I'm sure most of you with COPD (Chronic Obstructive Pulmonary Disease) have heard of Spiriva, and I am quite sure, as well, that many of you are taking it. Since it is still a relatively new medicine, I wrote this article to answer questions, clear up any confusion, and help you get on with your life by achieving the most effective COPD management possible.
First a little background. I'd been hearing about Spiriva for a while before it became available in the United States. I heard that it worked like Atrovent, a staple of COPD treatment (most of my patients were on Combivent, a combination of Atrovent and Albuterol) and that Spiriva was supposed to be sort of a "super Atrovent." A more powerful medication in a once-a-day dose At the time, a patient of mine was able to obtain Spiriva from Germany, so it was nice to have a preview by hearing how it worked for him - and he said that he was breathing a lot better. I was excited at the prospect of it being FDA (Food and Drug Administration) approved and made available here in the US and to patients in our pulmonary rehab program.
Rescue and Prevention
When I ask patients what their inhalers do, they always respond, at first, by saying, "They open up my lungs." Well, yes, but, what's really important for all patients with COPD to know and understand is that there are different kinds of inhaled medicines that open the airways in different ways.
There are two different, very basic, ways that medicines act to open up the airways in your lungs: Prevention, also referred to as Maintenance or Controlling - and Rescue also referred to as Relief. For the sake of this discussion, let's use the words Prevention and Rescue and we'll refer to the medicines as either Preventers or Rescuers.
There are four main categories of inhaled medicines: Corticosteroids, Fast-acting bronchodilators (beta-2 agonists), Long-acting bronchodilators (beta-2 agonists), and Anticholinergics. In this article we're going to talk about just two of these: Anticholinergics and Bronchodilators. I know this is sounding kind of complicated, but stay with me here.
An easy way to understand Prevention and Rescue in pulmonary medicines is looking at it just as we look at fire.
Prevention: You do your best to prevent fires by maintaining your home to keep the electrical wires operating safely, turning the stove off when you're done using it, and putting hot matches in a ceramic dish or water. All these things prevent a fire from occurring. If you skip any of these steps, what might happen? Well, a fire might start. And we all know it makes a lot more sense to prevent a fire than to let one start and then have to put it out!
Rescue: If and when a fire does start, you do (or certainly should) have a fire extinguisher handy. And you also have the 911 system to call for help. Thank goodness for these resources! But, if you can prevent a fire from starting - even knowing all the while that you have help to put it out - you would do it.
You can think of medicines for your lungs in much the same way. When at all possible, use the prevention medications as directed to be as effective as possible and keep your airways from having spasms and getting tight. If you do all you can to prevent airway tightness and increased shortness of breath and you still run into problems, that's the time to reach for your rescue medication.
Right now you're probably wondering which of your meds are Preventers and which ones are Rescuers. This is not a complete list by any means (we're not going to talk today about Steroids or Long-Acting Bronchodilators), so for the sake of this article, the Preventers are: Atrovent and Spiriva; and the Rescuers
are: Albuterol, Proventil, Proventil HFA, Ventolin, Pro-Air HFA, and Maxair. So, where does Combivent come in? Combivent is both a Preventer and a Rescuer because it contains Atrovent, and Albuterol.
How does Spiriva work?
Let's learn what Spiriva and Atrovent are and what they are supposed to do. Spiriva and Atrovent are medicines called Anticholinergics. These medications work to block the message to nerve impulses that are trying to cause spasms of smooth muscles in the airways of the lungs. So, Atrovent and Spiriva actually stop airway muscle tightening before it starts, preventing it, kind of like putting a roadblock in the way of the signal that starts a problem.
What's the problem?
When Spiriva was approved and became available in the United States in May of 2004, it seemed like many of our patients loved it and said they were breathing much better. Now, we all know that not all meds work for everybody. But I guess that I could say that more people than I expected were dissatisfied with it, saying that they were more short of breath. Why?
Well, in my conversations with COPD patients I discovered that when their doctor started them on Spiriva, he or she took them off Combivent, implying that the Spiriva was completely replacing the Combivent. Remember - Combivent is actually a combination of two medicines, Atrovent (Preventer) and Albuterol (Rescuer). Aha! I can hear you right now. You're getting it! Yes, you're right - by taking away the Combivent, the doctor was actually taking away the rescue medication that many people still needed! No wonder so many of these folks felt more short of breath! As a result many people stopped taking Spiriva simply because they not only didn't understand what this new medicine was supposed to do (prevent spasms), but they didn't understand what it was NOT supposed to do (relax the spasms once they started).
What to Do?
How can you maximize the effectiveness of Spiriva and other powerful prevention and rescue medications?
- Understand not only what each med is supposed to do, but how it is supposed to do it. Ask your doctor or respiratory therapist to explain it to you. You're smart enough to understand this stuff!
- Take your preventer medicines as prescribed, day after day, even when you're breathing well.
- If you're doing all this and still have trouble breathing, you might need to take Albuterol or another medicine in the rescue category. It's alright. If you need it, you need it.
Remember the fire analogy? First of all, prevent, and hopefully you won't have to do a whole lot of rescuing. It's important for you, the COPD patient, to know - and clearly understand - which medicines are preventers and which ones are rescuers, and how they work. Once you do, you'll be much closer to controlling your breathing - and your life!
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