What’s important about Asthma?

01 Jun 2012 5 Comments

by lynnawiensmd in Asthma, Education about your ALLERGIC condition Tags: , , ,

If you’re like me, your schedule can’t take another committment–how can you add one more task for asthma?  Don’t neglect treatment for your asthma as proper attention now will save you time & money in the end.  Anyone remember the Fram oil filter commercial….”you can pay me now or pay me later?”  We’ll help you focus on what needs to be done everyday and which tasks are to be used just when needed. 

But first, how does asthma really work and why do I have it?  Review this link for “real time” photos!

 What is my hope for you by using these techniques?

1.  More activity without wheezing, coughing, or becoming short of breath

2.  No unscheduled office visits or Urgent care/emergency room visits for asthma flares

3.  Preserve your lung function for your retirement…we all love being active with our grandkids!

4.  Get you on the cheapest medicines available to prevent asthma.

So what’s most important in treatment of your asthma to avoid the top box?

1.  Get a written Asthma Action Plan…if we don’t bring it up, ask.

2.  Review your inhaler use like you would an oil change–every 3 months.  Which medicines are “everyday” and which ones are just “as needed?”

3.  Peak flow meter.  Use for 1-2 weeks as a baseline and thereafter like a thermometer for your asthma. 

Need extra help:  Click on the link to the American Academy of Allergy (AAAAI)

Are We Overreacting?

31 May 2012 Leave a Comment

by lynnawiensmd in Asthma, Newsworthy items, What's New in Medical Literature? Tags: , , , , , , ,

The Journal of Allergy and Clinical Immunology
Volume 129, Issue 5 , Pages 1280-1281, May 2012

Thanks Dr Pedersen for your insight!  The bottom line: maybe combination Advair, Symbicort, or Dulera aren’t as bad as they are put out to be. 

Over the last decade, the aims of asthma management have altered to focus on achieving and maintaining good asthma control and reducing future risks, such as decrease in lung function, asthma exacerbations, hospitalizations, death, and adverse effects from treatment.  The benefits of good asthma control include a variety of asthma outcomes that are important to both patients and society.

These include:

  • No restriction in lifestyle
  • Better physical fitness and quality of life
  • Reductions in patients’ perception of the asthma burden, health care resource use, and lower risk of exacerbations, hospitalizations, and death.

Inhaled corticosteroids (ICSs) or combination therapy with an ICS and a long-acting β2-agonist (LABA) have become established as cornerstones in guideline-recommended asthma treatment because these therapies have been the most successful in achieving asthma control and reducing future risks in the vast majority of patients with asthma. 

Changes in the goals of asthma management, as well as treatment recommendations, have revolutionized management from both the patient’s perspective and a societal perspective. The main question that remains is whether the clinical benefits balance or outweigh the risks of the treatments?

When regular ICS treatment was introduced 4 decades ago, safety concerns were common, and initially, the treatment was reserved for patients with severe disease. The concerns were based on fears generated by the side effects of oral corticosteroids rather than data generated by using ICSs, but with increasing knowledge and experience, the concerns decreased, and ICSs became a first-line therapy for asthma because the benefits of the treatment clearly outweighed the risks.  Fast foward to 2012 and our concern is overuse of combination therapy with LABAs/ICS as a risk factor for severe, albeit rare, severe asthma exacerbations. 

In this issue of the Journal of Allergy and Clinical Immunology, Wells et al add to the paucity of real-world data by reporting the findings from a large, population-based, real-world observational study comparing the effects of ICSs and fixed-dose ICS/LABA combination therapy on severe asthma exacerbations in a racially diverse population of 1828 patients with a total of 3791 person years of follow-up. Data were obtained longitudinally from a managed care organization, and LABA exposure was estimated from pharmacy data. It was found that ICS/LABA combination therapy had an overall protective effect on asthma exacerbations that was as good as or better than that for ICSs alone. The protective effects of ICS/LABA combination therapy seemed particularly marked in patients older than 18 years, male subjects, patients with moderate and severe asthma at baseline, and reassuringly, African Americans (who have been suggested to be at greater risk).

