What are the treatments available?

Presenter - Now Martin tells us a little bit about the treatments for asthma then, what can we do to try and help patients lead a normal life?

Martin - Yes yeah. Well I suppose as always we should start with lifestyle things and sorry if this sounds a bit familiar but the very first thing to do is not smoke.

Presenter - Yeah it would seem obvious but people I mean if you're hooked you're hooked aren't you at the end of the day it's difficult.

Martin - It would seem obvious. Yeah absolutely and sometimes it worth saying 'cos I have had patients who have said to me "You never told me to give up smoking." Fairly obvious to most people but some, perhaps the message hasn't got through to others, 'cos a) it's not good on a million different fronts, but certainly if you're asthmatic that absolutely will not help. Taking regular exercise obviously helps, being.

Presenter - Does that not trigger, or can it not trigger?

Martin - You're absolutely right and those who have exercise induced asthma yes, but still taking exercise is good because it keeps you fit, makes your body function better, gets that oxygen pumping round your system, and we can cope with the exercised induced asthma, you know we can help this person with inhalers and so on to get on top of that problem and if in the meantime they're making themselves healthier that will help, and at then of the day probably will mean that they have to have fewer inhalers.

Presenter - Right.

Martin - So still it's the right thing to do. Maintaining a normal weight because obviously the less weight you're carrying around the less oxygen you need etcetera etcetera.

Presenter - Yeah that's a good point.

Martin - So all those lifestyle things are definitely worth mentioning. But fair to say you could be the fittest person in the world and still have asthma I mean probably a lot of people watching won't remember Alan Pascoe but he was an Olympic

Presenter - I remember him yeah,

Martin - hurdler who had asthma. And good for him he made a thing of it and he is absolutely living proof that can have asthma and be an Olympic champion hurdler.

Presenter - Yeah that's amazing when you think about the lung capacity that they must need and.

Martin - Yeah, but what he's basically emphasising is, it's totally controllable you know for most people if they do the right thing.

Presenter - Right and how do you do that then how do you go about controlling it?

Martin - Well a visit to the GP really or the Asthma Nurse would probably be the first step and what they would do is they would assess firstly is it asthma? You know just to check 'cos other things can make to breathless etcetera, secondly how bad is this asthma? And thirdly are there any sort of trigger factors that we can talk about?

Presenter - Right.

Martin - And then according to the answers to those questions we then almost certainly would end up prescribing an inhaler or sometimes a couple of inhalers.

Presenter - Right and there are two different types of inhalers aren't there?

Martin - Well there are more than two

Presenter - Oh right

Martin - and actually unfortunately although there are just a few drug groups in inhalers the number of different types of inhaler have absolutely mushroomed to the point where it confuses us quite often actually. But to keep it simple you could boil it down to the reliever, which most people would think of as a blue inhaler.

Presenter - Right.

Martin - You know the most commonly use one is something called Salbutamol but there are others.

Presenter - And you use that when you're having an attack.

Martin - When you're having an attack, or if you feel a bit wheezy, or if it's night time cough is a bit of problem, and you would use it and you would know if it was working because within minutes you feel better.

Presenter - Right.

Martin - Problem with a reliever is it wears off, so nothing wrong with it and for somebody who just has mild asthma or like your husband who you know a particular situation will spark him off not problem, with taking a couple of puffs, fantastic relieves him immediately he can get on with life no problem.

Presenter - Yeah.

Martin - But if you're finding that you're having to use the reliever more than you know two or three times a week.

Presenter - Right.

Martin - Probably the GP or the Asthma Nurse might start talking about the other main group which are the preventers which people would think of as their brown puffer, they're always brown but you know most people think of as their brown. Now this works in a different way where you would use it regularly, so morning and evening, almost whether you have symptoms or you don't have symptoms you use this inhaler.

Presenter - It your insurance policy really.

Martin - Yeah absolutely right this sort of puts the fire out it's the way that I sort of think of it.

Presenter - Right. Yeah and would you use that as well as a reliever?

Martin - Yes you would. You would but you would normally find is if this person is quite compliant with their preventer they might well find that they then don't have to use their reliever so often. Because remember what we said is that the main problem with asthma is this inflammation in your breathing tubes and although the reliever will work a little bit on the contraction of the tubes that we talked about it won't do anything about the inflammation, and that's where the preventer comes in by reducing that inflammation in your tubes which has a much more fundamental effect on how bad your asthma is.

Presenter - Right.

Martin - So probably the most common combination that we would see is somebody who uses their preventer twice a day, couple of puff twice a day and then their reliever as and when they need it, that would probably be the most common scenario.

Presenter - And do people who have asthma and have frequent attacks, does it scar the inside of their lungs? Does your asthma get worse as you get older?

Martin - No it doesn't actually there's absolutely no evidence certainly that I know of that that happens, so you can carry on with this combination for as long as you like.

Presenter - So there's no cure as such for asthma you just have to manage it as best you can?

Martin - That's exactly is management thing like so many things in medicine unfortunately it's a management thing. But most times we can manage it. So the common thing would be you know reliever, possibly a preventer, is that wasn't working you then would get on to what are sometimes called long acting relievers which are usually most people would recognise that as their third inhaler, their third puffer.

