Nov 18, 2014

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Well at least you don't have to organize billets. That was always the worst part. During my parents recent visit, I was whining about having to coordinate my daughter Emily's home hockey tournament. My dad reminded me that when I grew up in Pinawa, when we had a home tournament, the parents would have to organize places to stay for all the players. I had kinda forgotten about billets. My son Eric asked what billeting was. I told him billeting meant when he went away to a tournament, Eric and one or two teammates would stay at a complete stranger's house. Eric looked at me like I had three heads. He expects an out of town tournament to involve a hotel stay with his parents, and preferably with a pool. But billeting wasn't bad, and it definitely saved some money for parents. For tournaments in Pinawa billeting was almost necessary. Pinawa had a tiny motel and the nearest other hotels were between half an hour to an hour away.

Sometimes older ideas like billeting get forgotten about when they shouldn't be. My favorite asthma device isn't a brand new one. My favorite is still the turbuhaler. No, no one from AstraZeneca paid me to say that. However, if anyone from AstraZeneca wants to buy me a coffee or a Porsche now that I have said it, I won't say no. Asthma devices are notoriously difficult to use. The most common is called a metered dose inhaler, more commonly known as an MDI or a puffer. To use an MDI properly, you have to shake the canister, put it in your mouth, start inhaling and then spray. It is surprisingly difficult to coordinate spraying and breathing for many people. I've seen many long term asthmatics that don't use their puffers properly.

That is what I like about the turbuhaler. It is breath activated. You click the dial on the bottom away from you and back to load a dose. Then you just inhale the tiny amount of powder. No breath-spray coordination required!

Turbuhalers have been around for years, but I don't think they get enough credit. One of the medications that come in a turbuhaler is called symbicort. Symbicort has the steroid budesonide and long acting beta-agonist formoterol in it. The steroid budesonide reduces inflammation inside the lungs. The long acting beta-agonist formoterol opens the airways. Symbicort is usually prescribed 2 puffs twice a day and is what we call a maintenance or preventor medication. It prevents asthma flare ups if you use it every day. Asthmatics will also be prescribed a fast acting reliever medication to use if they are having trouble breathing now. That means asthmatics will have 2 inhalers to carry around.

Another idea that has been around for a few years that I don't think gets enough attention called SMART dosing. SMART dosing stands for Symbicort Maintenance and Reliever Therapy. That means an asthmatics will only have to carry around 1 inhaler. They will use their symbicort 2 puffs twice a day regularly and then use it again if needed for breathing problems during the day to a maximum of 8 total inhalations per day.

There have been a few studies to back up this SMART dosing. The STAY study by Paul O'Byrne et. al. published in 2005 in the American Journal of Respiratory and Critical Care Medicine was interesting. They showed SMART dosing was better than symbicort as a preventor medication and terbutaline as a reliever medication. The SMART dosing patients had less severe asthma flare ups. Severe was defined as ending up in the hospital or ER, needing oral prednisone or having really low peak flow readings. That might not be that surprising. What was surprising was the SMART dosing patients also had less severe asthma flare ups than patients on budesonide for maintenance and terbutaline for relief. Except the budesonide was at 4 times the regular dose. So the symbicort as preventor and reliever medication was better than budesonide alone at 4 times its regular dose plus terbutaline as a reliever medication. That is a pretty cool result.

Sometimes new ideas are better. Boehringer Ingelheim has a new inhaler device that it will be rolling out shortly. Respimat kinda looks like a straightened out MDI. However, it works very differently. You turn the inhaler, open the cover, put it in your mouth, press the go button and inhale. The spring in the respimat sprays out the medication in a long slow mist. The mist spray lasts for a full second. That is much longer than the about 0.2 seconds a regular inhaler sprays. That should reduce the breathing-spraying coordination problem with the MDI puffer. The droplets coming out of the respimat will also be very small. That means they will get very deep into the lungs which is good too.

The two potential problems I see with the respimat are: it is a little complicated to set up, and you might spray it in your eye. The set up involves getting a new canister into the device and priming it. I recommend you get your pharmacist to set up your respimat before you leave the pharmacy. Spraying in your eye sounds silly, but just make sure you have the respimat in your mouth before you hit the go button.

I think what I am most excited about with the new respimat is the medications that will be available in this format. Boehringer says it will bring back combivent in the respimat inhaler. Combivent was a combination of salbutamol and ipratroprium. Many people with COPD use both salbutamol and ipratroprium, so it was very convenient to have 1 inhaler instead of two. Unfortunately, combivent has been off the market for a while now, so it will be nice to see it back. I think I am even more excited to hear that spiriva or tiotroprium will be coming out in the respimat format. Spiriva or tiotroprium is a very effective and very popular once a day inhaler for COPD. The down side to tiotroprium is the inhaler. It is called a handihaler and you have to load a capsule of medication into it, puncture the capsule, inhale from the device and throw out the capsule. Many people found the handihaler difficult to use, so I hope they have an easier time with the respimat.

Eric has a hockey tournament coming up in Killarney. I think the last time I was in Killarney I was being billeted there during one of my minor hockey tournaments. Billeting had some advantages. You were usually fed really well, you met some new people you wouldnt have met before and your parents saved some money. However, since I now need a child abuse registry check just to volunteer to go on a school field trip with my own children, I can't see billeting coming back for minor hockey tournaments. I guess Emily and Eric will have to suffer through hotel pools, breakfast buffets and I'll just pay the hotel and restaurant bills.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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