Tag Archives: symbicort

Medication 101: Symbicort

Symbicort was the second of three combination inhalers I have tried and although it worked well for me, I did experience some quite significant side effects that meant that I should change to a different combination inhaler.

Symbicort like Flutiform is a preventer inhaler used to reduce asthma symptoms and prevent attacks. Symbicort contains 2 different medications and is therefore a combination inhaler. Symbicort is made up of a steroid [budesonide] and a long acting bronchodilator [Formoterol], and is indicated for use in people with moderate to severe asthma which isn’t controlled by a low-medium dose steroid inhaler alone.

Dose:

Symbicort comes in 3 different doses, the 100/6 [containing 100mcg Budesonide and 6mcg Formoterol], the 200/6 and the 400/12.
[Note: these doses are for the Symbicort turbohaler available in the UK, doses for the aerosol versions of Symbicort may vary]

Symbicort tends to be taken as 1-2 inhalations twice daily [max 8 inhalations a day for 100/6 and 200/6 doses]. However, some patients [age 18 and over] may benefit from Symbicort SMART therapy where Symbicort is used as both a preventer and reliever inhaler with a maximum of 12 inhalations taken a day [DO NOT SELF PRESCRIBE THE SMART THERAPY, SPEAK TO YOUR DOCTOR] Please note that the SMART regime is only available in 100/6 and 200/6 doses.

I took Symbicort from January 2013 all the way through to March 2014, so for quite a long time. I took the 100/6 dose and started off with 2 inhalations twice a day, then had it increased to 3 inhalations twice a day which worked when I wasn’t flaring or didn’t have a cold, but when I was flaring/ill I increased it to 4 inhalation twice a day.

Precautions:

Tell your doctor before you take Symbicort if you have diabetes, a chest infection, high blood pressure, thyroid problems, adrenal problems, low levels of potassium in your blood or severe liver problems.

You should also let your doctor know of you are taking any of the following medications before you take Symbicort including beta-blockers, medication for a fast, uneven or irregular heartbeat, heart failure medications, diuretics, theophylline for asthma, anti-depressants, anti-psychotics, anti-virals used to treat HIV, antibiotics, Parkinson’s medications or thyroid medications.

Side effects:

[I have marked the side effects I have experiences with an asterisk]

Common side effects occurring in less than 1 in 10 people include:
•Heart palpitations *
•Thrush
•Mild sore throat
•Headache

Uncommon side effects occurring in less than 1 in 100 people include:
•Feeling restless *
•Feeling nervous or agitated
•Disturbed sleep
•Feeling dizzy
•Nausea
•Fast heart beat *
•Muscle cramps * [these would wake me up in the middle of the night and were really painful, but I could usually sort them out quickly]
•Bruising of skin

Rare side effects occurring in less than 1 in 1000 people include:
•Bronchospasm * [I would end up having to take my reliever inhaler after taking Symbicort because of the bronchospasms, and this was the reason I switched to Flutiform]
•Rash, itching
•Low levels of potassium in blood
•Uneven heartbeat

Very rare side effects occurring in less than 1 in 10,000 people include:
•Depression
•Behavioural changes (especially in children)
•Angina
•Increase in blood glucose levels
•Changes in taste
•Blood pressure changes

Almost all of the side effects that I experienced [with the exception of bronchoconstriction] with Symbicort were a result of Formoterol, but I have also found that formoterol is the most effective long acting bronchodilator I have tried… But I have also found that the side effects didn’t effect me enough to warrant me changing to a different combination inhaler, until I started to experience bronchospasm, which my doctor and I have identified was a result of Symbicort being a dry powder inhaler.

Pros:
+ very flexible dose
+ easy to use
+ no need for a spacer as it is a dry powder inhaler
+ available as an aerosol in the US
+ Has a dose counter

Cons:
Only available as an aerosol in the US
it’s surprisingly loud and therefore hard to take discretely
Only contains 120 doses in the 100/6 and 200/6 doses which meant that I was going through and inhaler about every 15 days when I was taking 4 puffs twice a day which meant a lot of trips to the pharmacy… The 400/12 only has 60 doses.

