Thursday, December 13, 2012

Milk Protein in Asthma Medications

I took my daughter to the allergist to find out about a daily asthma medication, because she is at the point of coughing every time she laughs too much, cries more than a little, or runs a few laps around the living room.  This is not good.  For a child at risk for anaphylaxis, she cannot afford to have her "baseline breathing" compromised.  If she were to have an accidental exposure/anaphylactic reaction, she would literally have less "breathing room".

The allergist prescribed a combined treatment plan of Flovent, Xopenex HFA (rescue) and Veramyst (nasal spray for allergic rhinitis).  

The only problem was, I opened the pharmacy bag with the Flovent Diskus box in it and right on the front of the package reads, "WITH LACTOSE"!  Um, excuse me?!  I open up the patient insert and it reads,
------------------------------ CONTRAINDICATIONS -----------------------
•Primary treatment of status asthmaticus or acute episodes of asthma requiring intensive measures. (4)
Severe hypersensitivity to milk proteins. (4)
...and further down...
5.6 Hypersensitivity Reactions, Including Anaphylaxis
Hypersensitivity reactions, including anaphylaxis, angioedema, urticaria, and bronchospasm, may occur after administration of FLOVENT DISKUS. There have been reports of anaphylactic reactions in patients with severe milk protein allergy; therefore, patients with severe milk protein allergy should not take FLOVENT DISKUS [see Contraindications (4)]. 

Now, the seed was planted in my brain to look out for this, because I had read a Facebook post from a fellow blogger (please forgive me, as I cannot recall who it was - Allergic Child? The Eczema Company?) about unexpected sources of allergens in medications, so I can't say I was entirely surprised that an asthma medication contained lactose/milk ingredients, but I was flabbergasted that it had been prescribed to my milk allergic daughter!

I called the office back and told them that I could not use this medication and asked if they could find another one that did not contain lactose or any milk ingredients.  They told me they found one, but when I went to pick it up, it was a version of Pulmicort that also had lactose, so I sat in the waiting room and they brought me a sample of a medication called Qvar to take home and try.  The insert reads that it's for children ages 5 and up, and my daughter is only 4 years old, so my search is still underway for an appropriate medication.
(Update:  I spoke with both a friend who is a respiratory therapist and my daughter's pediatrician, and they both agree that Qvar would be safe and effective, even for a 4-year-old.)

Back to the milk protein issue, though.  Why would an allergist prescribe the Flovent Diskus to a milk allergic patient?  I went to do some research, and though I have not spoken directly with the allergist about this, it might be because she was convinced that it was not a great risk.  I must disagree, however.  My entire reason for going on this medication, was to strengthen my daughter's lungs, just in case she were to come in contact with a trace of her anaphylaxis risks (like, hmm, milk!).  It makes absolutely no sense to spin a dangerous "Wheel of Chance" every morning and every evening, with my daughter taking a puff of an inhaler filled with powder, laced with lactose, that just might possibly have enough milk protein (since the puffs are not uniform) to cause a reaction.

Here's a page from the American Academy of Allergy, Asthma & Immunology that I found on the subject:

It's a long article, and at first it seems like they are downplaying the risks, but here is what I believe to be the pertinent part for those with severe milk allergies:  (my yellow highlights are added for emphasis)

