Author Archives: Jackie Aim

Unlicensed or off-label medicines

Medicines are said to hold a licence when they are approved for use with patients in the UK. This licence states who the medicine should be given to and which medical conditions it should be used to treat.

When they are used for a group of patients or a medical condition outside this license this is known “off-label” prescribing.

Not all medicines are licensed for use in the UK. Sometimes they are licensed in other countries and sometimes they don’t have a license at all. These are known as “unlicensed” medicines.

Over the counter medicines are the non prescription medicines which can be bought at the pharmacy or chemist shop in the UK.

Antifungal medicines

Sometimes having asthma can make you more susceptible to an infection which is not caused by a bacteria or virus but by a fungal infection. This is treated using anti fungal medication.

Examples of anti fungal medicines include:

Itraconazole (Sporanox®).

What do they do?

Some asthma patients have lung infections which can make their asthma symptoms worse and more difficult to control.
These medicines stop the fungus from growing and allow the body a greater chance to fight the infection.

Steroid sparing immunosuppressant medicines

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There are some people whose asthma control can only be achieved using steroid tablets. Steroids can have side effects especially when used long term. Doctors try to keep the dose of steroids as low as possible in to order to reduce the risk of side effects.

To assist in keeping the steroid dose as low as possible some people may be considered for additional therapy in order to reduce the need for steroids. Some people will be offered Omalizumab as a steroid sparing drug. Other drugs include Methotrexate, Ciclosporin and Gold.
Steroid sparing medicines:

Are rarely used.
Can all decrease long term steroid requirements but all have significant side effects.
They have no persisting effect when they are stopped and people’s response to the drugs is very variable.
Risks and benefits should be carefully discussed and monitored.
Treatment should be in a specialist centre with experience of using these medicines.

What do they do?
Immunosuppressant’s are used to enhance the effects of steroids.

They alter the body’s immune response making it easier for the steroids to work.
This means a lower dose of steroids can be used and the risk of long term effects is reduced.
They are usually given as a trial (up to 3 months) to see if they help.
Male and female patients must be agreeable to using effective contraception (birth control methods) before receiving methotrexate.
If you are taking other medication (it is important your doctor knows all the medication you are taking including herbal or homoeopathic medicines and those bought over the counter).

Inhaled steroids

If you are prescribed inhaled steroids this is a smaller does than you would get in tablet form with fewer long term side effects. Inhaled steroids do not work right away, it takes time to build up over days or weeks so do not stop your inhaled steroids when you start to feel better. Your symptoms will return. It is important that your healthcare team review your medication on a regular basis to ensure you are on the correct treatment to minimise the risk of side effects.

If you need to take steroids for a long period (months rather than weeks) and you have any of the following medical conditions, you will be carefully monitored by your doctor.

High blood pressure or a heart condition.
Liver or kidney problems.
Diabetes.
Osteoporosis.

When to ask for medical advice

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Living with difficult to control asthma can be challenging and you may have up and down days. However if you suspect you may be having side effects from your medication you should ask for medical advice urgently especially if you:

Develop a rash, have a change or worsening of your breathing.
Develop swelling in your legs, face or any part of your body.
Develop feelings of light-headedness or feel you may faint.
Develop severe abdominal pains (caused by inflammation of the pancreas).
Are feeling depressed, including negative thinking with prolonged low moods and your mood affecting daily life.
Have feelings of high mood (mania) or mood “swings”.
Have felt anxious, are having problems sleeping or difficulty in thinking (including confusion or losing your memory).
Have been feeling, seeing or hearing things which you then become aware do not exist. This can also include having strange and frightening thoughts, changing how you act or having feelings of being alone.

Important

Ask for medical advice if you experience any of the signs and symptoms above.

Oral steroids and injections

Prednisolone tablets

Oral steroids and injections are usually given as:

Prednisolone tablets.
Methylprednisolone. (Medrol^®)
Triamcinolone (Kenalog®) injections. Usually injections are used if tablet form does not give sufficient relief or when some people have side effects. Can be given every 4-6 weeks.

What do they do?

Reduce the inflammation in the lining of the lungs.
This reduces the tightening of the airways. and means breathing becomes easier.
They can be taken to help control the symptoms of an acute asthma attack.
Steroid tablets can also be taken daily by some people with asthma that is difficult to control.
It may take a few days to feel the full benefits of taking steroid medication.

Antibody treatment – Omalizumab

A doctor giving a young man an injection in the upper arm.

