write a prescription for one of these medicines, or have your doctor contact us with a good reason."

I gave the letter to the secretary at my doctor's office, so I don't have it in front of me, but that is the gist of what the letter said. My pharmacist (Mr. Prick) said my insurance sends these letters every year, meaning I will have to have my doctor contact them every year.

 It's kind of another one of those medical regulations (this one created by my insurance) where every asthmatic is treated as though they are all the same. And, if we are all the same, that means none of us are exceptional, meaning we are all stupid. So that's why they have to send these letters out every year. That's also the reason my doctor has to "educate me" about my medicine every year, even though I'm an asthma expert. 

Maybe we are all stupid. A study came out recently showing that 90% of asthmatics use poor inhaler technique. Even experts like me use poor technique. I know I use poor technique, and I don't care: the medicine still works. My friend Shauna and I used to joke about how we both use poor technique, but that's what we want to do. That's what works for us.

So my insurance company is aware of this, and they took this study as a reason why they should annoy asthmatics every year, and lecture them about proper asthma technique, because we are all stupid. 

I'm kind of on a tangent on this lately, aren't I. Yes, I am. As a respiratory therapist I know that much of what we do in the hospital setting is not what doctors want to do, but what insurance companies, what Medicare, makes them do. For example, in order for someone with pneumonia to qualify for admission, they have to have three failed breathing treatments, even though breathing treatments have no effect on pneumonia. But doctors, like you and me, are stupid as far as Medicare is concerned, and this is why the regulation is how it is. They treat every patient the same, because being creative, trying something different, costs more.

Oh, and by the way, that's the bottom line to these changes. The reason my insurance company sends my doctor letters like this, the reason my pharmacist has to "educate me" is not because the insurance company wants to keep me healthy. Well, that is part of the reason, because a healthy me is a less expensive me. But the true reason is cost. The true reason is they have a contract for Symbicort and Dulera, so they are cheaper than Advair. 

The irony is that, even though Advair works better for me than Symbicort or Dulera, they want me to be on Symbicort or Dulera because that saves them money. Plus I'm too stupid to figure that out on my own, so they have to send these letters to my doctor, forcing him to remind me, the stubborn asthmatic that I am.

Sunday, July 03, 2016

A normal situation for an asthmatic

Yesterday my kids were busy playing with the neighbor kids and my wife went out with her friends. So it was an ideal night for sorting out my baseball cards. I set up a table in the garage, and enjoyed the evening. I even cracked open a beer.

My brother Bob gave me the cards he collected in 1980, which included Topps, Donruss, and Fleer. It also included some baseball cards, and a 1978 Dr. J Card. That was a cool find. I sorted the cards out earlier, and had one box of star cards I wanted to put into plastic cases. 

Because I know these cards are older, and that they were stored in my brother's basement, I have been limiting myself to no more than a half hour a day sorting them. But I was having fun last night, so I spend several hours doing this. It was fun, and when you are having fun you keep doing it, right?

Well, not when you have severe allergies along with asthma. Not when you have allergic asthma. When you have a lung disease, you either don't do it or you limit your time doing it. So, I had a mild asthma attack. I took a breathing treatment and was fine. 

I was smart enough to quit at this time. It was about 10:30 p.m., and I went to bed. Then my wife came home around 1 a.m., and this was when the late phase reaction occurred. I wasn't severely short of breath, but just enough so that it was uncomfortable. I had to get up and deal with it. 

The bummer was that my Advair was empty, and I had no albuterol inhalers. So, this meant I had to get out of bed and use my nebulizer. I also don't have any sudafed, something that works well for allergies, and doesn't cause drowsiness. So I had no choice but to take a Benadryl 

Needless to say, this entire event impacted my next day. It was hard to get up considering the Benadryl effect. It also made it so there was no way I was going to be able to play with my baseball cards. This was no fun, because I had the whole day off and pretty much nothing else to do. Plus, after the job done last night, I had the baseball card itch. 

This is not that big of a deal, as I always find ways to cope; there are other things to do. It's just that, despite asthma experts always saying it, you really can't live a normal life when you have severe allergies to go along with asthma. You can cope, you can adjust, but you really can't live a normal life. This is, however, a normal situation for an asthmatic. 

Friday, July 01, 2016

New Asthma History Blog

Depiction of Rene Laennec using the stethoscope he invented.
For the first time those asthmatic wheezes could be heard.
Another thing I need to make a note of here is that I started my asthma history on this blog. Then I moved it over to Respiratory Therapy Cave, and then I decided to just start a new blog called "Asthma History."

So, if you are interested in reading the history of asthma, click on over to my new blog. Keep in mind that this is a living history, meaning that I'm adding to it on a regular basis. So, if your'e interested in the history of our disease, check out my new blog: "Asthma History." 

