Dr. Kaushal Bhavsar
Pulmonology (Asthma Doctors)
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
My son has reactive airway since he was young. He has no asthma but allergic asthma. He has been tested. He passes all tests from his allergist and he does have allergies. He takes Zyrtec. He had an allergy-related cough and it has been treated for almost one month now with the medication Trelegy, Budesonide with Albuterol, and Zyrtec. When his nose gets clogged he takes Sudafed. Occasionally the doctor asks him to take Mucinex D. He feels well and doing well however, the cough is still lingering even with all the medications. His allergist and pediatrician say he is fine and this can linger. With that said we are anxious and awaiting an appointment with a pediatric pulmonologist just to confirm all is good. He has had X-rays and tests and all were negative. Please let me know your thoughts.
Hello,
Welcome to icliniq.com.
I can understand your concern. If all reports are normal then the possibility of bronchitis is more likely. Do you have any breathing difficulty or wheezing sound from your chest? Have you done any CT scans of the lungs? Please reply with answers to the above-asked questions so that I can guide you better.
Thank you.
Patient's Query
Hello doctor,
He has had the spiro test and pulmonary test. He had allergy-related asthma but not regular asthma, which is confusing to me. However, his lung function is excellent. He had a chest X-ray, which was negative.
Hello,
Welcome back to icliniq.com.
Thank you for your follow-up question. In my opinion, if the chest X-ray is normal and the patient is symptomatic then he should definitely get a CT scan of the thorax because sometimes a chest X-ray can be false negative. So for screening purposes, I will suggest getting a CT scan of the thorax. Is there any family history of allergy or asthma? Is there passive smoking possible? In spirometry, did he undergo a bronchodilator reversibility test?
Thank you.
Patient's Query
Hello doctor,
There is no family history. We did a pulmonary function test and it was perfect. They tested for all bacteria and RSV and it came back negative. His allergist says he is in perfect health and his pediatrician as well. He is having us do a blood test next week and we are awaiting an appointment with a pediatric pulmonologist since me and his mother are concerned. However, he does not seem concerned and says the cough can flare up with his reactive airway for many reasons especially allergies which he has. We asked for a CT scan however his allergist does not think it is necessary. We are just concerned because he still has a cough for about five weeks now. The cough did subside during the past two weeks and was minimal but then he got a cold and it came back. So we have him on all medications again. I am thinking it came back because of the cold however not sure if he should go on antibiotics at this point. We contacted both doctors today and they said if he does not have a fever or present any other symptoms than cough to begin medicines again. He also was given a Prednisone dose three weeks ago on top of all this and now having issues again. As mentioned he had a cold last week so maybe it irritated the airway again. Do you agree with the medications he is on or have any suggestions for changes or additions? More than anything can cough longer and be around this long. It has been five weeks on and off. Please let me know.
Hello,
Welcome back to icliniq.com.
No, it is not normal for any cough to stay this long. In children most likely cause for chronic cough is allergies. The second most common cause is infection. But since all infection reports are negative, no fever no need to worry about infection, and hence no role of antibiotics. In my opinion, you should start Montelukast with Levocetirizine combination as this is having a good effect on allergic cough. Does he have a dry cough or it is a wet cough? Does it occur more at night? Has his IgE level checked? Any discussion about Montelukast (anti-allergic) from the doctor's side?
Thank you.
Patient's Query
Hello doctor,
He said Trelegy is better and stronger and Zyrtec is better.
Hello,
Welcome back to icliniq.com.
Trelegy (fluticasone furoate) is an inhaler. It is different than montelukast. Zyrtec is antihistamine drug. It is different than Montelukast. A combination of anti-histamine (Levocetirizine or Fexofenadine) and anti-allergic (Montelukast) is better than anti-histamine alone. If not tried it before, he should definitely try Allegra M (Montelukast plus Fexofenadine). What about IgE? Does he gargles after inhaler use?
Thank you.
Patient's Query
Hello doctor,
He does gargle when done every time he uses the inhaler. Do you feel Singulair with Allegra or Zyrtec which one of the antihistamines is better in combination with Singulair and why so? I think his allergist did an IgE test and it was normal but will check today for sure. Also, Trelegy does not work the same as Singulair. Please let me know how they are different in what they target. The doctor told us Trelegy is stronger than Singulair so we thought they were similar but if Singulair works in a way that targets the area he needs we must speak to him about changing. I just want to know the difference so we can discuss it with his allergist and have knowledge prior to seeing him again.
Hello,
Welcome back to icliniq.com.
Zyrtec is Cetrizine. It is an older antihistamine. It can cause sedation. Allegra is taking Fexofenadine. It is a newer antihistamine and has very little sedation. Fexofenadine is more efficient and potent than Cetrizine. So, Singulair (Montelukast) is better with Fexofenadine (Allegra). Trelegy is an inhaler. It is basically for asthma. It usually works well when PFT, spirometry is abnormal. Sometimes it can cause more coughing because of fluticasone (inhaled corticosteroid) in a Trelegy inhaler. Fluticasone can stick to the throat and cause irritation. So if PFT is normal then I do not think Trelegy will work. Have you noticed if his cough worsens after Trelegy?
Thank you.
Patient's Query
Hello doctor,
The only last question is on Singulair. It shows it has issues with side effects regarding mood and suicidal thoughts that peaked in 2020 causing major concerns. Has that been resolved, it is still prescribed and recommended. Are there any other alternatives that are similar with fewer side effects?
Hello,
Welcome back to icliniq.com.
These are very rare side effects. I have been using this medicine with a combination of Levocetirizine or Fexofenadine for years. Many patients have been taking it once a day for years but none of them is showing any such side effects. So I will consider this drug as safe for long-term use. The other one is Sodium chromoglycate. But it is not as popular as Montelukast. I hope I have solved your query. I will be happy to help you further. Wishing him good health.
Thank you.
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Pulmonology (Asthma Doctors)
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