Controllers

Some pharmaceutical manufacturers have combined two controller medications into one inhaler. These inhalers are referred to as “Combination Medications”.

Combination medications combine at least two medications — a corticosteroid plus a bronchodilator (usually a LABA) — in one inhaler. The bronchodilator opens your airways, making it easier for you to breathe. The inhaled corticosteroid reduces inflammation in your airways. Recent studies show that many people with asthma find that combination medications give them better control and are convenient to use.

Examples of combination medications are:

Possible side effects of combination medications include:

• Rapid heart beat
• Cough, throat irritation
• Hoarseness

Leukotriene receptor antagonists, called LTRAs for short, are a class of oral medication that is non-steroidal. They may also be referred to as anti-inflammatory bronchoconstriction preventors. LTRAs work by blocking a chemical reaction that can lead to inflammation in the airways. Although not preferred first choice therapy. LTRAs can also be used when an inhaled corticosteroid cannot, or will not, be used.

If you’ve been taking inhaled steroids and your asthma still isn’t well-controlled, your doctor may prescribe LTRAs instead of increasing the dosage of your inhaled steroids.

LTRAs do not contain steroids; they come in pill formats (including chewable tablets or liquid for children) and have few side effects. LTRAs may also be prescribed to treat allergic rhinitis. If there is no improvement in your symptoms after 4 weeks of use, your doctor will change your treatment.

Examples of LTRAs include:

• Montelukast (sold as Singulair®)

The most common side effects reported were:

• abdominal pain
• headache
  
• thirst
  
• diarrhea
  
• hyperactivity
  
• asthma
  
• scaly and itchy skin
  
• rash

Please note the Product monograph update: Singulair (montelukast) from Health Product InfoWatch, August 2020.

Serious Warnings and Precautions

• Serious neuropsychiatric (NP) events have been reported in patients with and without a previous history of psychiatric disorder during Singulair treatment and after its discontinuation. The mechanisms underlying NP events associated with Singulair use are currently not well understood.
  
• Highly variable NP event types were reported with the use of Singulair including, but not limited to, agitation, aggression, depression, sleep disturbances, suicidal thoughts and behaviour (including suicide).
  
• The benefits of Singulair may not outweigh the risks in some patients due to the risk of serious NP events, particularly when the symptoms of the disease may be mild and adequately treated with alternative therapies.

Anti-IgE treatment might be recommended if you have allergic asthma and you keep experiencing persistent symptoms despite taking your controller medications.

If you have allergic asthma (about 60% of asthma is caused by allergy), your symptoms are triggered when you inhale certain allergens in the air. These allergens cause a chain reaction that leads to inflammation in the lungs.

While inhaled steroids work by treating and reducing the inflammation, anti-IgE therapy works by keeping inflammation from developing in the first place. It does so by blocking immunoglobulin E, a substance in the body that is one of the underlying causes of inflammation in allergic asthma.

Anti-IgE therapy is only available by prescription. Unlike other asthma medications, it is not administered by pill or by inhaler. It needs to be injected once every two or four weeks by a doctor or other trained healthcare professional.

The only anti-IgE therapy available in Canada is omalizumab (Xolair®).

The most common side effects of anti-IgE therapy are: skin irritation or reaction at the site of the injection, and respiratory tract infections (e.g., common cold).

Who is Anti-lgE therapy for?

Anti-IgE therapy with omalizumab is for adults and adolescents (12 years of age and above) with moderate-to-severe, persistent allergic asthma who continue to have asthma symptoms even though they are taking inhaled steroids.

How quickly does anti-lgE therapy work?

It does take time for the IgE blocking to start working. It is normal not to feel a difference right away. It is important to keep getting your injections until your doctor tells you otherwise. In scientific studies testing omalizumab, the benefits of IgE therapy were shown in most patients by three months.

Does omalizumab (Xolair®) have any serious side effects?

In scientific studies, cancer was seen in a small number of patients receiving omalizumab, as well as in those receiving placebo injections. The rate was higher in patients treated with omalizumab than placebo (0.5% vs. 0.2%). This difference has not been conclusively linked to the omalizumab. Some patients in the studies had a serious allergic reaction called anaphylaxis. This was rare, occurring in less than 0.1% of patients. Doctors have been advised to observe patients for a period after omalizumab injection to make sure that no anaphylaxis develops. If it does, it can be treated.

Will I still need to keep taking my inhalers?

Yes. Anti-IgE therapy is meant to complement, not replace, your existing medications. Although many patients taking IgE therapy have been able to have the dose of their inhaled steroid decreased over time, you will still need to keep taking your other asthma medications as directed by your doctor.

How often is omalizumab given?

Depending on your body’s IgE level and your body weight, omalizumab will be given once every two or four weeks.

