Theophylin no longer top line asthma med

In 1976 my pediatrician started prescribing liquid theophylline Sustaire to control my asthma. I remember my mom feeding me that stuff with a teaspoon, and it tasted nasty. For the next 30 years I would end up chronically dependent on this stuff.

In the 1860s Dr. Henry Hyde Salter wrote a book, "On Asthma," where he recommended strong coffee and tea to help control hardluck asthma. In fact, this was occasionally tried by a young asthmatic Teddy Roosevelt.

Salter may have known coffee was a member of the xanthine family, but he probably didn't know the xanthines are mild bronchodilators (they dilate the air passages in your lungs). This wasn't proven until 1921, and by 1922 theophylline suppositories were used to treat asthma.

Amimophylline is the IV version of theophylline, and was first used in 1937. If you were admitted to a hospital with asthma between 1950 and 1990, chances are you had this running in your IV at some point. I know from my medical records I did.

The bronchodilator effects from caffeine are very suttle compared to Theophylline, which was first extracted from tea leaves in 1888 by a german scientist. It wasn't until 1950, however, that it was approved for use as a bronchodilator. For the next 4 decades it was a top line therapy for treating asthma and COPD.

The problem with theophylline was that it had a very narrow therapeutic level. Too low and it didn't do anything, yet if your theophylline level was too high (as in greater than 20) there were toxic effects, such as vomiting and even death. So you had to have your blood level checked frequently.

Another problem with this drug is it only lasted in your system 4 hours, so I had to take it every 8 hours or my levels dipped in the middle of the day causing asthma symptoms. Once as a kid I had a 24 hour theophylline study done, and had to have my blood drawn every few hours. It wasn't so bad, though, because they put a line in my hand to draw from.

My doctor told me in 1995 that the normal dose he prescribes is 300mg twice a day. I required 600mg twice a day, and somehow that still kept me under the toxic level. (I wonder how many cups of coffe that's equivelent to.)

In the early 1980s theophylline was determined to be "less efficacious" than anticholinergic medicines like Atropine when it comes to dilating bronchioles, yet it wasn't until the 21st century that it faded away as a top line asthma drug.

Many doctors were staunch defenders of this medicine because it worked so well for them for so many years. I was a staunch defender of it because my body became dependent on it to the point that when I forgot to take a pill I would have the worse asthma attacks ever.

Perhaps some of my fellow asthmatics will empathise with me. A good example of this was when I forgot to take my theophylline for three days when I was busy in college in 1988. Absent this bronchodilator my lungs freaked out. My chin became itchy, my chest burned, and my mucus production increased almost to the point I felt I might choke.

My room mate Frank walked in on me and I must have been a sorry sight all frogged up on the edge of my chair, grunting with each expiration, tears in my eyes, misting nebulizer clipped between my teeth.

"Do I need to take you to the ER," he said.

"NO! I'll be fine," I grunted.

"You look like you're gonna die."

"NO!" I insisted. I had just popped a Theo-Dur pill dry. I knew from past experience it would take about 20 minutes before my breath started coming back.

The Albuterol treatment was useless during one of these attacks, however I always took one. When I was really little and this happened I'd go to the ER, but at some point in my asthmatic life I learned the difference between a regular asthma attack and one induced by a low theophylin level.

"Give me ten more minutes," I grunted, "If I still look like I'm going to die, drag me to the ER." Feeling helpless I'm sure, he stood by and watched as I suffered.

Then, right on cue, I felt the mucus letting up; the chest tickling feeling letting go, and my breath coming back. First came a quarter breath, then a half a breath five minutes later, and finally... "Ahhhhh, man it feels good to breathe."

That's why I was such a staunch defendent of this medicine, and was vexed to learn Theodur was no longer made, and I had to swallow generic theophylline horse pills instead.

The problem with theohylin is it's a systemic drug with some undesirable systemic side effects. The thinking used to be if you need it for a chronic lung condition you need it, because some minor side effects are far better than suffering or dying from asthma.

Most side effects, though, are generally mild. Some are similar to when you take caffeine, such as irritibility, insomnia, nervousness and jitters. Since Xanthines are also mild diuretics, it might cause you to pee more. It can also irritate the lining of your stomach.

