Dr. Amol Kumar Wasudeorao Diwan
Allergy Specialist
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Patient's Query
Hello doctor,
My mother is 62 years old. She is a diabetic on OHA and under good glycemic control. She weighs about 123.46 pounds. She is suffering from a dry cough for four months now. The chest X-ray is normal and the ENT consultation also ruled out any local cause. She complained of a tickling sensation and coughs following it. Coughing even wakes her from sleep at night. Blood investigations done had all findings within normal limits except for a high eosinophil count. Spirometry was done with the following results: % values pre-inhalation are: FVC 60.47 FEV1 63.18 FEV1/FVC 113 PEF 68.89FEF (25-75) 59.25. % values after inhalation: FVC 70.60 FEV1 71.72 FEV1/FVC 110 PEF 70.7 FEF (25-75) 54.43. After this, the treatment was started with a diagnosis of moderate restrictive and obstructive lung disease. She is currently on Budamate 200 trans caps one in the morning through Lupihaler. Budate 200 and Triohale Rotacap one cap each through inhaler at night, tablet AB Phylline one tablet daily in the night. But, her symptoms improve intermittently and again recur spontaneously.
Kindly suggest what to do.
Hello,
Welcome to icliniq.com. I have seen the PFT (pulmonary function test) report of your mother. (attachment removed to protect patient identity). Let me tell you first that the PFT test is not done properly as the post-test is done immediately only after four minutes of the pre-test. Ideally, we do it after 15 minutes. So we cannot rely on this PFT report. Even if we see the report, it shows moderate obstruction and no bronchodilator reversibility. So it goes more in favor of COPD (chronic obstructive pulmonary disease). The treatment of COPD is mainly bronchodilator drugs by inhaler route. So I suggest stopping Budamate, Budate, and Triohale Rotacaps. Start Foracort inhaler (400) with Zerostat spacer two puffs twice daily morning and evening, and Duova inhaler with spacer two puffs only in the morning. Continue tablet AB Phyllin 200 one tablet daily. If she feels too breathless after any type of exertion she can take, a Duolin inhaler by spacer two puffs as required. Strict sugar control is advised.
I hope this helps.
Patient's Query
Hello doctor,
Thank you for your reply.
But, why change the inhaler when both have the same composition of Budesonide and Formoterol? Triohale additionally has Ipratropium bromide and my mother reported improvement when Triohale was added to the regime. I am a medico and need your guidance on her. I am apprehensive about starting OCS to avoid the long-term sequelae owing to her DM and history of hysterectomy. So, as you have mentioned two puffs of the drugs. So, should I increase the dose to two caps twice daily? To add to the history she recently complains of thick dry bits of mucus plugs to cough out when she has to wake up at night due to cough. But, the strange thing is she has zero history of any dyspnea.
Kindly guide me.
Hello,
Welcome back to icliniq.com.
I changed the inhaler because even though it contains the same medicines, the dose is different. Also, she does not need a triple-drug combination at this stage. So if she becomes dyspneic and has a lot of breathlessness we should reserve a triple-drug combination for future use. At this stage, she needs just Foracort 400 and Duova inhaler by a spacer to ensure adequate drug delivery. With Rotacap use, we cannot rely on the actual delivered dose if the patient effect is not good. But with the inhaler and spacer patient does not need extra effort to take medicine into the airways. Just she has to breathe normally into the spacer.
I will not advise oral steroids at this stage as she is not that breathless. Might be she is also having a history of allergy to anything which provokes cough. Hence, she is bringing out that excess cough. Also, the tablet Ab phylline is mucolytic and aids in removing cough from the airways. So it is nothing to worry about. It is better to cough out excess mucus from the airway. So just continue two inhalers and that is the thing she needs for the time being.
Thank you.
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Allergy Specialist
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