Who will administer the injection?

Omalizumab needs to be injected by a trained healthcare professional. You may be able to have it done at your usual doctor’s office. In some cases, your doctor will refer you to another location to have the injection given. There are specialty clinics in many Canadian cities that have been especially set up to give injections of omalizumab.

Learn more about oral corticosteroids for asthma here.

Occasionally, doctors will prescribe oral (tablet or liquid) corticosteroids for more severe or troublesome asthma symptoms.

Oral corticosteroids can have serious side effects if used for a long time. However, they also have significant benefits that can outweigh their negative side effects. Speak with your healthcare professional who can explain the pros and cons of using oral corticosteroids.

Examples of oral corticosteroids are:

• Prednisolone (sold as Pediapred®)
• Prednisone (sold as Deltasone®)

Possible side effects of long-term oral corticosteroid use include:

• Water retention
• Bruising
• Puffy face
• Increased appetite
• Weight gain
• Stomach irritation
• Mood changes
• Fractures

A DISKUS® is a dry-powder inhaler that features a built-in counter, so that you always know how many doses you have left in it.

Use your DISKUS®:

1. Open your DISKUS®: Hold it in the palm of your hand, put the thumb of your other hand on the thumb grip and push the thumb grip until it “clicks” into place
2. Slide the lever until you hear a click. Your medication is now loaded
3. Breathe out away from the device
4. Place the mouthpiece gently in your mouth and close your lips around it
5. Breathe in deeply until you have taken a full breath
6. Remove the DISKUS® from your mouth
7. Hold your breath for about ten seconds, then breathe out slowly

If you drop your DISKUS® or breathe into it after its dose has been loaded, you may cause the dose to be lost. If either of these things happens, reload the device before using it.

Do not use a spacer with the DISKUS®, Turbuhaler®, Twisthaler®, or any other dry powder inhaler.

The dial in the dose-counter window tells you how many doses are left – always check it after using your DISKUS.

How to clean and maintain your device

Make sure to keep the device dry, at room temperature, and closed when not in use. Do not wash the device or get it wet. If you want to clean the mouthpiece, wipe it with a clean, dry tissue.

A Turbuhaler® is a dry-powder inhaler available in an easy-to-use format.

Some Turbuhalers® feature a dose counter that shows the exact amount of medication left. If your Turbuhaler® doesn’t have a dose counter, then check for a red indicator in the windows on the side of the device. When you see red in the window, there are approximately 20 doses left and it’s time to order a refill.

Use your Turbuhaler®:

1. Unscrew the cap and take it off. Hold the inhaler upright
2. Twist the coloured grip of your Turbuhaler® as far as it will go. Then twist it all the way back. You have done it right when you hear a “click”
3. Breathe out away from the device
4. Put the mouthpiece between your teeth, and close your lips around it. Breathe in forcefully and deeply through your mouth
5. Remove the Turbuhaler® from your mouth before breathing out
6. Always check the number in the side counter window under the mouthpiece to see how many doses are left. For the Turbuhalers® that do not have a dose counter window, check the window for a red mark, which means your medication is running out. When finished, replace the cap.

If you drop your Turbuhaler® or breathe into it after its dose has been loaded, you may cause the dose to be lost. If either of these things happens, reload the device before using it.

How to clean and maintain your device

Keep the cap on when you are not using your inhaler. Store it at room temperature in a dry place. Clean the outside of the mouthpiece once a week with a dry tissue. Never use water or any other fluid when cleaning the mouthpiece.

How to Use a Diskhaler®

A Diskhaler® is a dry-powder inhaler that holds small pouches (or blisters), each containing a dose of medication, on a disk. The Diskhaler® punctures each blister so that its medication can be inhaled.

Use your Diskhaler®:

1. Remove the cover and check that the device and mouthpiece are clean.
2. If a new medication disk is needed, pull the corners of the white cartridge out as far as it will go, then press the ridges on the sides inwards to remove the cartridge.
3. Place the medication disk with its numbers facing up on the white rotating wheel. Then slide the cartridge all the way back in.
4. Pull the cartridge all the way out, then push it all the way in until the highest number on the medication disk can be seen in the indicator window.
5. With the cartridge fully inserted, and the device kept flat, raise the lid as far as it goes, to pierce both sides of the medication blister.
6. Move the Diskhaler® away from your mouth and breathe out as much as you can until no air is left in your lungs.
7. Place the mouthpiece between your teeth and lips, making sure you do not cover the air holes on the mouthpiece. Inhale as quickly and deeply as you can. Do not breathe out.
8. Move the Diskhaler® away from your mouth and continue holding your breath for about 10 seconds.
9. Breathe out slowly.
10. If you need another dose, pull the cartridge out all the way and then push it back in all the way. This will move the next blister into place. Repeat steps 5 through 9.
11. After you have finished using the Diskhaler®, put the mouthpiece cap back on.

