Believe it or not the pollen season is just around the corner–6 weeks to be exact.
I had the privilege this week of watching my favorite sport….10 players dribbling an inflated ball up & down a court, trying to throw it through a steel hoop more times than the opposing team. Yeah, it’s my passion. The Thunder vs Bobcats and Oral Roberts University vs the Sooners of Oklahoma. (little in state rivalry) What impressed me about the current state of basketball is how fast any human 6 ft 8 inches tall can get up and down the court! As a devout Kansas Jayhawk fan growing up, we (of course I’m part of the team!) had some good exhibits, but never with the agility, speed, and shooting accuracy seen today. Regardless of better nutrition, year round practice schedules, and the 3-point shot, we all practice to get better. I didn’t realize that despite many alternatives to oral steroids, our use of a “quick fix” is increasing. Is that why we call this the “practice of medicine?”
I report here a study published barely one month ago on the use of steroids for treating many medical conditions. Our approach to steroids (by mouth) is to use them when necessary, but substitute with inhaled steroids or other alternatives whenever possible. Why? Side effects. In fact, did you know that based on systemic absorption, a 5 day “burst” of oral steroids is equal to 20 years of the inhaled route? Based on this poster presentation, it would seem that we need more practice in reducing the use of steroids, especially in children! My recommendations:
American College of Allergy, Asthma & Immunology (ACAAI) 2012 Annual Scientific Meeting: Abstract P313. Presented November 11, 2012.
The number of prescriptions for prednisone has been increasing steadily since 2000 in the United States, and not all prescriptions are appropriate, researchers reported in a poster session here at the American College of Allergy, Asthma & Immunology 2012 Annual Scientific Meeting.
“I have been in residency for the past 3 and a half years, and was surprised at the amount of steroids being prescribed and the diseases they were being prescribed for,” Tricia Lee, MD, 2012 chief resident in internal medicine and pediatrics at the University of Louisville in Kentucky, told Medscape Medical News.
“This impressed me because we are taught in medical school about all of the significant side effects of systemic steroids, which include weight gain, thinning of skin, psychiatric changes, and adrenal suppression. I wanted to see if we, as physicians, were truly prescribing more prednisone now than we were a few years ago,” Dr. Lee explained.
She and her group examined data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey databases, which were collected by the Centers for Disease Control and Prevention, from 2000 to 2009.
During that time, 11 billion visits were recorded in the 2 databases. Prednisone was prescribed in 178,655,280 visits for any diagnosis — an increase of 17% for all ages.
For adults, prednisone was prescribed 13% more frequently in 2009 than it was in 2000; for children, it was prescribed 38% more frequently, Dr. Lee said.
Diagnoses Associated With Prednisone Prescription
More than 1000 different primary diagnoses were associated with a prescription for prednisone. Asthma, allergy, bronchitis, rheumatoid arthritis, urticaria, contact dermatitis, acute upper respiratory infections, and pneumonia accounted for the majority of prescriptions.
For allergic rhinitis, prednisone prescriptions increased from 1.9% in 2000 to 2.2% in 2009, Dr. Lee noted.
“The worry is that a patient will go to one doctor to get a prescription for prednisone for his rheumatoid arthritis, go to another to get prednisone for a pain in his shoulder, go to another to get a prescription for his asthma, and so on, until he is taking a dangerous amount of prednisone, without all of his doctors being aware,” Dr. Lee said.
“The danger to the patient is that, in the span of a few months, they may be exposed to steroids for a chronic period,” she said.
Emergency Department Implicated
John Oppenheimer, MD, clinical professor of medicine at the New Jersey Medical School in Newark, was asked by Medscape Medical News to comment on the study. “This abstract highlights a significant rise in the use of prednisone, specifically in the emergency department setting,” he said.
He added that “in the case of allergic respiratory illness, this is overall the most effective therapy; however, as pointed out by Dr. Lee and her colleagues, it is not without side effects.”
Dr. Oppenheimer called this increase in the use of prednisone “alarming.”
“The authors postulate that this is the result of a lack of appreciation of potential side effects. However, one may also argue that this is the sequel to the undertreatment in a proactive approach of the underlying illness.”
I always enjoy National Medical Meetings….good food, meeting old friends, and yes, even learning something! The College of Allergy annual meeting was held in California just one week ago……and what are the hot topics this year?
Here’s an article and interview from Medscape about this year’s meeting. Why am I interested? Dr. Portnoy was my mentor (professor) during my fellowship training in allergy. Way to go Jay!