Sources:
Patient information leaflet

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The wonders of Flutiform

Every time I see my asthma nurse it feels like my asthma plan is getting more and more confusing. Recently my lungs have been good! I have only been in the pool environment once in the past couple of months which is probably a large contributory in the fact that I have only had one (pretty scary) attack since I started Flutiform in March. My asthma nurse and I discussed how much my asthma is affecting me, and compared to before I am doing really well, my Ventolin usage is right down, I have hardly any nighttime symptoms and my peak flow is relatively stable. So we decided that we can reduce my Flutiform dosage from 125/5 2 puffs twice a day, to 50/5 two puffs twice a day… Now, we do recognise that dropping my total daily dosage of Fluticasone (the steroid component of Flutiform) from 500mcg (equivalent to 1000mcg Beclomethasone) of  to 200mcg (equivalent to 400mcg of Beclomethasone) is quite a drop and we have no idea how my lungs are going to react since the last time we attempted to reduce an inhaler I ended up having an attack. But right now I feel confident that my lungs are up to this reduction, and so I am going to give it a go.

I asked the nurse what I was supposed to do if I started yellow zoning, or having issues so we decided that whilst my main inhaler will be the 50/5 I will also have the 125/5 on my prescription and I will start that inhaler for a few weeks when I start having issues. So this means that I will have 2 different doses of Flutiform to work with which makes my asthma plan a lot more flexible but it also makes it somewhat more confusing. However we have decided that if I feel like I need the 125/5 instead of the 50/5 then I can ring in and she will move me onto the 125/5 fully.

We also discussed why we thought Symbicort was making me cough, and  the nurse agreed with my GP that the dry powder was causing paradoxical bronchospasms and that I shouldn’t try another dry powder inhaler… which is a shame because I did prefer the dry powder inhalers delivery system but if it makes me sick, I’m going to give it a wide berth.

I also explained that I am possibly going to university in September and that I am slightly concerned about prescription costs and having everything sorted for university. Apparently I can get an exemption form so I wouldn’t have to pay for prescriptions until the end of university, which means I don’t have to worry about prescription costs until then. And my asthma nurse is also organising me to go in for my flu jab at the start of September so I will be covered. And she also said to start looking for a GP surgery in the city where I will be staying as soon as I know that I will be going to university.  So now I’m feeling relatively relaxed about the whole thing because I know what is going to happen.

There aren’t many words to describe how happy I am about this reduction in steroid dose, this is the first time I have actually had a reduction in dosage… We attempted to reduce Symbicort before but that just went wrong straight away but I am feeling so much better than I did when we tried to reduce the Symbicort so I’m feeling pretty confident that this will work… and if it doesn’t, we have a plan for that too.

Bye Symbicort.

As I said in my last post, Symbicort and I haven’t been getting on very well and although I am grateful that Symbicort has pretty much calmed my lungs down, I am finding it hard to deal with a potentially serious side effect… Paradoxical bronchospasm. According to my GP the coughing I have been experiencing after taking my Symbicort is actually a reaction to the medication but we both believe that it is a result of Symbicort being a dry powder inhaler rather than the actual medication itself.

This morning I phoned my GP to try and swap Symbicort to another combination inhaler which contains Formoterol as I feel that this LABA works better for me than Serevent ever did. Unfortunately, my GP isn’t that clued up on asthma meds and wanted me to try Clenil 100mcg (dark brown inhaler) twice a day which is ludicrous since I am just about controlled on 600mcg of steroid (which would be Clenil 100 3 puffs twice a day) and on top of that, Clenil doesn’t contain a LABA. I explained all of this to my GP who was really understanding and asked what medication I would suggest. I told him that the only two combination inhalers that I know of, which contain Formoterol, are Flutiform and Fostair. I don’t really know of much difference between Flutiform and Fostair, other than the steroid component so I figured it didn’t really matter which one I tried since I could always swap to the other if things went pear shaped. So it was decided that I am going to try Flutiform and see if that causes any coughing, and if it does then we shall try Fostair.