Why I started drinking coffee

Kerri MacKay wrote an excellent article recently at asthma.net called "Coffee and Asthma: What's the Deal?" She even referenced this blog, and made my ego go up a notch, from zero to one. If you delve deep into my blogs you'd know I was chronically dependent on theophylline for over 30 years, only to finally be weaned off it in 2000 thanks to another great asthma medicine called Advair. It was at this time, and I was 40, that I started drinking coffee. 

A theory that arose in my mind was that I started drinking coffee because I quit taking those two little white pills every day. I knew that both theophylline and caffeine come from the same family: they are both Xanthines. Kerri taught me something that I did not know: that theophylline is a byproduct of the breakdown of caffeine. That, in effect, I am still on theophylline, albeit a low dose of it. 

I never had any desire to drink coffee before I was off theophylline. I drank a cup here and again, although never really cared for it. I hated the taste. And I hated that it made me jittery. I remember telling people I didn't drink coffee because it made me feel like a jolt of electricity was flowing through my vessels, and this was probably because I was already on theophylline, so this made the side effects doubly strong.

And for the record, I do not drink coffee because it has a mild bronchodilating effect. I would imagine if you had very mild asthma it might prove useful, but my asthma is not mild. I don't like to refer to my asthma as severe, although that's how my wife refers to it. 

Anyway, nice article. Go read it!

Thursday, June 30, 2016

Pharmacists now required to annoy asthmatics, part 3

(Editors Note: Read Part 2 here)

Just as an aside here, I love the cartoons in my header, although it looks so gloomy. Even the name "hardluck" resonates gloom. I had actually changed the name once to "Gallant Asthmatic," and I think I should have kept it that way, as it offers a more positive tone. If you see a change in the future, this should explain it.

So, that said, I had finally had a run in with the pharmacist at Meijer. I went there to pick up my prescription for prilosec, and that's when he accosted me. He was nice, very nice. And he started asking me about my other medicines, the ones that put up a "red flag," so he said, from my insurance company.

The red flag was that I need to set up an appointment with him to discuss my medicine, side effects, and how to take them properly. He said, "Your wife said you are a respiratory therapist, and an asthma blogger, so I knew you would be a tough nut to crack."

He said all it takes is an hour. He said he has to do it once a year, unless I refuse. But if I refuse the red flag comes up every three months, and he has to ask me if I'm ready to set up my appointment.

He said it has nothing to do with Obamacare that he knows of. He said it's a policy of Medicare, and my insurance picked it up from that. Then he just started asking me questions about my medicine, the ones the red flag was in reference to, not the one I was picking up.

I explained to him that I tried Symbicort, Dulera, and Breo, and that the long acting bronchodilator in these medicines (I named them by their chemical names as though to show how deep my knowledge of these medicines went), formoterol and vilantnerol, were too powerful and caused me to become jittery and nervous.

I explained to him that I took Advair for 10 years and it worked great. But for some reason my doctor got a bug up his butt about getting me off Advair and on to one of the other combination inhalers. I tried them all. They all worked great, but had side effects I couldn't tolerate.

I even told him that I used to take salmeterol, the LABA in Advair, by itself back when it first came in the early 1990s. Even that made me jittery and nervous. But, for some reason, the dry powdered salmeterol doesn't cause that effect.

He shrugged as if to indicate, "That doesn't make any sense." But it does make sense. DPIs don't distribute the medicine as deep as MDIs, so it does make sense. Every asthmatic is different, and respond differently to different medicines, even different forms of the same medicine. So it does make sense. But I didn't want to get off the subject as I am here. 

So I realized I was going into a lot of detail, so I said, "Can we consider this our discussion?" He said, "No!"

What a prick. Sorry, but that's what I've decided he is. He was nice, very nice. But he is a prick. I say this because, over the past month, I have asked many of my fellow asthmatics if their pharmacist bugs them about their medicine. They all said that they ask, but when they say, "No. I'm a nurse", or "I'm a respiratory therapist," and they drop it.

This guy is one of those rule followers. He has no ability to use his common sense to walk around the rules. He is not able to think on his own. He may not like the rule, but it is how it is, so he follows it, even if it means annoying the crap out of me and my wife every time one of us picks up a prescription form Meijer Pharmacy in Ludington, Michigan, when he is working. 

That's how I define prick. Sorry, I will not tell him that to his face. I am political when we are face to face. But here, at "Hardluck Asthma," soon to be "Gallant Asthma" as soon as I get time and energy to make the change, I am not politically correct. I will not be politically correct. I do not have to be "Nice!"

And there's another aside I'd like to mention here real quick. A part of me wants to start over: a new blog, that is. I'm seriously pondering making a new blog, combining Respiratory Therapy Cave and Hardluck Asthma. But, for the life of me, I cannot think of a good name. When it comes, I will make the change. So, in the meantime, breathe easy.