If you drop your Diskhaler® or breathe into it after its dose has been loaded, you may cause the dose to be lost. If either of these things happens, reload the device before using it.

Your Diskhaler® should always be cleaned according to its instructions and before you insert a new medication disk into it.

Aermony RESPICLICK™ is an ICS/LABA combination inhaler. Aermony RespiClick is offered as prophylactic therapy for patients aged 12 years and older, in a simple-to-use inhaler. The device features a cap that integrates the opening and priming steps, with a ‘click’ sound that confirms the dose is ready.

How to Use Aermony RespiClick™

To use your Aermony RESPICLICK™ do the following for one dose:

1. When you are ready to use your Aermony RESPICLICK for the first time, remove the inhaler from the foil pouch. There are two main parts of your Aermony RESPICLICK inhaler: the white inhaler with the mouthpiece and the green cap that covers the mouthpiece of the inhaler.

2. Make sure the cap is closed. Hold the inhaler upright. Open the green cap all the way back until you feel and hear a ‘click’. Once the cap is opened and it clicks, one dose is ready to be inhaled. Do not open the green cap unless you are taking a dose.

3. Before inhaling, hold the inhaler away from your mouth and breathe out through your mouth as much air as you can and as is comfortable. Never breathe out into the inhaler mouthpiece.

4. Place the mouthpiece in your mouth and close your lips around it so you form a good seal. Breathe in quickly and deeply through your mouth, until your lungs feel completely full of air. Do not block the vent above the mouthpiece with your lips or fingers.

5. Remove the inhaler from your mouth. Hold your breath for about 10 seconds or for as long as you comfortably can. Important note: Your Aermony RESPICLICK inhaler delivers your dose of medicine as a very fine powder that you may or may not taste or feel. Do not take an extra dose from the inhaler even if you do not taste or feel the medicine.

6. Close the green cap after inhaling so that the inhaler will be ready for your next dose.

7. Rinse your mouth with water after taking your dose. Spit out the water. Do not swallow it.

8. Throw the inhaler away 30 days after you have opened the foil pouch, or when the counter reads ‘0,’ whichever comes first.

An Atectura® Breezhaler® inhaler belongs to the class of medications called long-acting beta agonist bronchodilators. It works by relaxing the muscles in the walls of the small air passages in the lungs. This helps open up the airways, making breathing easier, preventing symptoms such as wheezing and shortness of breath.

How to use your Atectura® Breezhaler® Inhaler:

To use your ATECTURA® BREEZHALER® inhaler, do the following for one dose:

1. Pull off the cap, open the inhaler, and remove a capsule. Separate one of the blisters from the blister card. Peel open the blister and remove the capsule. Do not push the capsule through the foil. Do not swallow the capsule.

2. Insert the capsule into the chamber. Never place a capsule directly into the mouthpiece. Close the inhaler.

3. Pierce the capsule once. Hold the inhaler upright. Pierce the capsule by firmly pressing both side buttons at the same time. You should hear a noise as the capsule is pierced. Only pierce the capsule once. Release the side buttons.

4. Breathe out fully. Do not blow into the inhaler. Inhale medicine deeply. Place the mouthpiece in your mouth and close your lips firmly around it. Do not press the side buttons. Breathe in quickly and as deeply as you can. During inhalation you will hear a whirring noise. You may taste the medicine as you inhale.

5. Hold your breath for up to 5 seconds. Rinse your mouth with water and spit it out.

6. Check that the capsule is empty. Open the inhaler to see if any powder is left in the capsule. If there is powder left in the capsule, close the inhaler, and repeat steps four and five.

7. Remove empty capsule. Put the empty capsule in your household waste. Close the inhaler and replace the cap.

^{Enerzair® Breezhaler® is a combination of a long-acting beta2-adrenergic agonist (LABA), a long-acting muscarinic antagonist (LAMA) and an inhaled corticosteroid (ICS). It is used as a maintenance treatment for asthma in adults whose asthma is not being adequately controlled with a maintenance long-acting beta2-agonist (LABA) and a medium or high dose of an inhaled corticosteroid (ICS), and those who have experienced one or more asthma attacks in the previous year.}

^{This medication is not intended for the relief of the sudden (acute) symptoms of asthma (i.e. as rescue therapy for the treatment of sudden episodes of bronchospasm).}

How to use your Enerzair® Breezhaler® Inhaler:

To use your Enerzair® Breezhaler® inhaler, do the following for one dose:

1. Pull off the cap, open the inhaler, and remove a capsule. Separate one of the blisters from the blister card. Peel open the blister and remove the capsule. Do not push the capsule through the foil. Do not swallow the capsule.