Flutiform contains Fluticasone as it’s steroid component and Formoterol as it’s LABA component and comes in 3 doses. I have been prescribed the middle dose of 125/5 with two puffs twice a day. My GP has said that my script is waiting at the Surgery’s reception for me to go and collect but unfortunately I can’t collect it until Wednesday or Thursday. I tried to explain this to the GP and asked if he would be able to send it to a pharmacy nearer where I go to college but because I didn’t know the fax number for any of the pharmacies near me (not many people would, I imagine) it wouldn’t be possible. So now I am staying on Symbicort until Wednesday or Thursday but I have been told to use Ventolin before I take Symbicort and to keep it near by in the hours following a dose to try and prevent/reduce the severity of the paradoxical bronchospasms I experience. Thankfully, after I have got this initial prescription, I can order my Flutiform online into a Pharmacy closer to my college so I can get it more easily.

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I am still going to be sad to see Symbicort go since I have been on it for over a year, which is the longest I have ever been on any asthma medication, other than Ventolin. I’m really hoping that I won’t need to change medications again, and that I am able to reduce the amount of medication I need back down to Clenil or even nothing at all, however that isn’t a reasonable expectation right now. But it is a hope for the future.

Stubborn lungs

I feel that I haven’t really talked about my asthma for quite a while, probably because I have been having quite a hard time with my joints lately.

In all honesty my lungs haven’t been great either. Since Bonfire Night (October 5th) my peak flow has been up and down, my lungs absolutely hate mornings and my ventolin usage is quite high again. I haven’t increased my Symbicort to 4 inhalations twice a day although that would probably be the sensible option purely because I want to decrease my Symbicort but that isn’t an option right now.

My lungs are being stubborn and I am being stubborn too, which isn’t a good combination. I just really want my lungs to calm down again, even if that means that I have to stay on the dose I am now. The thing is, I’m not quite sure if I can reduce my dose until the spring now because it seems like the cold is effecting my lungs more than it did last year. And that, in itself, is worrying because I am supposed to go skiing in February and if my lungs can’t cope with 10 degrees Celsius, how are they going to cope with -10 degrees Celsius?

Last year, I was in a similar situation and I got by at skiing with increasing my Symbicort to 3 then 4 inhalations and a couple of hours of skiing a day as opposed to the 7-8 hours I used to be able to ski. But I got by without any pred. And now I can’t even get down to 2 inhalations and I am just managing with 3, I’m not entirely sure that 4 inhalations will actually be able to cover me, which could potentially mean pred, if I can’t get things under control by then. Although I think having a rescue course of pred as a just in case when I go skiing is quite a good idea anyway, I just don’t want to have to need it!

Bonfires, fireworks and asthma – not the best combination

Smoke never used to be a huge trigger for my asthma. It used to make me get slightly tight and maybe cough but it was never a massive trigger like chlorine or humidity are for me.

Today is bonfire night which is basically a night where everyone goes crazy with fireworks and bonfires (surprisingly).

Today I also had my driving lesson (which, may I say, was chaotic due to all the fire engines and ambulances on shouts for, most likely, fire related injuries and probably respiratory problems too). Now normally where I live is quite busy during bonfire nights with a lot of fireworks being set off, but today I drove past 3 huge bonfires (all of which the fire brigade was in attendance for) and the smoke was so thick everywhere. It was like driving through thick fog.

I seriously didn’t think that my lungs would be too bothered by all the smoke as, in the past I have been okay, otherwise I would have mentioned this to my asthma nurse yesterday and not decreased my Symbicort dose to 2 inhalations twice a day, today. I posted this on Facebook, which pretty much explains today’s situation:

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Luckily, I did take my inhaler with my while I was out driving, and I did already have 4 puffs (400mcg) of ventolin on board due to my lungs being sucky (from the smoke) in the hour leading up to my lesson. And fortunately because I did have my inhaler with my, I was able to prevent an attack, although I was wheezing and coughing up a storm and it did feel like an elephant had been sitting on my chest.

