Prescriber 2010:21(15/16) (August)

A new treatment for migraine sufferers – 10% menthol crystals in ethanol, 1 ml applied to a 5 x 5 cm area of the forehead/temporal area on the more painful side, repeated after 30 minutes, has been found to work better than a placebo solution.

The other article of interest was a review of asthma treatment.  Since I tend to get a touch fuzzy on the doses, I’ll review the stepwise chart here:

In adults, Step 2 is an ICS at 200 – 800 mcg per day (BCLM equivalent).  So, Clenil 50 to 200 at two puffs bd, or Qvar 50 to 200 at 1 puff bd (or 100 up to two puffs bd), or Fluticasone 50 one or two puffs bd or 125 one puff bd (or 100, but that’s only available in Accuhaler form and works out more expensive).  In practice, unless it was unusually severe or mild I’d likely start with the Clenil 100 two puffs bd or Fluticasone 50 mcg two puffs bd.

Step 3a (it’s not really called that, but as Step 3 has more than one stage I’ll think of it this way) is, of course adding a LABA, but if this makes no difference you drop it.  If Step 3a doesn’t achieve decent control, then Step 3b is to increase the ICS to the maximum allowed at Step 2 (800 mcg BCLM equivalent), with or without continued LABA depending on whether it had at least some effect.  Simplest way of doing this with combination inhalers seems to be Symbicort 200/6 two puffs bd or 400/12 one puff bd.  Step 3c is to try montelukast/zafirlukast (or theophylline, but no thank you).

Step 4 can be increasing the ICS up to 2000 mcg/day and/or adding further oral drugs (LTRA/theophylline if not already added, oral beta-2 agonists), and Step 5 is oral steroids, now with possibly added omalizumab or immunosuppressives, but at those stages I’m going to be referring to a chest physician anyway.  However, don’t forget to review five questions in cases of poor control: Is the patient taking his/her inhalers at all?  Is he/she taking them properly?  Are there any other possible reasons for poor control, such as tobacco smoke exposure or allergens?  And, if all those have checked out – is asthma actually the correct diagnosis in the first place?  And is it the only diagnosis, or is something else going on as well causing the breathlessness?

For 5 – 12-year-olds, the dose of ICS at Step 2 is 200 – 400 mcg BCLM equivalent – Fluticasone 50 mcg or Clenil 100 mcg, one to two puffs bd.  Step 3 is as for adults, with the maximum dose of ICS at this step being 400 mcg BCLM equivalent.  At Step 4, the ICS can go up to 800 mcg/day BCLM equivalent.

For under-5s, the dose of ICS at Step 2 is as for 5 – 12s, but Step 3 would be an LTRA rather than a LABA.  Also, LTRA can be considered as a regular therapy at step 2 ‘if steroid cannot be used’.  And refer if Step 3 hasn’t worked.

For review of control, the Asthma Control Test is recommended – aim for scores of 20 or above.  And, finally, in a well-controlled patient, when can we think about titrating the treatment down again?  After 3 months, in steps of 25 – 50% of ICS dose.


About Dr Sarah

I'm a GP with a husband and two young children.
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