2. Insert the capsule into the chamber. Never place a capsule directly into the mouthpiece. Close the inhaler.

3. Pierce the capsule once. Hold the inhaler upright. Pierce the capsule by firmly pressing both side buttons at the same time. You should hear a noise as the capsule is pierced. Only pierce the capsule once. Release the side buttons.

4. Breathe out fully. Do not blow into the inhaler. Inhale medicine deeply. Place the mouthpiece in your mouth and close your lips firmly around it. Do not press the side buttons. Breathe in quickly and as deeply as you can. During inhalation you will hear a whirring noise. You may taste the medicine as you inhale.

5. Hold your breath for up to 5 seconds. Rinse your mouth with water and spit it out.

6. Check that the capsule is empty. Open the inhaler to see if any powder is left in the capsule. If there is powder left in the capsule, close the inhaler, and repeat steps four and five.

7. Remove empty capsule. Put the empty capsule in your household waste. Close the inhaler and replace the cap.

About Spacers

The most basic spacer is a tube that attaches to a puffer, so that you breathe the medication in from the tube instead of directly from the puffer. This makes it easier to “aim” the medication and breathe it right into the deepest part of your lungs, instead of having the spray end up in your mouth. If sprayed into your mouth, the medication can cause side effects like thrush (yeast infection). You can buy spacers from a pharmacy.

Also known as aerosol-holding chambers, add-on devices and spacing devices, spacers are long tubes that slow the delivery of medication from pressurized MDIs.

Spacers should always be used with MDIs that deliver inhaled corticosteroids. Spacers can make it easier for medication to reach the lungs, and also mean less medication gets deposited in the mouth and throat, where it can lead to irritation and mild infections.

While a spacer can make it easier to co-ordinate breathing in and activating an MDI, it can also make the MDI less portable because a spacer takes up extra space in a purse or a bag. However, inhaled corticosteroids are usually prescribed to be taken twice a day, so the spacer can be left at home for morning and evening use.

There are several other types of spacers available for people with specific needs. A large-volume spacer is useful for people who need to take their medication dose more slowly, over the space of five or six breaths. For young children, a spacer with a breathing mask attachment is often used. If you need to use one of these types of spacers, please ask your healthcare team how to use and maintain them.

Should I be using a spacer?

Asthma Canada recommends that anyone, of any age, who is using a puffer should consider using a spacer. A pharmacist, respiratory therapist, asthma educator, or doctor can assess how you use your puffer and will recommend the best device for you.

It is recommended that children use a spacer device with their puffer.

Spacers should not be used with dry powder inhalers — only with puffer-style devices. Puffers with either a rectangular or a round mouthpiece should be able to fit into a spacer — ask your healthcare provider for a demonstration if you are unsure how to set it up.

To Use your Puffer with a Spacer:

1. Shake the inhaler well before use (3-4 shakes)
2. Remove the cap from your inhaler, and from your spacer, if it has one
3. Put the inhaler into the spacer
4. Breathe out, away from the spacer
5. Bring the spacer to your mouth, put the mouthpiece between your teeth and close your lips around it
6. Press the top of your inhaler once
7. Breathe in very slowly until you have taken a full breath. If you hear a whistle sound, you are breathing in too fast.
8. Hold your breath for about ten seconds, then breathe out.
9. If you need to take more than one puff at a time, wait a minimum of 30 seconds between puffs and be sure to shake the puffer (as in step 1) before each puff. Only put one puff of medication into the spacer at a time.

Cleaning Your Spacer

To clean your spacer, follow the instructions that come with it. In most cases, they will advise you to:

1. Take the spacer apart.
2. Gently move the parts back and forth in warm water using a mild soap. Never use high-pressure or boiling hot water, rubbing alcohol or disinfectant.
3. Rinse the parts well in clean water.
4. Do not dry inside of the spacer with a towel as it will cause static. Instead, let the parts air dry (for example, leave them out overnight).
5. Put the spacer back together.

If you are using your spacer every day, you should replace it about every 12 months.

Important Reminder about Spacers

Always follow the instructions that come with your spacer. As well:

• Only use your spacer with a pressurized inhaler, not with a dry-powder inhaler.
• Spray only one puff into a spacer at a time.
• Use your spacer as soon as you’ve sprayed a puff into it.
• Never let anyone else use your spacer.
• Keep your spacer away from heat sources.
• If your spacer has a valve that is damaged, or if any other part of the spacer is damaged, do not use it. The spacer will have to be replaced.
• Some spacers have a whistle. Your technique is fine if you do not hear the whistle. However, if you hear the whistle, this means you should slow your breath down.
• It is very important that you consult your  healthcare professional to review proper inhaler technique.