To some extent, I've experienced all of these side effects. However, the one that bothered me the most was an irritated stomach that I attributed to this medicine, and why I wanted to get off it.

I approached my doctor about getting off theophylin, and he said, "It's neat you bring this up, because when I started as a doctor nearly every one of my asthma patients were on theophylin, and now you're one of only two."

In the past Theophylin was a top line bronchodilator usually used in conjunction with corticosteroids. New long term bronchodilators with fewer side effects have replaced theophylin, they are called Serevent & Formoterol, and are usually given in conjuction with the inhaled corticosteroids Flovent and Pulmicort respectively in the popular medicines Advair and Symbicort.

My doctor said, "You've been on theophylin so long, and it seems to work so well for you, I'd hate to tinker with it."

"One attempt, doc" I said. "I just want to make one last attempt at getting off it. If it doesn't work, it doesn't work."

We decided on a very, very slow wean. In fact, the wean took a full year to complete. And it worked. On January 31, 2007, I took that last pill. And, just in case (as if in tribute to an old friend), I left an unopened prescription bottle of theophylin in the medicine cabinet just in case. It's still there to this day, a daily reminder of what used to be.

So while Teddy Roosevelt guzzled cups of coffee praying it would help him catch his breath, scientists gave asthmatics theophylin in the 1950s. Now, with even greater advancements in asthma medicine, theophylin is little needed today.

(For a doctor's perspective on theophylin click here).

New study backs up the hygeine hypothesis

I wrote a while back about the hygiene hypothesis and how exposing a baby with the asthma gene to certain bacteria while his immune system is developing in the first few weeks of life may prevent asthma. Likewise, lack of exposure may actually cause asthma.

In my recent search of the Internet I found this explains that bacteria present in house dust mites may determine if a child in that house develops asthma. They explain that recent research shows household dust mite actually holds "diverse" amounts of bacteria.

Likewise, "bacterial populations are greatly impacted by the presence of dogs and cats and whether or not children attend day care." Of course we have hypothesised that exposure to day care centers and dogs and cats diminishes the chances of a child getting asthma.

The article also notes that "Additionally, dust samples collected from homes of infants, with or without pets and varying day care attendance, showed differences in dust bacteria were linked with asthma development in children."

Slowly but surely the pieces of the asthma puzzle are coming together.

My experience with Singulair

So Advair worked wonders in helping me finally obtain good control of my asthma (as I wrote about here). Now it was time to get those dreaded allergies under control.

All my life there just seemed to be nothing available to control allergies. When I was really little my doctor wouldn't let me take anything for allergies, because on the box it said, "Do not take if you have asthma."

As I look back I think how stupid that was. There were many miserable nights for me because of that stupid wisdom. Later I was allowed to use antihistamines, although they did little good.

Pretty much the only thing that worked for allergies was avoidance. Yet it was hard to stay away from my brother's house, my friend's home, and the cabin where the guys hung out. It was no fun to avoid those places, yet that was often the only option, unless I wanted to take risks (which I often did).

And the boxes I set in the basement of my new home three years earlier were still sitting down there, because every time I tackled that job the allergies would strike, and quite often that also lead to an asthma attack (although now less severe due to Advair).

So along came Claritin. And then along came Singulair. Yet, because I didn't complain enough about my allergies to my doctor, these meds were around several years before I tried them.

One day, late 1997, this topic just happened to come up while I was having a friendly discussion with a doctor friend of mine at work. He said, "I think you definitely should be on Singulair. In fact, I think every asthmatic should be on Singulair."

I went home and researched the medicine. Of course I already knew that 70% of asthmatics have both allergies and asthma, and that quite often these allergies trigger asthma. So, if scientists could come up with a medicine to stop the allergy response, then they could control asthma.

Scientists also know that during an allergic reaction a chemical called leukotriene is released. This chemical causes bronchospasm. Finally, in 1998, after spending millions of dollars and 63 years researching leukotrienes and working on a way to block their release, Singulair was approved by the FDA.

Singulair has an active ingredient in it called Montelukast sodium, which blocks the action of leukotriene, thus preventing allergies, and preventing bronchospasm caused by allergies, and, in turn, preventing asthma.

