A 12 y/o asthmatic patient, who's been compliant with his therapy and under good control based on peak flow measurement at home and during his last office visit, reports to your clinic with a complaint of shortness of breath. He had been pretty well controlled on albuterol MDI alone. You added ipratroprium MDI just a couple of days ago. The patient's inhaler technique is very good as witnessed by you and the clinic nurse on his last visit. His inhalers are both almost full when tested by floating in water. He's has no other medical conditions. He is afebrile with no obvious signs of infection. He and his mother claim he has no drug allergies but is allergic to peanuts. He and his mother claim no other changes in health, environments, exposures, etc.

What may be causing this relatively sudden loss of control?

 ** THANKS to CAPT (Dr.) Barb Hoeben for the idea for this Pearl. **

Obviously, one would perform a thorough physical exam and more in-depth history. Other precipitants of loss of control would be evaluated and ruled in or out. Ipratroprium [Atrovent®] metered dose inhaler (MDI) contains an ingredient in the formulation similar to soya lecithin or food products such as soybean and peanut. Atrovent® MDI (not the nebulizer solution) is CONTRAindicated in patients with a hypersensitivity to any of these agents.

Treatment will depend on the severity of the reaction. Stopping the Atrovent® would be a good first step. Steroids, nebulized b agonists, SQ epinephrine, etc may be indicated. Long-term maintenance may now include inhaled steroids, leukotriene antagonists, etc.

Dr Hoeben asks anyone possessing a list of medications containing any type of food component(s) in them, to email it or the web address to her at Barbara.hoeben@lakenheath.af.mil.