Q: Some inhaled asthma medications (Pulmicort, Advair) contain small amounts of lactose and possibly small amounts of milk proteins. Is there a real danger here for milk-allergic patients, or does it seem to be more of a theoretical concern? Thank you very much.
For many years we had advised patients that "pharmaceutical grade" lactose was devoid of milk proteins. In retrospect, perhaps no one was looking because patients had not been reporting reactions. However, occasional reactions have been noted, for example in a severely milk-allergic asthmatic patient of the late Gail Shapiro, MD who used a dry powder inhaler containing lactose. Testing of various lactose-containing DPIs (Nowak-Wegrzyn et al JACI 2004) indeed disclosed presence of trace quantities of milk protein. The exact amount was not determined, but there is a notion that lot to lot variability exists. Additionally, the amount of lactose delivered varies by device (e.g., some routinely deliver more of the lactose carrier per inhalation). The package inserts of the DPIs are now typically commenting upon their containing milk protein (associated with the lactose carrier). The product insert I viewed online for the type mentioned here (Flexhaler) did mention milk protein in a parenthetical statement associated with "lactose". Of note, the allergic response would be directed to residual milk proteins (the lactose is derived from skim milk) and not to the milk sugar itself.
As with any food allergy, individuals may have a particular reaction threshold (for example, not everyone reacts to trace amounts). It is probably the case that the trace amount in the inhaler would not trigger a noticeable reaction for most with a milk allergy. However, it has been hypothesized that inhalation of a trace amount may be more likely to cause some reaction (e.g., the respiratory mucosal route having a more direct response and leading to asthma reactions) than if the same amount were eaten (affected by digestion).
We do not have a strong understanding of the extent of contamination in various lactose containing products. There is a study of a lactose containing soy formula where no milk-allergic children reacted and the investigators could not detect residual milk proteins (Fiocchi et al Pediatrics 2003).
As an aside, about 75% of children like the one described here tolerate a small amount of milk baked into a bakery product (e.g., cookies) even though they do not tolerate whole milk proteins (e.g., cheese, milk, yogurt) presumably because the bakery product has less protein and the heating in a airy environment further alters the allergens. Unfortunately, there is no easy way to know who may have this level of tolerance (no accurate skin or serum tests) and we have seen children have anaphylaxis to milk in baked goods.
Though this child described may qualify as one unlikely to react to the trace (if any) residual milk protein in the DPI (basing this assumption on the observation that he tolerated milk in baked goods), and certainly risk/benefit plays a part in decision-making, it seems reasonable to use an equally effective treatment without this additional concern. I am not aware of a DPI that has lactose and has been proven NOT to have potential milk contamination.
Scott H. Sicherer, MD
Associate Professor of Pediatrics
Jaffe Food Allergy Institute
Mount Sinai School of Medicine
Now, I must add that the decision to completely avoid lactose-containing asthma medications is based on my daughter's specific level of milk allergy.  She has a history of reactions to baked milk, so she's not one of those with a "mild milk allergy".  I understand that her anaphylaxis risk lies in the milk protein and not in the lactose, but they cannot guarantee me that there will not be traces and it would be too great a risk for her to possibly inhale a trace of one of her top allergens straight into her lungs.  The thought of it makes me dizzy.  

Sometimes, I think they don't pay as much attention, because it's a milk protein.  Imagine if a doctor prescribed an asthma inhaler that doesn't contain peanuts, but is made with an ingredient that just might contain trace amounts of peanut dust/protein.  Would they better understand my apprehension, then?  Would they see why I don't want my daughter taking her chances morning and night, breathing that in?

The bottom line is that you need to be ever-vigilant, even when something is prescribed to you by a physician.  Read every label on everything...check, check, and check, again.  We have to stay on top of things, because doctors are so busy these days and are many seem to be on auto-pilot, prescribing the same medications day-in, and day-out, without deep thought put into the fine details of the patient's history.  We are the ones who know our children's history best.  

As always, I share this information to help you in making your own decisions, but hey, don't even trust me!  You will always have to do your own research and look into yours/your child's specific medical needs and consult with a physician and use every resource you can gather to hopefully come up with just the right plan to keep everyone healthy and happy. :)    

Edited to add:  Here is a story shared on Allergic Living's Facebook page, about peanut oil in ear drops.  


  1. Most of the diskus inhalers have lactose in them. Flovent is also available as a metered-dose inhaler that does not have any lactose. My daughter has been using it for years.

  2. I think it was me. I remember being horrified that some of the inhalers had traces of corn, an allergy for my son. We gave it to him before we knew this and sure enough, he reacted, although not severely - thank goodness. We switched to another brand, which he's been fine with.

    Can't believe Flovent would add lactose - so strange.

    1. That's what I was thinking, but I looked back through pages and pages of Facebook posts and couldn't find it, sorry! I've said it before and I'll say it, again - medication should be labeled just like food, according to FALCPA. I also think FALCPA should be expanded to include corn, sesame and mustard!

