IMPORTANT MESSAGE. This letter is in reply to Helen who had been told by her doctor to take the short-acting bronchodilator (Albuterol) before the long-acting one (Advair) "To open up the airways". Mark Mangus explains why this is not good advice and results in excessive drug usage. If it applies to you, talk to your doctor and show him a copy of this letter.
From: Mark Mangus at Efforts
Hi Helen,
What your pulmonary doctor told you is what the vast majority of pulmonary doctors are saying. The same is true of other pulmonary health care professionals like respiratory therapists, pulmonary nurse practitioners and pulmonary physician's assistants.
There's a long story about how that recommendation came about. But, the truth is that it is based upon false assumptions and - more important, there is a complete lack of evidence to validate it. No one argues against the fact that fast/short-acting versions open up the airways quickly. Where the problem arises is that the fast/short-acting versions exert their action on the same receptors in the lungs as do the long-acting versions. So, when you use the fast-acting versions and then follow them immediately with the long-acting ones, there are few if any receptor sites within the lungs with which the long-acting version can bind because they've all been tied up by the short-acting medication.
Consequently, the long-acting medication floats around until it is sent to be disposed of from your body having never had the opportunity to do any work. As a result, folks who use the fast/short-acting versions first and then follow with the long-acting ones find they do not get the predicted benefit from the long-acting medications that they are supposed to expect. And worse, they end up taking twice as much medication, since they then have to use the short-acting medications more often than they would otherwise need to. This is because the long-acting ones are mostly lost in the body and never get a chance to work.
The other fallacy in the recommendation has to do with the notion that you have to take any of them "very deeply" into your lungs. The receptors for those medications are in the small to mid airways. Yes, they do require a good quality deep breath and hold, but they don't require the deepest breath you can take. For the amount of "opening up of the airways the short/fast-acting medications do, actually there is no real difference in the "amount" of opening. Actually, there is only a few minutes difference in how long it takes the long-acting drugs to reach 'comparable' dilation with the short-acting ones.
Finally, there has never been a study done to test the widely held belief and recommendation you have received. It came about because of incorrect use and introduction of the long-acting medications when they were introduced to us many years ago. While none of us on either side of the question has high-quality empirical evidence (evidence that has been shown to be "cause and effect-related" to the stated condition). I have at least gathered 'some' amount of prospective evidence from a significant number of subjects over several years - and I have discussed the question with pharmacokineticists who are expert in bronchopharmacology (how drugs act in the bronchial tubes) who back my contentions and rationale and dispute the validity of the popular and widespread, but erroneous notions in this regard.
Also, right here on our EFFORTS list there are many folks who can tell you their own experience with changing the order of taking their inhaled medications. Helen, you should take your Advair, followed in a few minutes by Spiriva. If after 30 more minutes, you are still having a hard time breathing, only then should you take additional Albuterol. The Albuterol should be no more than an "as needed"/back-up medication to use on occasion between doses of Advair.
Best Regards, Mark
Mark W Mangus, Sr. BSRC, RRT, RPFT, FAARC
San Antonio,Texas.
From: Mark Mangus at Efforts
Hi Helen,
What your pulmonary doctor told you is what the vast majority of pulmonary doctors are saying. The same is true of other pulmonary health care professionals like respiratory therapists, pulmonary nurse practitioners and pulmonary physician's assistants.
There's a long story about how that recommendation came about. But, the truth is that it is based upon false assumptions and - more important, there is a complete lack of evidence to validate it. No one argues against the fact that fast/short-acting versions open up the airways quickly. Where the problem arises is that the fast/short-acting versions exert their action on the same receptors in the lungs as do the long-acting versions. So, when you use the fast-acting versions and then follow them immediately with the long-acting ones, there are few if any receptor sites within the lungs with which the long-acting version can bind because they've all been tied up by the short-acting medication.
Consequently, the long-acting medication floats around until it is sent to be disposed of from your body having never had the opportunity to do any work. As a result, folks who use the fast/short-acting versions first and then follow with the long-acting ones find they do not get the predicted benefit from the long-acting medications that they are supposed to expect. And worse, they end up taking twice as much medication, since they then have to use the short-acting medications more often than they would otherwise need to. This is because the long-acting ones are mostly lost in the body and never get a chance to work.
The other fallacy in the recommendation has to do with the notion that you have to take any of them "very deeply" into your lungs. The receptors for those medications are in the small to mid airways. Yes, they do require a good quality deep breath and hold, but they don't require the deepest breath you can take. For the amount of "opening up of the airways the short/fast-acting medications do, actually there is no real difference in the "amount" of opening. Actually, there is only a few minutes difference in how long it takes the long-acting drugs to reach 'comparable' dilation with the short-acting ones.
Finally, there has never been a study done to test the widely held belief and recommendation you have received. It came about because of incorrect use and introduction of the long-acting medications when they were introduced to us many years ago. While none of us on either side of the question has high-quality empirical evidence (evidence that has been shown to be "cause and effect-related" to the stated condition). I have at least gathered 'some' amount of prospective evidence from a significant number of subjects over several years - and I have discussed the question with pharmacokineticists who are expert in bronchopharmacology (how drugs act in the bronchial tubes) who back my contentions and rationale and dispute the validity of the popular and widespread, but erroneous notions in this regard.
Also, right here on our EFFORTS list there are many folks who can tell you their own experience with changing the order of taking their inhaled medications. Helen, you should take your Advair, followed in a few minutes by Spiriva. If after 30 more minutes, you are still having a hard time breathing, only then should you take additional Albuterol. The Albuterol should be no more than an "as needed"/back-up medication to use on occasion between doses of Advair.
Best Regards, Mark
Mark W Mangus, Sr. BSRC, RRT, RPFT, FAARC
San Antonio,Texas.