Here’s what he had to say–This international food allergy conference features the latest on eosinophilic esophagitis, unusual and “off the beaten track” food allergies, spice allergies, and developments in food immunotherapy.
“Food allergy is always something that people are interested in,” Jay Portnoy, MD, professor of pediatrics at the University of Missouri, Kansas City, and Mercy Children’s Hospital, told Medscape Medical News.
Dr. Portnoy, who chaired this year’s abstract committee, highlighted a few of the presentations on food allergy that he considers particularly noteworthy.
“Researchers at Northwestern University in Chicago have found that kids with egg and milk allergy are more likely to outgrow those allergies than if they have tree nut or shellfish allergy. So when the doctor says your child will probably outgrow their egg or milk allergy, they’re not too far off,” he said.
Another study examines how people who are allergic to hen eggs might be able to tolerate them when they are baked. “It turns out that baking the egg actually denatures or neutralizes the allergen, more so than if you just partially cook it. If you introduce cakes and cookies into your diet, you will be able to most likely broaden your diet and improve the quality of your life,” he said.
One presentation of definite note is on a newly identified and possibly life-threatening allergic reaction to mammalian meat. Researchers have determined that the lone star tick is the primary reason for meat-induced alpha-gal allergic reactions.
“This new food allergy, alpha-gal, is more common than we thought. There is a high prevalence in some areas of the country, particularly in the central and southern regions of the United States,” Dr. Portnoy explained.
Alpha-gal is a sugar found in red meats such as beef, pork, and lamb. In the study to be presented, positive alpha-gal rates were 32% higher in areas with a lone star tick population than in other areas of the United States.
Symptoms of alpha-gal allergic reactions range from mild hives to potentially life-threatening anaphylaxis.
“The reaction is delayed. A lot of people have experienced this, and now we know what it is. This is why it is so important to come to the annual meeting and learn about these unusual allergic reactions,” he said.
The topic of spice allergies is also on the meeting agenda.
According to a statement issued by the ACAAI, spices are one of the most widely used products, and are found in foods, cosmetics, and dental products. The US Food and Drug Administration does not regulate spices, which means that they are often not noted on food labels.
As a result, they are one of the most difficult allergens to identify and avoid.
“While spice allergy seems to be rare, with the constantly increasing use of spices in the American diet and a variety of cosmetics, we anticipate that more and more Americans will develop this allergy,” said Sami Bahna, MD, DrPH, from the Louisiana State University Health Sciences Center in Shreveport.
“Food allergy is a very important topic for allergists because we need to understand the most current research; recently, the field has seen a lot of changes,” ACAAI President Stanley Fineman, MD, from the Atlanta Allergy and Asthma Clinic in Georgia, told Medscape Medical News.
“There is a lot of new understanding about food allergies, new diagnostic tools, and some potential treatments,” he said. “This is the place to find out the latest information; when you go back to your practice, you [will] be on the cutting edge.”
Back by popular demand is the annual literature review course, where experts present what they feel are the key articles of the year on topics such as immunology, allergic rhinitis, ocular allergies, and immunology. “We have almost 500 people already registered for this program. Some people look forward to this program all year long to catch up on the literature. It’s a very popular feature of the meeting,” Dr. Fineman said.
The slogan for this year’s meeting is “Over the Horizon: Expanding Expertise,” which captures the essence of what the conference is about, he noted.
“The program committee selected this theme to help us see what is going on in the future, to expand our expertise, to make sure that we are able to keep current, and to hone our skills so we can adapt to any changes in healthcare and any new research involved with treating our patients,” Dr. Fineman explained.
“Most allergists go to the meeting to find out what’s new in allergy, to keep their skills up, to interact with colleagues, and to validate what they do. Because, like most allergists and most physicians, if you are in practice and you don’t interact with other physicians, you can start to develop quirky styles of practice that may not be the best practices. It’s really a good idea to touch base with colleagues, interact, and hone your skills,” Dr. Portnoy added.
“At this meeting, allergists will hear about an unusual case and then remember a patient who had the same thing. That’s how advances in our field are made,” he said.
I could say it better. With all the controversy swirling around health care reform, it’s refreshing to learn about what really matters for taking care of patients….that’s why I keep going to work every day!
Tomorrow starts the American Academy of Allergy, Asthma, & Immunology national meeting in Orlando. Great fun and food, but more importantly, great new information about allergy. If you watch the news at all, you’re bound to hear about natural products for your health. Organic anyone?
