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Thursday, November 1, 2012

So why is Brovana feared by RTs, RT bosses and doctors?

Brovana (Aformoterol) is the latest medicine to be introduced to hospitals.  From my brief experience with it my fellow respiratory therapists are ignorant about it, and RT bosses fear it.  So the general consensus is to complain about it, and ignore the facts.

Yet this is nothing new among a medical profession that tends to be skeptical of new ideas and dogmatic of old ones.

For many years now Duoneb has been the medicine of choice for COPD patients, even when it's not truly indicated.  If someone has COPD, those patients get Duoneb every four hours (or at least QID) regardless of indication (Note: indications are rarely heeded in the hospital setting, at least when it comes to respiratory medicine).

So now we have this new medicine called Brovana.  A few of the wisest doctors are ordering it, and I'm not sure even they understand it.  Allow me to explain.  You see orders like the following:
Brovana BID, Duoneb Q6
I've observed twice a day my fellow RTs have been giving both Duoneb and Brovana.  So I question them:  "Do you not know what Brovana is?"

They say, "It's a long acting beta adrenergic."

I say, "It's also a rescue medicine."

They say, "No it's not. It's a LABA."

I say, "True, but it's also fast acting"

And this goes on and on, but you get the idea.  So I go to the physician, and he gives me the same defiance.  I go to the pharmacist, and he says, at least, "I'll look it up."

The bottom line here is that not only is Brovana a LABA, it's also fast acting, like Ventolin, like Duoneb, like Xopenex.  In fact, in Korea and Europe Symbicort (which has basically the same LABA in it) is used as a rescuemedicine (look it up).

Brovana should not be given at the same time as a rescue medicine.  When Brovana is given, a rescue medicine should be ordered PRN, and given only when needed, which is when rescue medicine should be used.

And this brings me to my other theory:  RT Bosses fear it.  In fact, even my coworkers fear it.  The other day I said, to my boss, "Why isn't Brovana on the new Order Set for COPD?" My boss ignored me, and my coworker said, "What are you trying to do, get us out of a job?"

So while Duoneb is habitually ordered by doctors for years, Brovana is a much better medicine.  If you give Brovana and Pulmicort BID, you should only need to give Duoneb as needed.  So you can see, there's a fallacy Brovana will put us out of a job.  Yet it's just another ignorant, selfish fallacy of the RT profession.

Yes, the RT Profession survived the first four stages of respiratory therapy while their demise would all result in the end of our profession.  The RT profession will survive, so we don't have to fear doing what is best for the patient just so we can keep our jobs.


CajunGal said...

I have read on my Advair information that because it contains a LABA it shouldn't ever be used with another LABA-containing medicine.

I have asthma, not COPD so maybe the indications are different?

I guess my question (like most of my questions) is *why* can't you use 2 medicines containing a LABA?

Rick Frea said...

Because a LABA stays in your system long term, you don't want want to double up on this due to risk for increased side effects. However, I see no reason why you can't alternate between two different LABAs, such as Symbicort and Advair, or Advair 250 and Advair 500. When you wake up and need quick relief, you can use Symbicort. When you are feeling good, you can use Advair 250. When you're feeling a cold coming on, you can use Advair 500. This is pretty much what I do.

Rick Frea said...

Of course you have to have a reasonable doctor who understands these asthma medicines, and trusts you.

CajunGal said...

I don't have Symbicort, but do have Advair 500 and if I'm in a particularly rough spot with my asthma I use it a little earlier in the day than I normally would and it seems to help a lot more than using my inhaler/neb every 4 hours.

I'll have to talk to my doc about getting Symbicort and using it like you said.

I read/research everything I can about asthma because I went through a really scary 2 months before I was diagnosed but I still have SO many questions that my doc just doesn't answer satisfactorily sometimes.

Thanks so much for running this blog. It has been my source of go-to info when my anxiety about my asthma/asthma symptoms gets the best of me.

I wish you would have been my RT when I was in the hospital!

Rick Frea said...

Actually, you may want to try Symbicort as an every day medicine. It provides quick relief, and considering it's an HFA inhaler, gets deeper into the lungs, according to early studies. It makes me too jittery when I use it every day, although it may work for you.