Presenter - Oh right you've got to have a whole handbag full of stuff haven't you.

Martin - I know that right, and they all come in different colours so people will often talk about their blue inhaler, their brown inhaler, and their sort of orange or green inhaler, and that third one is usually a sort of long acting reliever which is sort of somewhere in the middle actually.

Presenter - Right. Yeah.

Martin - And then just to sort of cover the whole gambit if I can, some people are actually on a tablet.

Presenter - I was gonna' ask that actually is there a pill as well that could do the same thing?

Martin - Yeah. Yeah. There is a pill called Montelukast is the most common one or Singulair is what most people would recognise it as. Which is pill that's works for some people it seems to be particularly good for exercise induced asthma. It doesn't work with everybody but obviously and it's often used in addition to. You know you wouldn't very often start somebody on the tablet they would usually be in addition to I somebody was.

Presenter - So you would sort of build up to that if you think out need it and would you take that everyday then?

Martin - You would take that very day that's exactly right almost as another sort of preventer thing. And for those who get bad asthma attacks occasionally you know some people who are watching would recognise those sort of scenarios where their Doctor would give them a burst of steroids by mouth.

Presenter - Right.

Martin - So the brown inhaler that we talked about 9 times out of 10 will be and inhaled steroid but sometimes if things get really bad and if somebody is struggling we will give a short burst of steroids by mouth which will calm that inflammation that we talked about

Presenter - Right but is it bad to have that a lot are there any side effects with the inhalers talking about steroids that always a bit of a nasty word isn't it, steroids.

Martin - Yeah. Yeah. Steroids yeah. I mean there are certain words that GP's hate to mention 'cos they know they're gonna' get this terrible reaction. Asthma strangely enough is one of them you know the minute you say to Mum "your child may have asthma", oh my God you can see the panic across their face you immediately have to follow it by "it's very mild" usually. But yeah the steroid issue is an on going thing really. The answer to that is that in low doses so these preventer inhalers that have very low doses microgram doses, used in low dose there is no real evidence that they have any long term effect but in those quite severe asthmatics who have to use high doses yes some of it is gong to get into your blood stream and there is some evidence that it can effect your own production of certain hormones in you body.

Presenter - Oh right.

Martin - Something called adrenal suppression but without being too technical your adrenal glands produce your own steroids and if you have too many steroids in inhaler form or in tablet form you own adrenals stop producing what you should produce.

Presenter - Oh dear so it all goes a little bit wrong.

Martin - It goes a little bit wrong and the problem with that is in certain situations that can be a problem but I want to emphasise that that is only usually a problem for people on really quite high doses of inhaled steroid or for people that have to have very frequent bursts of you know steroid by mouth. But remember as always the Doctor is doing this for a reason. He doesn't sort of wake up in the morning and think 'I know what gonna' do I'm gonna' provide'.

Presenter - What can I inflict on my patients?

Martin - What can I poison them with today? This Doctor is trying to keep you well and in certain circumstance's he's trying to keep you alive.

Presenter - Yeah. If it saves you life then maybe you have to put up with the side effects. And are there ways of managing different drugs, trying out different drugs to try and find that one that if, you're having really bad side effects maybe try a different brand.

Martin - Yeah absolutely right, absolutely right. So our aim and the Asthma Nurses aim will be to control this persons asthma so he can have a normal life with a minimum medication to their life as simple as possible, so we are not gonna' leap in you know with high dose steroids just to make this person better, we are gonna' start with something low and we are gonna' gradually increase until we get to that recipe of inhalers that controls this persons asthma, allows them to lead a normal life but with a minimum of fuss.

Presenter - Yes it's a bit of trial and error with every patient. Isn't there?

Martin - It really yeah. Against a background of having taken the history, you know examined them, and most often you know we will use this thing called a peak flow inhaler, a peak flow meter which most asthmatics will recognise that you sort of blow into and it will tell the Doctor how good your lung power is at the particular moment. It's not an absolutely guarantee, it's not a precise tool but it's part if a jigsaw puzzle of you know how bad is this asthmatic how often do they get it, and quite often we will give this person a peak flow meter to take home with them.

Presenter - Oh right to see how it works through the day.

Martin - Yeah.

Presenter - And different activities they are doing through the day etcetera.

Martin - Absolutely or remember we walked about this business where often asthma will get worse at the end of the day or in the morning.

Presenter - In the morning or at the end of the day yeah.

Martin - Well one tool that we use is to give this person a peak flow meter get them to do a peak flow in the morning, get them to do a peak flow perhaps in the middle of the day, peak flow in the evening write it down and actually draw a graph, and what you'll often is like a dip in this graph at night and first thing in the morning and that is you know if you look at this you think almost certainly these persons got asthma, you know.

Presenter - Right.

Martin - It's part of that jigsaw puzzle of working out does this person have asthma? But if you see that pattern of peak flows dipping you know that's very-very useful guide as to this person's got asthma and the peak flow meter can also be a very-very useful tool for that asthmatic to monitor their own.