So, new asthma wisdom in hand, I had a nice discussion with my asthma doctor during my next visit. He was skeptical at first. He asked me if I tried over the counter antihistamines like Drixoral or Clariton. I said I tried them all to no avail. "Nothing EVER worked," I said, "And I can't go through one more spring feeling miserable. I just can't!

He said he was "cautious" about starting me on newly released medicine. He didn't want his patients to be a guinea pig. But, being open minded, he said, "I'll let you try it for a month."

"Doc, " I said, "I think you should let me try it at least through spring. If I can make it through spring without having miserable allergies, I'll know this medicine is working."

Finally March arrived -- no allergies. April arrived -- no allergies. May arrived -- no allergies. June, July, August... No allergies at all that summer. In fact, I haven't had allergy symptoms at all since I started taking this asthma/allergy miracle medicine in January of 2008.

Obviously all medicines come with a risk of developing some side effects, but I developed none. Thank God, because allergies held me back for the first 38 years of my life. Not anymore! Now, with the combination of Advair and Singulair, I actually feel like a normal person for the first time in my life.

I have talked with doctors that say every asthmatic should be on Advair, and every allergic/asthmatic should be on Singulair.

By the way, another advantage I've come to enjoy regarding Singulair is it works well to prevent exercise induced bronchospasm. Now, thanks to Advair and Singulair, I'm actually able to run.

So, if you're an asthmatic and allergies continue to hold you back despite your best efforts, I highly recommend you talk to your doctor about Singulair.

Now, keep in mind that what works for me won't necessarily work for every asthmatic. Singulair is simply another option for us asthmatics to try. Thankfully, for me, it worked like a charm.

My experience with Serevent

I've decided in this post to share my experience with the long acting beta adrenergic Serevent. Perhaps there's some asthmatic somewhere who might benefit from my story here.

I guess you can say that even though I've always been a gallant asthmatic for the most part, I was also a hard luck asthmatic up until about 2005. That is: no matter what medicines I was on my asthma was still not controlled (although it didn't stop me from doing much).

As a quick review here, Serevent is a long acting bronchodilator that should be taken twice daily for chronic asthma. It is a time released medicine that does an excellent job of preventing bronchospasm from occurring and thus it works to PREVENT asthma.

Actually, based on studies, the FDA now recommends if you need Serevent to control your asthma you should also be using an inhaled corticosteroid (like Flovent) to control chronic inflammation. This didn't really apply to me, though, as I was already on flovent.

Actually, if you need serevent, you might as well take Advair, which is a combination inhaler with both Serevent and Flovent in it. Another similar medicine is Symbicort.

In 1998 I was still on the same asthma preventative meds I took way back in 1985. I was taking Azmacort four puffs four times a day, I was on Theophylline 600 mg twice a day, and I had a Ventolin inhaler which was prescribed for me to used whenever I needed it.

I actually used my Ventolin quite frequently, and one would last anywhere from a week to a month. My asthma never stopped me from living a normal life, although avoiding my asthma triggers was sometimes a challenge.

So, basically here it was 1998 and I was still on pretty much the same meds antiquated asthma meds I was on in 1985, which you can see here. After I graduated from respiratory school, I moved to my current home, and in the process of moving, dust mites and molds hit me hard and I ended up the the hospital for 10 days.

Once I was feeling better I discussed with my doctor about trying some more updated asthma meds. He advised that I try Severent and Flovent. The Flovent worked great, especially since I only had to take it twice a day as opposed to the 4 puffs 4 times a day I was taking with Azmacort.

The Serevent, on the other hand, made me so jittery I could hardly function at work (it was hard to draw blood, one of my favorite duties). So after a couple weeks I quit taking it.

Actually, I moved into my current home in 2004, and in 2007 many of the boxes still sat unopened in my basement. Every time I went down there I'd have an allergy/asthma attack.

In the meantime I talked to asthmatic friend who said since she started taking Advair she no longer feels like she even had asthma. So I talked with my doctor again about trying Advair. However, AGAIN, I got very jittery and had to quit taking it.

I think the reason I was having such a hard time with the Serevent was because I was using so much Ventolin. So I decided to try something on my own. I decided that I would SLOWLY decrease my use of Ventolin at the same time I weaned myself onto the Sevevent (Advair).