John Carter said...

Hey guys read your comments I am glade to find such very informative information, do you know how many dosage should be taken of Brovana 15 Mcg while having Asthma???

Susan Setley said...

I'm 71 and have very late 0nset asthma (68, diagnosed at 69). The last half of last year I was hospitalized five times in seven months because of the asthma. The last time was pretty scary, with the ER doctor telling me that I could be in a lot of trouble (the time before that, the Hospitalist told me that it could kill me). Neither of them were exaggerating.

I saw someone from the same Hospitalist group each time (except one time when the ambulance had to take me to a different hospital), and this last episode, before Christmas, the Hospitalist ordered Brovana. He hadn't seen my spirometry and I suspect he thought I really had COPD -- I don't. Nevertheless, the Brovana really did work as a rapid rescue. Two treatments and I thought I was ready to go home. They kept me because of my history of flaring up again even in the hospital, but after two treatments with Brovana they brought in a spirometry, and I blew the top off it (when I'm healthy I have huge lungs and huge lung power, peak flow of 590).

The Brovana broke the spine of those repeated hospitalizations. They would release me after 4 days, or 6 days, or once, 8 days, still wheezing but much better. But the wheezing would never stop, gradually build again, and then turn into an emergency.

Since the Brovana I had a long stretch where I didn't wheeze at all. Now I probably wheeze every day, but it's not severe, there's no distressed breathing with it, and my rescue inhaler turns it off. In fact Brovana may have saved my life last December. It certainly kept me out of ICU, a place I haven't been so far and don't care to visit.

At my age I doubt the would have me use Brovana at home. As I understand it, it poses special risks for people my age. But in the hospital and closely monitored, it was a miracle worker for me.

I think people who use it at home need to be extremely careful as it is the only LABA one can accidentally take without a steroid, which as I understand it, is a very bad idea. The Brovana comes with one capsule, and a second capsule of liquid steroid must also be used, at least with asthma--I can't speak for COPD. I think it would be easy to get distracted and forget to put in the steroid (in the hospital, they put both in the nebulizer at the same time.)

I think the Hospitalist was brilliant to try this, although I know he thought I didn't really have asthma. I have found research demonstrating that when asthma comes on every late in life as it did with me, it tends to be both more severe and harder to manage. It didn't help that I was supersensitive to the ethanol in my ProAir RI. A very sharp respiratory technician knew that Ventolin has no ethanol in it, and got me some when it flared up in the hospital between Duoneb treatments. I was working really hard to breathe and the nurse was staying right by me and assuring me that she wouldn't leave my side, so I know I was in the soup. The RT brought in the Ventolin. I used it with a spacer, and five minutes later I was still wheezing a little, but no longer spinning out of control.

Nevertheless, I believe the Hospitalist thought he was treating COPD, not asthma. I've only found one comment online from a doctor cautiously looking at Brovana for asthma. It's not common, and I think anyone using it for astdhma should be seeing a pulmonologist who is likely familiar with the drug, and really have a detailed conversation about it, what to watch for, etc.

For me, I can't believe how much better I feel, and it's a tremendous relief to have an RI that works instead of making me worse.

Susan Setley said...

John Carter, Brovana is a powerful LABA and can have really signifiant side effects. You should be discussing dosage with your pulmonologist. Don't go by what someone else you know is doing.

Rick Free, I would comment this: I have really hard to manage asthma, and have been on all three of the standard LABAs for asthma: Dulera, Symbbiort and Advair. The three actually have differences, and Advair is the one that works best for me. Each person is going to be different.

I wish it didn't take so much experimentation, but in my case I am allergic to NOTHING ON THE PLANET and it's taken two years of detective work to get my asthma under control.

john bottrell said...

Hi Susan. Your experience with LABAs appears to be similar to mine. I experimented with all the other LABAS, and ended up settling on ADVAIR (right where I began). It's a great medicine and, to me, produces the fewest side effects. John. Site Moderator.

john bottrell said...

John Carter. I would agree with Susan, that you should talk to your doctor about dosing.