Dr. John James, a board-certified allergist, answers top questions people have about asthma and allergy medicines.

Question: I was recently diagnosed with asthma. My allergist prescribed two inhalers. Why did they prescribe two? How do I know when to use each one?

Dr: James: This is a very important and practical question about asthma inhalers. First, ask your doctor to clearly explain the purpose of each inhaler and when and how to use them. Ask if there are any expected side effects of these medicines.

It is very likely one of these inhalers is an asthma controller medicine. It should be used regularly as directed. These controllers typically contain an inhaled steroid and may also include a long-acting bronchodilator medicine. They work very well to keep asthma symptoms to a minimum and prevent flare-ups of symptoms.

The second inhaler is very likely a quick-relief asthma medicine. It provides immediate relief of asthma symptoms, such as cough, wheeze, shortness of breath, and chest tightness. It does not provide long-term control of asthma symptoms. If you use of this type of medicine too often (i.e., more than six times a day or more than two days per week) you may have poor overall asthma control.

Question: How do I choose an over-the-counter antihistamine for allergy symptoms? Is BENADRYL® the best antihistamine to take?

Dr. James: For many years, people used diphenhydramine (known under the brand name BENADRYL®) as an antihistamine for their allergies. But for many reasons, this medicine is not a good choice to take for allergy symptoms because of its short-term action to manage symptoms and several known negative side effects. The major side effects of diphenhydramine include drowsiness, sedation, and fatigue. It can also impair alertness, concentration, multitasking, and memory. In turn, this antihistamine can affect important functions, such as learning and test performance in children, as well as operation of machinery and cars in adults.

Diphenhydramine and related short-acting antihistamines should be avoided.

Fortunately, there are many newer over-the-counter antihistamines available that work much better, are longer acting, and are safer than diphenhydramine. These newer antihistamines (such as ZYRTEC®, Allegra®, and Claritin®) are less likely to have major clinical side effects compared to older antihistamines like diphenhydramine. Also, these newer medicines do not carry the risk of toxicity and death that has been associated with older antihistamines. Finally, regarding the use of antihistamines in pregnancy, cetirizine (ZYRTEC®) and loratadine (Claritin®) are the medicines of choice.

Important note: If you are experiencing symptoms of a severe allergic reaction known as anaphylaxis, the recommended treatment is epinephrine (given via injection).

Question: Are spacers or valved holding chambers for asthma inhalers only for children, or should adults use them too?

Dr. James: Children and adults can use spacers and valved holding chambers (VHCs) with certain asthma inhalers. They tend to be used more with children, but they can also be effective in adults with asthma. Spacers/VHCs are medical devices approved by the Food and Drug Administration (FDA) and they are readily available from your doctor or pharmacist.

The purpose of using a spacer/VHC is to improve the delivery of inhaled medicines to the lower airways of your lungs. This also decreases potential side effects from asthma medicines (such as thrush and hoarseness).

Spacers or valved holding chambers are used with the type of inhalers known as metered dose inhalers or press-and-breathe inhalers. (They are not used with other types of inhalers that are activated by your breathing in.)

The speed of inspiration (how fast you breathe in) is important, so the asthma medicine is deposited into your lungs and not your mouth or throat. Instructions should be given to both children and adults using these devices. The correct use for press-and-breathe inhalers include:

1. Make sure the mouthpiece is clean and not blocked.
   
   
2. Remove the cap of the asthma inhaler, shake the inhaler 10 times, and insert the inhaler into the non-mouthpiece opening of the spacer.
   
   
3. Activate (press down) the inhaler immediately after the start of a slow deep breath and continue to inhale for 3 to 5 seconds.
   
   
4. Hold your breath for 10 seconds or as long as comfortably possible.
   
   
5. Repeat as prescribed.
   
   

Some asthma inhalers are breath activated and do not need spacers/VHCs. Check with your doctor or pharmacist regarding this issue.

It’s a good idea to have your asthma care provider show you how to use your inhaler and then watch you as you practice. With some adjustments, many people can improve their technique and get more medicine into their lungs.

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Question: Which is better – a nebulizer or an asthma inhaler?

Dr. James: The delivery of asthma medicines by the inhaler route or with a nebulizer can be equally effective if you use them correctly and as directed. First, there are many types of asthma inhaler devices that deliver medicine, including metered dose inhalers, dry powder inhalers, and breath activated inhalers. For these to work well, you must use them correctly. Your doctor should give you step-by-step instructions. Your doctor should watch you use your inhaler to assure the best technique.

A nebulizer machine turns liquid asthma medicine into a mist, which is breathed into your lungs using a mouthpiece or mask. It is also known as a breathing machine, and they are prescribed by doctors, along with the asthma medicine (solution) you use in them. Nebulizers are relatively easy to use once you learn how.

In summary, if used correctly and as directed, asthma medicines delivered by inhalers and/or nebulizers can be equally effective in managing asthma symptoms.

Question: Who should use a nebulizer?

Dr. James: Any person with asthma can use a nebulizer to deliver asthma medicine into the lungs. A nebulizer is different from an asthma inhaler. Some people with asthma prefer to use nebulizers when their asthma has flared up a lot. Other people are unable to use asthma inhalers effectively and prefer nebulizers. Most people with asthma use inhalers with or without spacer devices to administer their medicines due to ease of use, cost, and how easy they are to carry.

Question: My doctor wants me to take a biologic to treat my severe asthma. It comes in a syringe that I will have to use to inject myself at home every few weeks. How can I mentally prepare to give myself an injection?

Dr. James: Over the past several years, several injectable biologic asthma treatments have become available. These are shots or infusions given every few weeks for ongoing control of asthma symptoms that have not been well-controlled by other traditional asthma therapies. These can be given in your doctor’s office or at home using an auto-injector device with a needle, depending on the type of treatment.

Here are some tips to mentally prepare you for these injections:

1. Have your doctor’s office review and discuss any potential side effects of the biologic with you.
   
   
2. Demonstrate using with an auto-injector device in your doctor’s office. This is typically what is done with epinephrine auto-injector training devices and will assure that you know the correct steps to follow.
   
   
3. Remember that the FDA has approved the use of some of these asthma biologics by self-injection at home. The side effects are minimal, and safety has been demonstrated.
   
   
4. Understand that being able to be at home to administer the asthma treatment decreases the stress of going into your doctor’s office, sitting in the waiting room for an extended period of time, and re-scheduling visits. All these things tend to lower overall stress and anxiety by using injected asthma biologics at home.
   
   
5. If possible, have a loved one or friend be with you to help with your first injection. Or ask if your first injection can be at the doctor’s office to have them assist you with it. Once you know how it feels and works, it can be easier to do it on your own.

John M. James, MD, is a board-certified allergist. He is a medical specialist and spokesperson for the Asthma and Allergy Foundation of America. He is also President of Food Allergy Consulting and Education Services, LLC. He has worked as a medical specialist in the field of allergy, asthma, and immunology for over 30 years. Dr. James received his bachelor’s degree from the University of Arkansas and his Doctor of Medicine degree from the University of Tennessee. Dr. James completed his allergy and immunology fellowship at Johns Hopkins Hospital in Baltimore, Maryland, and he is board certified by the American Board of Allergy and Immunology.