What I did was I took one puff of Advair every other day for a month. Then I took one puff a day for a month. Then I started taking it once in the morning and once at night, the recommended frequency.

It worked. By weaning myself onto the Advair the Serevent was SLOWLY introduced into my body. And, as the LABA started taking effect, I needed less and less Ventolin.

Finally I felt like a normal person. In fact, my asthma was better than it ever was in my life. Still, though, I wasn't able to clean my basement due to chronic allergies, and this is where Singulair comes into play (I'll get into that in my next post).

Advair brought upon a major change in my life. Honesty, for the first time in my life I felt I had control of my asthma. Advair is simply a "miracle" medicine. And, if I hadn't worked with my doctor on weaning myself onto it, my asthma would still be "controlled" by 1980s standards -- and that's no longer acceptable.

My point by sharing this experience is twofold. One, if you are doing everything you can to control your asthma and it's still not controlled, research other asthma meds, especially the newer ones, and discuss with your doctor your options.

Two, sometimes you may need to get creative with new meds, and you need to give it a chance to work. If you tried it once and had a bad experience like I did, try it again later. If all else fails, slowly wean yourself off the old medicine, and onto the new. Be patient, and hope for the best.

If I wasn't patient like this, I'd still be those old medicines and my asthma wouldn't be as controlled as it is now. Another neat thing about Advair and Singulair is they allowed me to wean myself off Theophylline, of which I was chronically dependent on for 30 years (also an upcoming post).

Despite my header, I no longer consider myself a hard luck asthmatic. Likewise, thanks to Advair, I no longer consider myself a bronchodilatoraholic either because I hardly ever use my Ventolin Rescue inhaler anymore. And that, to me, is major progress

History of Exercise Induced Bronchospasm

If you have asthma chances are you have exercise induced asthma (EIA), statistics show about 80% of asthmatics have it. Yet prior to 1966 few understood EIA.

I happened upon a book called "Allergy: Principles and Practice Volume II (5th edition, Elliot Middleton, editor, 1998) which, on page 953, so happened to have a good review of the history of EIA, which has actually since been changed to EIB (exercise induced bronchospasm). To learn more about EIB you can check out this link.

In upcoming posts on this blog you will get to know the asthma experts such as Sir Joh Floyer and Fredrick Hyde Salter that are mentioned below, for now all you need to know is they were physicians who helped shape the history of the disease you and I have: asthma.

E.R. McFadden, Jr, wrote the following history of EIA:

"EIA was formally brought to the attention of clinicians of the modern era in 1966. Actually, the association between strenuous exertion and the acute development of airway obstruction was originally recorded by Arateaus the Cappadocian in the first century AD.

It was then rediscovered in 1968 by Sir John Foyer, who was the first to point out the relationship between the level of ventilation and the severity of symptoms. In 1864, Salter (Fredrick Hyde Salter) recognized that the postexertional obstructive response could be accentuated if the exercise was performed in a cold environment. He too suspected the importance of the absolute level of ventilation achieved during exertion and suggested that the rapid passage of fresh and cold air over the bronchial mucous membrane could stimulate the airways either in a direct manner or by production of nervous system irritability (he believed asthma was a nervous disease). The importance of these thoughts were unrecognized until recently.

It wasn't until 80 years later, McFadden writes, that a man named Herxheimer published works on his theories about what EIA was. He actually believed that "hyperventilation during exercise was the key factor, but he reasoned that it brought about its effects through the constrictor action of airway hypocapnea (low CO2)."

When you breath fast you blow off CO2, and was believed to (through a series of reactions) to cause bronchospasm (airway narrowing). This was later disproven.

While others agreed with Herxheimer, some believed substances released from the muscles during exercise (such as lactic acid) were the stimuli that caused EIA. This theory, as well as the theory that low CO2 caused EIA, were found to be false in 1977.

What was not considered back then was temperature and humidity of the air inspired were important factors in the cause of EIA.

While scientists are still digging for all the facts about EIA, it appears we're pretty close. On a recent post at MyAsthmaCentral.com, I reported on the up to date definition of EIA. So here I quote myself:

"The best definition I could find came from this post at AAAAI.org, which notes exercise doesn't necessarily "cause" asthma, but that "hyperventilation (fast breathing) associated with exercise cools and dries the upper and lower airway resulting in the release of histamine and other substances that produce the bronchospasm (spasming of the muscles in the air passages in your lungs)."