Omalizumab is an Anti IgE monoclonal antibody. It is licensed for use only in adults and children over 6 yrs. It may be considered as therapy only if you:

Have impaired lung function.
Have frequent asthma attacks and are symptomatic.
Are taking high-dose steroid inhalers and Long-acting beta receptor antagonists which last for up to 12 hours.
Have an allergy as an important cause of your asthma.

Omalizumab treatment should only be started in specialist centres with experience of monitoring and managing treatment of people with severe and difficult asthma.

If you are being treated with omalizumab and have any of the following conditions make sure the specialist is aware of them:

Kidney or liver problems.
Autoimmune disease – disorders where your own immune system attacks part of your body.
Recent treatment for an infection by a parasite.

Common side effects include:

Fever, difficulty breathing, swelling or feeling faint.
Joint pain with or without swelling or stiffness, rash, fever, swollen lymph nodes, muscle pain.
Reactions at the site of the injection (pain, swelling, itching and redness).
Pain in the upper part of the stomach.
Headache.

Self management

These side effects can usually be managed with other treatments – seek medical advice on how. Sometimes you have to discuss living with a side effect with the risk of difficult to control asthma with your healthcare professionals.

Allergies and antibodies

Asthma is sometimes linked with allergies. If you have this type of asthma you will be looked after by an asthma specialist. Some people with asthma related allergies may be suitable for antibody treatment.

Antibody treatment is only effective for small number of people with allergic asthma, it doesn’t work for everyone. If the specialist thinks you may be suitable for this treatment they will:

Firstly take a blood test which will help to find out if you are likely to benefit from this treatment.
Give the treatment as an injection into the skin. It is given every two or four weeks depending on the dose you need.
Usually give as a trial for 12-16 weeks to see what benefits you experience after using it. It is a specialist medicine and therefore is given by a specialist in a hospital setting where they can monitor how you respond to the treatment.

The specialist will be concerned with various tests that measure:

How your body responds to these allergies by producing substances, one of which is called Immunoglobulin E.
Swelling in the airways. Some people with allergic asthma produce very high levels of Immunoglobulin E which can cause further swelling of your airways.
Monoclonal antibodies like (Omalizumab which is also known by the name Xolair®) can reduce the effects of Immunoglobulin E in this small group of people.

What do antibodies do?

Monoclonal antibodies stick to Immunoglobulin E.
This prevents the Immunoglobulin E from triggering specific parts of the immune system.
Antibodies can prevent or reduce further swelling or inflammation of your airways.

Important

It is important you continue to take your other medication as well.

Medicine to treat an acute asthma attack

Inhaler

There is a standard method of treating an acute asthma attack. It consists of high dose reliever medication and steroid tablets.

The usual reliever drug used is Salbutamol. It is delivered by a spacer device one puff at a time up to 10 times. Salbutamol may be given by nebuliser, there is a standard dose vial that is used in the nebuliser chamber. Some people will have a home nebuliser as part of their treatment regime for difficult to control asthma.

The steroid tablets are given to reduce inflammation and calm down the symptoms of the asthma attack over a number of days. Most people will receive about 40mg of Prednisolone for 5 to 10 days after an attack.

If you have an attack and are admitted to hospital the immediate treatment is with an intravenous steroid and/or intravenous Magnesium Sulphate.

Relievers can be given by injection. An example of this is Terbutaline infusion.

What does it do?

This is frequently used to treat the immediate symptoms of an asthma attack.
Injection is given so it can get to work quickly and it works by relaxing the airways.
Some patients with difficult to control asthma have infusions of relievers as part of their daily management plan. These infusions are given continuously (24 hours a day, 7 days a week) via a small cannula under the skin. This means that the level of medicine is continuous and the effects of the drug don’t wear off, resulting in the improvement of asthma symptoms. There are some risks and side effects associated with these infusions.

In a community or at home you should have your oxygen saturation levels checked. If the oxygen level is less than normal your healthcare professional will assess your need and may provide oxygen to aid recovery.

Medicine for difficult to manage asthma

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There are different types of commonly used treatments for difficult to manage asthma:

Monoclonal antibodies (e.g. Omalizumab which is also known by the name Xolair®).
Oral steroids or injection.
Steroid sparing agents (e.g. Methotrexate, ciclosporin, gold).
Antifungal medicines.
Terbutaline infusion (A fast acting reliever) Some medicines are preventative and others are used to treat an asthma attack.

See the section on Medications for more information on asthma medicines.