Study links rescue inhaler overuse to depression

A new research study reveals that "overuse of rescue inhaler in chronic asthmatics linked to depression." While the researchers were not conclusive on how to interpret these results, they seem to be leaning towards blame the asthmatic.

The study was conducted by the University of Arizona and involved 416 patients.  The results were as follows:

• About half of all participants used albuterol as expected, while 27 percent of participants overused albuterol and 22 percent underused albuterol.
• 45 percent of over-users used albuterol on a daily basis.
• Participants across the board used albuterol on symptom-free days about 20 percent of the time.
• Eighty-eight percent of daily users were over-users of albuterol.
• Over-users had more days in which they had symptoms and scored worse on the asthma control questionnaire, the shortness of breath questionnaire and the asthma symptom utility index.
• Over-users of albuterol had worse mental functioning when compared to expected users of albuterol.

So that was the first part of the study.  The participants were also studied to see how they scored on a depression test, with the following results. 

• 19% of those who underused albuterol had a depression score of 16 or more
• 17% of those who used albuterol as expected had a depression score of 16 or more
• 32% of those who used albuterol too much had a depression score of 16 or more

Researchers who interpret studies concluded the following: 

What isn’t clear is whether depression leads to worsened asthma symptoms and an increase in albuterol use or whether albuterol use contributes to the development of depression. Asthma has a significant relationship with one’s mental status, and emotional states like anxiety can contribute to asthma exacerbations, leading to the need for a rescue inhaler.

It also isn’t clear whether or not albuterol over-users were more or less compliant with the chronic medications asthmatics take on a regular basis in order to avoid exacerbations of their disease process. If this is the case, doctors need to educate patients — depressed or not — on the use of chronic asthma medications so rescue inhalers like albuterol are less necessary.

My problem with these results is this: Why do they always blame the asthmatic?  If I don't have good asthma control, it's because I don't take my asthma controller medicines.  Plus, how do you define albuterol overuse? I mean, I know they define it as using it more frequently than a doctor prescribes for, but how do they know the doctor is right.

Let me put it this way, many recent studies have confirmed that corticosteroids, a top line medicine used to reduce inflammation in asthmatic lungs to make them less sensitive to asthma triggers, does not work on those with severe asthma. Inhaled corticosteroids do not help those with severe asthma gain good asthma control.  So these patients, by default, will need to use their rescue medicine more frequently.

Likewise, most asthmatics do not have pure asthma, or asthma by itself.  Like myself, most asthmatics have something else with it, like allergies.  Actually, studies show that 75% of asthmatics also have allergies, and this is a double whammy.  My point here is that, even if you have good control, you can still have trouble breathing on a regular basis.  You may still need to use your rescue inhaler daily.

Yes, if you have pure asthma you shouldn't need your rescue inhaler more than 2-3 times in a 2 week period. There are many asthmatics who would fall into this category.  Still, there are likewise many asthmatics who do not qualify for this method of defining control because they do not have pure asthma.

I describe what real asthma control is in my post"What is good asthma control?"  I wrote:

The National Heart Lung and Blood Institutes (NHLBI) Asthma Guidelines define control pretty much the same as the GINA guidelines: Control is the degree the above guidelines are met plus the degree YOUR goals of therapy are met.

Your goals may be:

• I just want to be able to walk
• I want to be able to exercise
• I don't want to miss any more school or work due to my asthma

Another means to monitor control is your own personal satisfaction. Are you satisfied with your life given your asthma severity?

Plus this notion of monitoring control by how often you use your rescue inhaler doesn't work if you don't have pure asthma.  For instance, my current doctor ordered my rescue inhaler to be used four times a day. Well, how does he know when I'm going to be short of breath?  Sometimes I go weeks without using it. Other times, such as right now when I have a cold, I use it several times a day.

My point here is that you need to be careful when reading the results of research like this.  You have to take what you read, even in peer reviewed journals, with a grain of salt. While the studies themselves come to accurate conclusions, the people who interpret the results sometimes get it wrong.  They get it wrong because they do not have asthma so they don't know what it's like.

Further reading:

• Eureka Alert: Study: Severe asthma fails to respond to mainstay treatment
• Hardluck Asthma: What's it like to have asthma?
• NHLBI: Asthma Guidelines
• RT Magazine: overuse of rescue inhaler in chronic asthmatics linked to depression
• Lung Disease News: Overuse of rescue inhalers in asthmatics linked to depression
• Healthcentral: What is good asthma control?
• Healthcentral: How to obtain good control of your asthma?

Rescue bronchodilators: Here are my unfettered answers to all of your questions about them

The following are some questions real patients have asked me recently regarding rescue bronchodilators. The answers here are my humble personal and professional opinions and nothing more.

Keep in mind that your doctor might disagree with me, and that's fine. He can overrule me whenever he wants. But, the answers here are based not just on my 10 years as an RT, but over 30 years as a chronic asthmatic who's abused more than his share of inhalers and lived to tell about it.

Q) What is the recommended dose for albuterol

A) Every 4-6 hours as needed ( no surprise here.)

Q) What if I need it more often than that

A) For most patients, I'd recommend seeing your doctor if you need it more often than every 4-6 hours, because it's a sign that your asthma or COPD is getting worse and needs to be better controlled. However, it's a relatively safe medicine, and some doctors prescribe it to be used as needed for some chronic patients.