Likewise, when an asthmatic exercises when the temperature is cold, and the air dry, "Hyperventilation of cold dry air produces a similar response."

In this way, asthmatics are more likely to have asthma symptoms when they exercise in cold, dry air.

Dr. Randolph also said it isn't so much the cold weather that triggers the asthma attack, but the fact that the air is dry. Asthmatic lungs have a diminished ability to humidify the air, and this triggers the asthma response. This has been proven via various studies.

AAAAI.org also notes it doesn't help that "During strenuous activity, people tend to breathe through their mouths, allowing the cold, dry air to reach the lower airways without passing through the warming, humidifying effect of the nose."

Actually, according to Dr. Christopher Randolph, a clinical professor at Yale University who was interviewed by The New York Time's, EIA is not quite the same as asthma. He notes the "'preferred term' in the scientific community for exercise-induced asthma is exercise-induced bronchoconstriction, or EIB."

So by default we'll probably continue to call it EIA, although it's actually EIB. And that's why I titled this post, "History of EIB."

Do nebs work better in hospitals than at home?

The asthmatic patient took the breathing treatment from me, and puffed on it for about five minutes. I could tell just by looking at her that her breathing was getting better.

When the treatment was finished she said, "Wow! I feel much better! Why is it that breathing treatments work so much better in the hospital than at home?"

I get similar questions or comments regarding this all the time. People think that home nebs don't work as well as when they are given in the hospital. But, to be honest, it's the same medicine, so it shouldn't work any better.

So that got me to thinking. I remember the same thing when I was a bad asthmatic years ago. I remember feeling short of breath until I took a treatment in the hospital. Why is that? Sometimes I felt better as soon as I entered the hospital.

In fact, to be honest, even to this day I might use my inhaler a few times during the day at home, and when I go to work I never even take it with me because I never need it. Or if I do need it I just wait and my breathing gets better on its own. Why is that?

Here's my theory. I could be wrong, but then again, I could be right. As with most of medicine, it's based on theories, and my theory of why tx's work better in hospital as outside is that inside the hospital you are away from your allergens. Whatever "triggered" your asthma attack is not here.

Hence, your asthma symptoms seem to go away. Or, the treatment seems to work better.

Asthma Past and Future

When I was growing up the lone asthmatic among four brothers with normal lungs, I was forced to explore the world in a unique way. Instead of just going with the flow and enjoying what life offers, I was forced to think, and to choose my own path.

I'm not implying people without asthma don't think, but when you are forced to sit in your room while your brothers are out in the woods hauling wood, you either read or you sulk. When you're up all night due to your asthma, you either think or you go insane. I'm not particularly fond of insanity, so thinking grabbed me.

I imagine that's how I found myself in the blogosphere writing about things most people choose to take for granted (like Freedom and air), or simply ignore (like history). Ah, history. So many of us just take do simply take it for granted or ignore it. Yet, without a firm grasp of the past, we are doomed to repeat it. What great historian came up with that famous line?

As I was lying awake, gasping for breath, trying to decide whether to wake my parents up (or how long to suffer before I woke them up?), I remember thinking about what life would be like before the puffer. What would it be like to have been Teddy Roosevelt and having to have your dad take you for a buggy ride just to get some fresh AIR.

So, starting soon on this blog, I will be exploring the asthma past, and eventually the asthma future. What was it like to live with asthma 1,000 years ago, and what will it be like 1000 years in the past? Ah, are you curious as I am?

When I first started writing about the history of asthma I could find nothing on the subject. After three years of surfing the net, and digging through dusty, musty library journals, I have found some very interesting information. In the coming days here on this blog, I will share my new wisdom.

Bare with me, as it will take me a little time to organize and make this history and interesting and pithy. As you may well know from my past posts about asthma's past, I like to make complex, lawyer-like material and make it simple.

Now, that said, March is chock full of medical renewal courses for your humble RT here, so writing will be sparse. But once that is done, check back here now and again for a spoonful of asthma history and future to go along with asthma wisdom.