Frequently asked questions

Frequently asked questions

• My patient suffers from LACTOSE ALLERGY. Is it dangerous to prescribe an inhaler containing lactose?

  Apart from Pulmicort®, all dry powder inhalers contain lactose. It is perfectly safe to prescribe these inhalers to patients suffering from lactose intolerance. However, in case of true lactose or milk protein allergy, these inhalers should be avoided.

• What can I do if the inhaler containing inhaled corticosteroids causes OROPHARYNGEAL CANDIDIASIS OR DYSPHONIA?

  All inhalers containing inhaled corticosteroids (ICS) can potentially cause local side effects such as oropharyngeal candidiasis and dysphonia. Many strategies can help reduce them. See the side effects section for more details. Initial steps include minimising the ICS dose, gargling and mouth rinsing after each dose and ensuring a good inhalation technique, including the use of a spacer with MDIs. Dry powder inhalers (DPIs), particularly those containing Fluticasone Furoate (Arnuity®, Breo®, Trelegy®), may cause more local side effects. Switching inhalers to avoid Fluticasone Furoate or all DPIs may improve these adverse reactions. Ciclesonide (Alvesco®), a pro-drug with less local adverse effects is a preferred choice. Unfortunately, there is no combination inhaler containing Ciclesonide. Therefore, if the patient requires combination therapy, two separate inhalers must be prescribed which may lead to adherence issues.

• My patient suffers from NIGHT CRAMPS. Can it be related to its inhalers?

  Beta-2-agonists bronchodilators can cause muscular cramps, palpitations, and tremors. These adverse reactions can usually be minimized without giving up the drug class. In addition to ensuring a good inhalation technique, including the use of a spacer with MDIs, switching to an ultra-long acting (>24h) bronchodilator (Olodaterol or Vilanterol) usually allow for control of these side effects. For more details, see the side effects section.

• My patient’s has significant XEROSTOMIA with inhaled anticholinergic drugs. What can I do?

  Numerous drugs have anticholinergic properties (tricyclic antidepressant, 1st generation antihistamines, antispasmodics, etc.). Anticholinergic adverse reactions such as xerostomia usually result from the additional effects of all these medications and not only the anticholinergic inhaler. It is then advisable to first validate the patient’s pharmacopoeia and remove or reduce the unnecessary anticholinergic medications. Else, the anticholinergic inhaler may be switched to Aclidinum (Tudorza®, Duaklir®) as it is associated with less anticholinergic side effects.

• My asthma patient is PREGNANT. What should I do with her inhalers?

  First, it is essential to remind that inhalers SHOULD NOT BE STOPPED during pregnancy. Consequences of an uncontrolled asthma during pregnancy have been well-documented and include an increased risk of placental implantation abnormalities, cesarean section, prematurity, preeclampsia, and low birth weight. On the other hand, no human fetal risk has ever been documented with inhalers. The evidence of their safety in human is however scarce as randomized-controlled trials are not possible in this population. It is recommended to continue pre-pregnancy inhalers throughout the pregnancy, and the asthma management algorithm is similar to non-pregnant patients (see asthma management principles). However, if an inhaled corticosteroid (ICS) is started during pregnancy, Budesonide (Pulmicort®) or Fluticasone Propionate (Flovent®) may be favored as they have more safety data. It is however not recommended to routinely switch ICS during pregnancy as this can lead to a worsening in asthma control (and ensuing adverse maternal and fetal effects). If a switch is made during pregnancy, this should only be made after an informed risk-benefit discussion with the patient.

• When should LONG-ACTING MUSCARINIC ANTAGONISTS be used in ASTHMA?

  Three inhalers containing long-acting muscarinic antagonists (LAMA) are approved for asthma use in Canada: Spiriva® Respimat®, Enerzair® and Trelegy®. It is however commonly accepted that, although never studied, all LAMAs can be used interchangeably. LAMAs are usually added to high dose ICS/LABA, in uncontrolled or exacerbating patients. These patients have severe asthma and phenotyping is usually recommended prior to stepping up, in order to choose the most appropriate treatment, whether it is LAMA or not. A specialist evaluation to phenotype asthma should then be considered before prescribing LAMAs in asthma.

• My patient is struggling to ADHERE to the inhaled medication. What can I do?