    2. *basically anything under the FDA wing...cosmetics, shampoo, soap, etc...

  3. Hi Selena. You may have originally read this article by Karen of Avoiding Allergens: or this one she wrote about hidden milk protein: Thank you for writing a great article that informs us all. Best ~ Elizabeth Goldenberg, Onespot Allergy

  4. Oh My God!!! My son has just been perscribed some asthma medication in Australia and after reading your article I decided to double check our medications.... IT CONTAINS LACTOSE! It specifically says not to use it if allergic to milk protein... He's anaphylactic! I cannot believe our doctor and the pharmacist agreed to this... I actually asked the pharmacist, and they wrote down my concern... seriously! I am so mad!! Just rang the doctor, and all her options were lactose containing too...

  5. Hello, Elizabeth! I think I had seen that one about the general notion of medications having milk protein or lactose, but the one I was trying to remember, actually listed out specific asthma medications by name. All of those great websites helped to plant those seeds in my brain, though, and I am thankful for them all! :)

  6. Looking for info on milk derivatives in xopenex HFA aerosol inhaler. My daughter is ana to dairy with off the charts IgE levels. We have experienced anaphylaxis from pulmicort flexhaler. You are not crazy. Almost everytime something is prescribed, we have to go back to the drawing board. Doctors are very uneducated on inactive ingredients. Even the specialists.

  7. I am so sorry that happened to your daughter! As far as I know, most of the (metered dose inhalers) MDIs, like the Xopenex HFA inhaler, do not have lactose or milk proteins. My daughter uses the Xopenex HFA as her rescue inhaler. Here is a link to the prescribing information, which has no mention of lactose nor milk protein:

    It's the dry powder inhalers that typically contain the lactose, but of course we have to check every medication, every time! Right now, my daughter is also on Qvar, which is also an MDI and it does not contain milk proteins. It's a daily maintenance medication.

  8. Grace - I am SO sorry, your comment slipped through the cracks. I am also sorry the same has happened to you, but I am glad my post helped you discover the error! It also took a few rounds before the allergist's office came up with a safe option for my daughter. She is currently on Qvar. I agree that the options are narrowed by this problem, for those of us with milk-allergic children.

  9. Lactose isn't a protein, it's a sugar. Caseins are the proteins found in milk, so I think it's important to distinguish between a milk intolerance (to lactose) and a true Ig-E mediated allergic reaction to milk PROTEINS which can be life-threatening. The last one is VERY rare.

    1. Jen - Yes, I addressed that distinction in my post: "I understand that her anaphylaxis risk lies in the milk protein and not in the lactose, but they cannot guarantee me that there will not be traces and it would be too great a risk for her to possibly inhale a trace of one of her top allergens straight into her lungs." It might be rare, with estimates of prevalence in around 1-2% of children in the U.S., but my blog is geared towards the population of people with anaphylactic food allergies, so it's a very important issue for us.

  10. Recently had the same issue when prescribed Advair - will stick to Flovent MDI!
    Thank you for all your comments, I never reply to these threads but it's been a rough go with my daughter's 'reactive airway' and glad to know I'm not alone.
    Jen, we all understand the difference between a lactose intolerance and Ig-E mediated reaction - we live daily with fear for our milk-protein allergic children in a dairy-obsessed society. I would love it if she were merely lactose intolerant.
    Thanks all

  11. So glad you have posted this, as we ran across this issue last year. And now the insurance company will no longer cover Flovent inhaler (not diskus, as above). QVAR is one of the alternatives, and though I didn't see lactose as an ingredient on their prescribing information, it helps me to see it confirmed by an advocate. My son is milk allergic and also allergic to baked milk. He never outgrew it. Thanks again!

  12. Found this article that also helped me with regard to severe dairy or cow's milk allergies and asthma inhalers:
    A quote from the article: "Pharmaceutical grade lactose contains small amounts of milk protein."
    Years later this discussion is still relevant so thank you, Selena, for your post!