Although the study is well executed, carefully analyzed, and uses sound methodology, it was not of a sufficient size to make any firm conclusions about severe but rare asthma-related events, such as intubations, death, or both. Yet it is an important contribution to the literature on the perceived risk of serious adverse effects of LABAs. It is reassuring that the results from a carefully executed observational study, mimicking real-world study conditions, are in such good agreement with the findings in the randomized, controlled efficacy trials comparing ICS use alone with a fixed LABA/ICS combination.  In addition to significant improvements in asthma control, such studies consistently report reductions in asthma exacerbations, need for oral steroid bursts, and asthma-related emergency department visits compared with ICS treatment alone. Because such events normally precede more serious outcomes, such as intubations, death, or both, these findings make it unlikely (but do not prove) that treatment with fixed LABA/ICS combinations per se should be associated with an increased risk of these serious outcomes.

The US Food and Drug Administration has requested a series of very large postmarketing clinical trials to evaluate LABA/ICS combination safety, (see reference below) but the most serious asthma outcomes are so rare that even these studies might not be able to provide a definite conclusion. Moreover, the results from these studies will not be available until 2017 at the earliest. What should clinicians do in the meantime?

It would be a disservice to our patients if we, in the fear of doing harm to our patients, waited for the perfect. The study by Wells et al supports that a better option would be to follow the recommendations of the asthma guidelines, which unanimously have taken the stand that there is no convincing evidence that LABA/ICS combinations administered in a single inhaler are associated with serious adverse effects. Their benefits on asthma control and reduction of asthma exacerbations outweigh their risk, and we should be careful not to let the perfect become the enemy of the good.

Chowdhury BA, Seymour SM, Michele TM, Durmowicz AG, Liu D, Rosebraugh CJ. The risks and benefits of indacaterol—the FDA’s review. N Engl J Med. 2011;365:2247–2249

Steroids in Young Children–too Much of a Good Thing?

27 Feb 2012 2 Comments

by lynnawiensmd in Asthma, What's New in Medical Literature? Tags: , , , ,

 Intermittent budesonide therapy for children with recurrent wheezing 

Here’s the issue:  my doctor prescribes budesonide (or Pulmicort™) for my child’s asthma and tells me to use it EVERYDAY.  Is this really necessary?  Conventional wisdom says to use inhaled steroids or anti-inflammatory medications for asthma everyday or they don’t work well.  That attitude may now be challenged with this new study from the prestigious New England Journal of Medicine. 

That's a mouthful

This summary appears in the February issue of Journal of Clinical Allergy & Immunology.  Wow–that’s a mouthful!

Concerns over adherence and growth suppression in children with wheeze who are regularly treated with inhaled corticosteroids have prompted re-examination of some clinical guidelines by the National Heart, Lung, and Blood Institute‘s Childhood Asthma Research and Education Network. Zeiger et al (N Engl J Med 2011;365:1990-2001) compared low-dose, daily inhaled budesonide with intermittent budesonide therapy initiated at the beginning of respiratory tract infection and continued for 1 week in 278 children between the ages of 12 and 53 months with frequent, episodic wheezing at risk for asthma exacerbation.

The authors found that daily low-dose budesonide therapy did not differ significantly from the intermittent regimen with respect to the frequency of exacerbations. Although the difference in growth measures was not statistically significant between the 2 groups, they noted that the mean exposure to budesonide was greater in those undergoing the daily low-dose regimen.

Budesonide is given by nebulization as shown here

Zeiger et al commented that their findings of lack of superiority of daily low-dose budesonide to high-dose intermittent budesonide might be an important consideration in future clinical guidelines.