Q) What do you think of a doctor ordering Albuterol MDI every four hours?

A) Albuterol is typically a rescue medicine, and should be taken when you are short-of-breath (SOB) due to bronchospasm. It's not going to hurt if you use it more often than when you need it, but I don't see why it would be beneficial.

Q) My doctor says Albuterol will work to prevent an asthma attack, so I should use it every four hours all day. Is this true?

A) I was taught when I was kid to take my Albuterol before I took gym class, and I did. However, it never prevented me from getting SOB. It did, however, make me feel better once I was SOB. So to answer this from my own personal experience, I'd have to say no; Albuterol does not prevent asthma symptoms. However, you can try it to see if it works for you.

There are many doctors who do believe it can be used as a preventative drug. Not only that, it states this on the Albuterol package insert. However, if it is deemed necessary that preventative medicines be taken to prevent an asthma attack, there are far more effective medicines to be using, such as Vanceril, Flovent, Atrovent, Cromolyn, Advair, etc. (this will be discussed in a later post.)

Q. I've had an Albuterol inhaler for the past 3 years. Sometimes I use it more that 10 times in a day, which is more than the prescribed frequency of every 4-6 hours. Can I use Albuterol this much and feel safe?

A. I'm treading on thin water here, but I will say yes. I find from my own personal experience as a former Albuterol abuser, and professional experience giving treatments, that Albuterol is a very safe medicine. The most common side effect is that it might make you jittery, which you probably already know if you've done it before. If you were going to have a negative reaction to the medicine, like an increase in heart rate, it would have happened already.

However, if you have other medical issues besides just COPD or Asthma, then I'd be really cautious of using too much Ventolin. I'd recommend consulting your doctor if you need to do this. Personally, though, I still think Albuterol is safe and effective in most situations where real bronchospasm is the issue.

Q. But my doctor has me on all the right preventative medicines and I'm still finding myself going through an inhaler a week. Will this have long term implicaitons on my life span?

A. I asked my doctor that exact question when I was a kid, and he told me using my inhaler was better than suffering and chancing an anoxic episode. If you absolutely have no choice than to use your inhaler more than every 4-6 hours, make sure your doctor knows about this. Chances are, he will still renew your prescription because he doesn't want you to suffer. However, he may also continue to try to adjust your other medicines to make your life easier. Sometimes, however, as in some cases of COPD or end stage COPD, this is not possible.

Let me answer this question this way. I went through an inhaler a week from the time I was 13 or 14 until about a year ago when I started taking Advair. That was 25 years. I'm getting along just fine now. Will my Albuterol abuse cut some years off the end of my life? Well, nobody really knows. Albuterol has only been around since 1987. Personally, I doubt it will.

Q. My doctor prescribed Atrovent as my rescue inhaler, what do you think of that? Should I be worried if I use it more than four times a day, because I do?

A. Atrovent is not a rescue inhaler. Atrovent takes about 20-30 minutes to work, while Albuterol, idealy, should work almost instantaneously for bronchospasm. Then again, if Atrovent works for you, then that's great. If it isn't, then I'd talk to your doctor about getting an Albuterol inhaler.

Q. Am I safe using Atrovent more often than every four hours, because I do?

A. I don't see what it would hurt. When I was in school ten years ago we were taught never to use Atrovent more often than Q4. However, some new research shows that addtitional Atrovent during an exacerbation does benefit patients. If Atrovent is working for you as a rescue drug, all the power to you. However, if you continue to be short-of-breath, you should talk to your doctor about getting an Albuterol inhaler or (ideally) adjusting your preventative medications.

Q. Can I use my Combivent more than every 4 hours?

A. Again, I don't think it would hurt you, but it's not necessary. Technically speaking, the Atrovent in this medicine shouldn't need to be taken more than every four hours. If you need to use Combivent more than every four hours, then you should talk to your doctor and get an Albuterol inhaler. You can then use your Combivent four times a day, and Albuterol in between if you get short-of-breath. (and still I'd only recommend this only if other preventative medicines weren't working.)

Q. Do you think Xoponex is better than Albuterol?

A. No. I have never noticed a difference. Original studies claimed that Xoponex was stronger than Albuterol, but I've never noticed that to be true in my real life experiences with the two drugs. Not only that, I don't think the claim that Xoponex has fewer side effects than Albuterol is true either. Recent studies have confirmed this.

However, if you have experienced cardiac side effects, or excess jitteriness or nervousness, then you might be a candidate for a trial of Xoponex, if you want to flip the bill: Xoponex costs 5-10 times more than Albuterol.

Q. What if I go through an inhaler a week?

A. Every patient is different. Do you have end stage COPD? If so, you have to do what you need to do. Do you have asthma? Then perhaps you could trial Advair. Advair worked like a miracle drug for me. I went from one inhaler a week and 600mg of theophylin twice a day down to two 300mg pills a week and 4 puffs of Albuterol a day after being on Advair 9 months.

You and your doctor have to find what works best for you. If there is no other alternative, then an inhaler a week might be the best solution.

I meet albuterol abusers at work all the time, and the majority of them are end-stage COPD patients. However, on occasion, I have met a fellow asthmatic who abuses too. Most of them think they are the only one. And, most of them think they are doing this furtively without their doctor's knowing.

Many times I walk into a patients room to give a breathing treatment and find that MDI hidden under the pillow, a sign of a true rescue inhaler abuser.