  Non-adherence to inhalers is underestimated by healthcare professionals although it occurs in more than 50-80% of asthma patients. Asthma education may improve adherence as well as the choice of inhaler therapy. Choosing a once daily (QD) regimen and reducing the number of inhalers by prescribing combination inhalers have been shown to improve adherence.

• What should I do if my patient does NOT USE A SPACER with its metered dose inhaler (MDI)?

  To achieve maximal efficacy with a MDI device, a perfect synchronization is required between the actuation and inhalation (hand-lung synchronization). A patient may demonstrate a good technique in the office, but the perfect synchronization will be impossible to maintain on a day-to-day basis. This asynchronization leads to an increased oropharyngeal deposition, decreasing the inhaler efficacy and increasing its side effects. Valved holding chambers (VHC) are the most common type of spacers. They withhold the medicine in suspension, making hand-lung coordination unnecessary and ensuring optimal lung deposition. They are especially important for inhalers containing corticosteroids. If the patient finds the spacer inconvenient, choose another device, either a dry powder or soft mist inhaler.

• Are there benefits to INHALERS SWITCHING when the treatment is well taken?

  Although few head-to-head trials exist, it is commonly accepted that most inhalers within a same drug class have similar efficacy. Still, the individual response has been shown to vary between inhalers, with most patient benefiting more of certain inhalers over others. It is however impossible to predict which inhaler will provide the maximal response in a particular individual. That is why switching inhalers may be a good strategy in case of suboptimal response.

• The inhaled corticosteroids (ICS) dose EXCEED THE MAXIMUM APPROVED DOSE. What should I do?

  It is recommended to follow Health Canada approved maximal doses for regular ICS treatment. However, a short-term increase in ICS above maximal doses, as in asthma action plans, have been shown to be safe. Oropharyngeal candidiasis and dysphonia are the only demonstrated side effects. Regular ICSs over the maximal dose are sometimes prescribed in severe asthma patients. These massive inhaled doses generally amount to a low dose oral corticosteroid (OCS), with similar side effects. Still, they are frequently preferred to the introduction of chronic OCS in patients with asthma. Such a prescription should be restricted to specialist care.

• What is the ENVIRONMENTAL IMPACT of inhalers and how to mitigate it?

  Chlorofluorocarbons (CFC) deplete the ozone layer and have been replaced with hydrofluorocarbons (HFC) in modern metered dose inhalers (MDIs). HFC are harmless to the ozone layer but are powerful greenhouse gases, promoting global warming. The carbon footprint of a 200-dose MDI is considered equivalent to a 290 km car drive. Reducing MDI use, when appropriate, could therefore have a significant environmental impact. This could be achieved by choosing a dry powder of soft mist inhaler. The environmental impact is however only one of the numerous factors that should be considered in the selection of inhalers. MDIs and their containing medication still remain the best option for many patients, especially in the pediatric population. Their environmental impact should not result in their banishment but rather to a more responsible use.

• Which DEVICE should be chosen in PEDIATRIC patients?

  Although some dry powder inhalers (DPIs) are approved for children as young as 4 years old, most children between age 4 and 6 and even some older ones are unable to demonstrate appropriate technique or maintain it during asthma attacks. Therefore, up to 6-8 years, a metered-dose inhaler (MDI) with a spacer is the preferred device. For children under the age of 3, the spacer should be used with a mask. A transition to the mouthpiece can be attempted between age 3 to 5. Around 6 years old, if the MDI is continued, changing the inhalation technique from a tidal breathing technique to a breath-hold technique can be attempted.

• Can I use HIGH DOSE ICS in children below 12 years old?

  High dose inhaled corticosteroids (ICS) are rarely used in monotherapy. In combination therapy, they should be reserved to specialized pediatric centres where the risk/benefit ratio and alternatives can be properly considered. When using ICS in pediatrics, no matter the dosage, the growth curve should be monitored. A decrease in growth velocity without improvement with therapeutic adjustment (dosage decrease or ICS switching) or a loss of asthma control after the said adjustment should mandate a reference to a specialized centre.

• An inhaler is NOT APPROVED in my pediatric patient’s age. Can I still use it?

  A single inhaler is approved in Canada before the age of 4, and none is before the age of 1. As young asthmatics must still be treated and because one or two inhalers cannot suit all pediatric needs, using inhalers outside their approved age range (off-label use) is usual. An expert consensus established appropriate age group for each inhaler and those, along with their proper dosage can be found on the ICS equivalence page and in the respective inhaler information page.