Today I have taken a total of 800mcg of ventolin and I have also increased my Symbicort up to 4 inhalations twice a day, just until my lungs settle down and I can reduce it back down to 3 inhalations then (fingers crossed) down to 2 inhalations. I was also trying to decide what to do regarding my ventolin usage, as I really don’t want my lungs to get worse, and although I am pretty good for about 4 hours after taking ventolin, I can still feel it wearing off and then I’m practically back to square one. But I have spoken to my friends with asthma and although my original plan was to take 4 puffs of ventolin every 4 hours (my old plan says 4-10 puffs every 4 hours if I need it) I have decided that PRN is probably best and so I will be taking ventolin as and when I need it. Thank you Annie for helping me out with this!

I will be honest, today I did underestimate my asthma, and I am really kicking myself for it. I tried to reduce my Symbicort too quickly and I chose a stupid day to reduce it. I didn’t think that the smoke would affect me, and when it did, I didn’t cancel my driving lesson and stay in the house with the windows closed. And I didn’t anticipate how unpredictable asthma can be. These are all the things I would have done when I was newly diagnosed, but now, I should at least be able to draw from past experiences and use some common sense. At least now, I know that bonfires and fireworks DO affect me, and so I can avoid them in the future.

Adios accuhaler, welcome back evohaler!

This morning I had an appointment with my asthma nurse mainly to get my flu jab but also to discuss a few other issues I have been having.

First of all we talked about my peak flow and although she had a few issues with certain things such as the “pretty significant morning dip” and the two asthma attacks I had a week or so ago and the symptoms I still get fairly often we agreed that I am doing a LOT better than I was last time I saw her. And there is a significant difference in my ventolin usage since we increased my dose of Symbicort to 3 inhalations twice a day…

My home people flow this morning was 340 which was done at 7AM and by 9AM my peak flow was 360 (of course there is a variable in the peak flow device used) but that is the highest peak flow I have seen on a morning in a long while so I was pleased with that! I’m slightly (too) excited to see what this evenings peak flow will be.

She asked me what I think my major triggers are now and although they haven’t really changed I still feel that since increasing my dose of Symbicort has enabled me to work better when I am teaching swimming as I can actually speak in full sentences by the end of the session. But I feel that that I still haven’t grasped how to deal with weather changes and how they affect my asthma, particularly thunder storms. I still struggle during sudden thunder storms to control my asthma in a way that I am comfortable, I mean no asthma symptoms are comfortable but if I can avoid having an attack then I’m happy.

About a month ago, I was having issues with my heart palpitations while I was taking Symbicort, particularly since the palpitations would wake me up at night and I would get them frequently throughout the day, and so I spoke to the nurse about this. She said I was using a lot of ventolin that weekend in addition to Symbicort which didn’t really answer my question since I stopped the Symbicort because of the palpitations and then was struggling with my asthma because of missing the Symbicort and ended up need ventolin. But I guess since I haven’t had palpitations for a good month, it is just something to be aware of in the future.

I didn’t mention the wheezing issues I had last night. For those of you who don’t follow the MyLungsMyLife Facebook page, I posted about how I was just about to get to sleep when my lungs decided that they were going to start wheezing out of no where. So I ended up needing ventolin and staying up till 12 just incase my lungs decided to wheeze again. It is odd that I started wheezing though because it is so uncharacteristic to start wheezing before I cough, but then asthma can be unpredictable so I should be expecting the unexpected. But I mean apart from needing my ventolin a few times a week at most and a couple of attacks a month, I do feel really good. So I told her that I wouldn’t mind trying to lower my dose of Symbicort and she agreed that, that would be fine. She also said that she can see from my peak flow diary that I know what to do, when to increase my dose and when to lower it again even though I don’t have any sort of official plan and so that she is going to give me “free-reign” on dosing my Symbicort myself which I think is pretty cool, although I do that anyway.