Lead author, Robert Zeiger, MD, PhD, at Kaiser Permanente and University of California, San Diego, gave us this comment: “Our study offers a treatment option for wheezing preschoolers. . .while the study may benefit many preschoolers who wheeze during respiratory illnesses, it did not evaluate children who have more severe disease or persistent symptoms.

Bottom line?  Maybe doctors can treat preschoolers who wheeze with intermittent inhaled steroids and avoid year-round use of budesonide.  Stay tuned.

The Prescription for Wintertime Asthma Control

23 Feb 2012 1 Comment

by lynnawiensmd in Asthma, For Physicians Only Tags: , , , , , , ,

We haven’t had much of a winter in the Midwest, but the air is still dry enough to cause “winter” asthma.  Today I would like to discuss how clinicians can provide evidence-based care for their patients with asthma by advising them on how to control asthma during the cold winter months. Today’s discussion is based on the National Asthma Education and Prevention Program’s Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.

  • Extreme temperature changes during the winter can wreak havoc on patients with asthma. Inhaling cold air, especially during physical exertion, can cause drying of the airway and bronchospasm in patients with asthma. 
  • This can result in dangerous episodes of coughing and shortness of breath. Often symptoms occur minutes after exposure.

Patients may recognize that coughing and shortness of breath are a result of exposure to cold air. However, they may not understand that there are ways for them to reduce these adverse reactions to the cold.

Educate your patients about ways to deal with their asthma in cold weather.

  • Teach your patients to shield themselves from the cold air with a scarf, turtleneck, or jacket collar. Covering one’s mouth (and nose when possible) with a scarf will help to warm the inhaled air. Warming up before exercise and cooling down for at least 10 minutes after heavy exercise by walking or stretching can also help.
  • Every use one of these for outdoor activity when it’s cold?

    pearl izumi running mask--it works!

Most important, as their physician, explain the proper use of medication. All patients with persistent asthma (patients having any asthma-related nighttime awakenings or having daytime symptoms more than twice a week) should be on a controller medication, usually an inhaled corticosteroid. These should be taken daily, not just as needed.

The controller medication can be supplemented by the use of a short-acting beta-2 agonist inhaler before any outdoor activity in cold weather. It is better, however, to control the underlying airway inflammation and reactivity with a controller medication.

And remember: This is the time of year to give your patients a flu shot. It’s not too late even in March.  People with asthma are more likely to have serious health problems from getting the flu, yet most people with asthma don’t receive a flu shot every year. Flu vaccine is the first and most important step they can take to protect themselves from the flu.

Finally, the goal of good asthma care is for your patients to be able to enjoy life with as few symptoms as possible. Partnering with your patients through scheduled follow-up care can achieve that goal. Schedule regular follow-up visits. Assess control at each visit, beginning with a standardized questionnaire. Review the patient’s written Asthma Action Plan at each visit. Ask about asthma triggers and help your patients reduce or eliminate them. Review medications and be sure your patients understand how and when to use them.

Asthma Tragedy Overseas

17 Feb 2012 6 Comments

by lynnawiensmd in Asthma, What's New in Medical Literature? Tags: , , , , , , ,

My condolences to the family of the journalist (Anthony Shadid) who died from asthma covering Syria.  Several “learning points” for those with asthma:

1.  It appears he was exposed to horses and was very allergic to this animal.  Unfortunately, allergic asthma can strike at any time, depending on exposure to the allergen.  Many children are exposed to a cat or dog at grandma’s house during the holidays and have to go to the emergency department because of sudden asthma. 

2.  Even if you have your inhalers with you, asthma can be fatal.  This is why you take “controller” medication as prevention.  Sometimes the immediate rescue inhalers just aren’t enough.

3.  Asthma isn’t the same disease in all patients.  Sudden death from asthma occurs in two forms–>the type WITH warning and the type WITHOUT warning.  If you review asthma death registries, some asthma patients have died from an exacerbation WHILE IN the hospital already. 

For the full article, click on the following link.  Please call or reply if you have any additional questions.

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