Rule of 2’s and symptom control

Hi all,

Have you all ever chatted with your docs about what level of symptom control to expect with mild, moderate or severe asthma and how this relates to the rules of 2? Since starting triple therapy and azithromycin my symptoms have improved greatly (previously woke up every night and was symptomatic everyday) but still am not well controlled. 

Just last night I was looking at other adjuncts like theophylline or cromolyn, and thought to myself is it worth looking for other treatments to ask about, or is this as good as it gets for some of us? 

Thanks for your thoughts! 

Best, Em


Comments 6

  • Shea

    Hi Em! You always have good thoughts to ponder. I have tried different meds and found some I like better than others, and some good for a certain period of time, but then switched later on to a different med and routine. The big picture of my disease has improved, but progress from day to day has always been harder to see.

    I think you have come a long way too, and that you still can improve symptom control. We all can. Maybe by new medicines, maybe by getting better at avoiding triggers, maybe by adjusting action plans, and knowing when to do what and how much. I think in general, people get better over time, but it isnt from the passage of time alone, it is by observation, tests, trying new things, and learning from both successes and failures. And it is OK to make changes, it is also OK to seek comfort and stability where you are at… And we can just listen to ourselves to find out when to do which. 

  • Emelina

    Thanks for your insights and wisdom Shea. I was thinking last night and a bunch of my recent attacks have been triggered by cold air, pollen, poor air quality or GERD. So I’ll go back to the drawing board and think about ways to empty my bucket. Our lung diseases are tough! Taking the pill is the easy part … the tricky part is avoidance and lifestyle changes. Thank you!

  • Wheezy Me

    Well said, Shea!

    I agree. Generally we should aim to be well controlled, as much as possible, both for our relief and to prevent airway damage (such as permanent scarring) from chronic inflammation. I think if you still wake up at night, or have frequent symptoms, then generally yes- you should adjust your treatment. (Maybe higher doses of the same inhalers? Biologicals?)

    Sometimes it's OK to decide it's "as good as it gets", mainly if what causes you trouble is avoidable (strenuous exercise, specific scents). But not if it causes frequent or constant symptoms, for the reasons above.

  • dory2005

    Em, I was on theophylline for 30+ years (started when I was 13), and my pulmo discontinued it when I was hospitalized two years ago. It wasn't helping anymore, and it exacerbated my tachycardia. Because I had been on it for so long, I was nervous about stopping it, but I didn't notice any difference in terms of asthma control. I did notice that I didn't have nearly as many palpitations, which was nice. It worked for many years for me, especially in my 20s and 30s, but once I hit 40, it didn't seem to help at all. I still take zafirlukast twice a day, and it does help me. Also, I'm sure you know that with theophylline, you have to get labs done every 3-6 months to make sure that you aren't developing toxicity. It was a good choice for me for many years, so it's definitely something to discuss with your pulmo. Good luck! 

  • Js706

    I LOVE my oral theophylline, although I'm not fully controlled with it and the other bits and bobs it was the first drug I was put on that made a significant difference in symptoms! It can cause some pretty nasty effects if you become toxic on it so some docs don't like it but as long as they check your levels fairly often and you know what symptoms to look out for its generally fine. Also if you decide to ask about it and try it, make sure they start you on a low dose and titrate up slowly with regular levels being checked. And some people have side effects when starting that do settle after a bit.

    I also would maybe recommend asking about something like a sodium cromoglicate inhaler if you have a fair few allergic triggers (just looked and saw that's the cromolyn you mentioned). I got started on it a few weeks ago and I've definitely noticed that my airways are much less twitchy with the high pollen that's around at the moment (and I'm still getting pretty bad general hayfever symptoms so it must be the inhaler making the difference!!). Also from what I remember when I looked at the leaflet that came with it there are many nasty side effects to worry about – and certainly all I've noticed is that it tastes a bit gross! 

  • K8sMom2002

    Good points about different medications working differently for different people — and differently at various points in your life. My mom was on theophylline, but she eventually needed other meds to control things. 

    I'm with Shea on figuring out how to avoid stirring things up to begin with. I know I've shared this before, but my doctor has a way of looking at managing asthma that really makes sense to me.

    She sees asthma like a boulder on a cliff's edge …

    If it stays on that cliff's edge, then it doesn't take much of a nudge to tumble it on over. 

    But if you can roll it back downhill even a little, then it takes more of a shove to push it over. 

    Her approach is to find all the low-hanging fruit to push it back, inch by inch, from that cliff's edge. 

    Different people will find different ways of moving that boulder back. For some, especially if you're dealing with uncontrolled asthma, it's going to take a combination of medications to get you back under control.

    But for everyone, simple steps can make a huge difference:

    • getting the flu vaccine and the pneumococcal vaccine
    • improving your indoor air quality
      • if you have allergies to or , making sure your humidity is regulated is a must
    •  pre-treating before strenuous activity if exercise is a trigger
    • avoiding known triggers like bad air quality or tobacco smoke or other types of triggers
    • working to improve other illnesses or disorders you may have that could be contributing:
      • GERD
      • VCD
    • following your "sick plan" to make sure your asthma doesn't flare when you get an upper respiratory infection
    • washing hands and avoiding people who are sick

    Doing all of those things helped me get my asthma back under control — at least for now.

    We all know that you can do everything in your power, and sometimes asthma seems to have a mind of its own. But I like to think, during those times, "Gosh, how much worse would my asthma be if I weren't minding my p's and q's?"