I do absolutely love my peak flow diary, and I find it super helpful in tracking how my asthma has been and I write what has triggered each attack/exacerbation and why I have increased my dose etc so because it was so apparent to her that I do like to track my asthma (apparently other patients aren’t as good as keeping it up to date) she gave me another peak flow diary, despite the fact that I still have 8 months left on the one I am using right now. She had ran out of the official Asthma UK diaries so I got a generic NHS one but hey, it’s still good!

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I also asked if I could switch back to the normal ventolin MDI for a few reasons really:
1) I can’t take a ventolin accuhaler on pool side in case it gets wet
2) during an attack it is hard to breathe in deeply enough to get all the medication out and it is also hard to hold your breath for long enough, whereas when using and MDI and spacer you can use tidal breathing
3) the accuhaler is REALLY loud, especially to use in a quiet room
4) I am sick and tired of people asking me what on earth I am using… Clearly people haven’t seen many accuhalers around

So the nurse prescribed me a ventolin MDI and put it on my repeat prescription. She said that I didn’t need to get a new spacer as the one I have is only just over a year old and so, in theory, should still work. So it is adios accuhaler and a welcome back to the evohaler!

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And then I decorated it with some sheep Sellotape (my apologies for the slightly over exposed picture)

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To be honest, I wasn’t totally sure if I would be prescribed ventolin as my prescription says salbutamol which is the medication in ventolin (ventolin is the brand name) but a few people I know who have has salbutamol on their prescription have been given salamol at the pharmacy which is the generic version of ventolin. And I’m an pretty sure that it would have been fine but a) salamol is smaller than ventolin and so is harder to use, especially with stiff, sore and swollen hands and b) I wasn’t sure that the delivery system would be the same but as my friend GG assures me, the delivery system is the same and plus it doesn’t matter if you are going to use a spacer.

But anyway when I was at the pharmacy I asked if Salbutamol meant I was going to get ventolin or salamol, to which the pharmacist replied that ventolin IS salbutamol. But then again salbutamol IS also salamol, and that’s what I said… She looked pretty miffed with me, apparently pharmacists don’t like patients to correct them.

Anyway that was today’s events… I don’t need to be seen by the asthma nurse again until around May unless I am having issues that I can’t fix by upping my Symbicort. I did forget to mention about my hiccups but I haven’t had any since last week, so maybe that was just a phase.

Mexican waving lungs

Asthma was really kicking my behind yesterday, it wasn’t so much asthma attacks but the constant shortness of breath… Getting out of bed is normally a struggle, mainly because of the joint issue but yesterday was ridiculous.

When I woke up, my initial thoughts were “Oh, hi dyspnea!” Not the first think I like to think in the morning! I figured that since I was only short of breath and wasn’t wheezing or anything that I could manage without ventolin. WRONG!

My lungs decided to go a little crazy at me while I was in the shower, I guess it must have been the steam? So ventolin to the rescue it was then.

On the way to college I was still having a tough time breathing, not so much with wheezing but just being majorly short of breath. By that time, I realised I needed to stop kidding myself and take some more ventolin adding up to a grand total of 400mcg before 9AM, not a record for me but since I’ve been doing pretty well for so long. I was not best pleased.

To be honest my peak flows have been doing a bit of a Mexican wave over the last few weeks, jumping around a little more than usual:

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I’m thinking that my lungs are having a bit of a disagreement with the weather changes as Autumn is taking hold. My lungs really hate humidity, almost as much as chlorine, and since the humidity has been around 75-80% for a couple of days in a row, it makes a fair but of sense why my lungs are having a bit of a hissy fit.

But I am booked in to see my asthma nurse at the end of the month so if I am still having issues I’m sure she will be able to sort it out! Until then, I’m going to bide my time and if necessary increase my Symbicort once more, although I am hoping that things won’t come to that.