Read this blog about a patient who only THOUGHT she had allergy; it was really volatile organic compounds (VOC) causing her symptoms of sneezing and nasal irritation that made her think she had allergies.
Case reports like Mary’s are helpful to instruct allergists in the best treatment methods for our patients with rhinitis. Sometimes it’s allergic and sometimes it isn’t.
Take the following report for instance:
They may smell sweet, but popular air fresheners can cause serious lung problems.
That’s the message from a new study presented at the annual meeting of the American College of Allergy, Asthma and Immunology (ACAAI). Home fragrance products often contain volatile organic compounds (VOCs) that include such nasty chemicals as formalehyde, petroleum distillates, limonene, esters and alcohols. (Download a copy of the presentation here)
Exposures to such VOCs — even at levels below currently accepted safety recommendations — can increase the risk of asthma in kids. That’s because VOCs can trigger eye and respiratory tract irritation, headaches and dizziness, as Dr. Stanley Fineman, ACAAI president-elect, pointed out:
This is a much bigger problem than people realize. About 20 percent of the population and 34 percent of people with asthma report health problems from air fresheners. We know air freshener fragrances can trigger allergy symptoms, aggravate existing allergies and worsen asthma.
And if you hope that “all-natural” fragrance products can give you a nice scent without the chemicals, Fineman has bad news for you — even products marketed as organic tend to have hazardous chemicals. That shouldn’t be surprising since fragrance products don’t eliminate bad smells; they just cover them up, and that usually requires something strong.
Fineman suggests that you’d be better off simply opening up your window and letting fresh air in — though that advice might not work well where I live. OK, I get it!
The study also gives some much-needed attention to the problem of indoor air pollution. While air freshener-related asthma is certainly a health hindrance in the developed world — at least among those who like to live in artificially sweet-smelling homes — indoor air pollution is a major health catastrophe for much of the developing world, one that leads to the premature deaths of nearly 2 million people a year according to the World Health Organization. The majority of those affected are very poor women and children who might spent hours cooking food over a wood-burning fire in a hut with little ventilation.
To read more about indoor air pollution and how to avoid it, see: http://healthland.time.com/2011/11/08/why-air-fresheners-can-trigger-respiratory-problems/#ixzz1dnQJp6cD
I have trouble getting patients to use ONE much less TWO nasal sprays for nasal allergy & congestion. Now I may have a solution this year. The buzz on the street is Meda pharmacueticals
will be introducing a nasal spray product with two ingredients for patients suffering from congestion, runny nose and sneezing. Yes, for what ails you!
I’ll give you some tidbits from the College of Allergy/Asthma/Immunology meeting this past fall about this new medication.
November 16, 2011 (Boston, Massachusetts) — A novel nasal-spray formulation that combines the intranasal antihistamine azelastine with the intranasal corticosteroid fluticasone provides greater pharmacotherapeutic benefits for the treatment of seasonal allergic rhinitis than either of these agents alone, according to a study presented during an oral session here at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting.
“There are many patients with moderate or severe allergic rhinitis whose symptoms are not adequately controlled with the currently available pharmacological agents,” Eli O. Meltzer, from the Allergy and Asthma Medical Group and Research Center in San Diego, California, told Medscape Medical News. “Because of their morbidity, it is important to seek new treatments.”
National guidelines have been in agreement with this for the past several years, said session comoderator Mark Dykewicz, MD, from Wake Forest University in Winston-Salem, North Carolina.
Dr. Dykewicz, who was invited to comment on the study by Medscape Medical News, said that the 2008 Rhinitis Parameter Update of the US Joint Task Force on Practice Parameters stated that using this combination was effective.
“In contrast, most studies have failed to demonstrate that the addition of an oral antihistamine to an intranasal corticosteroid adds to the benefit of the intranasal corticosteroid,” Dr. Dykewicz said.
American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 39. Presented November 7, 2011.
What does this mean for you?
For years, patients have added OTC antihistamines (Allegra, Zyrtec, Claritin) for allergy symptoms. Research shows you are much better off adding another nasal spray (like Astelin) than adding an oral tablet to the steroid nose spray you’re already taking. That’s why antihistamines are often ineffective….you might as well take a vitamin!
I have just returned from the Annual Meeting of the American College of Allergy, Asthma, and Immunology held in Boston from Nov 3-8. Sure the meeting was good, but the food was even better. Consider the oldest “active” restaurant in America, Union Oyster House–the stew was delightful and if you’re bored with allergies, peruse the menu on-line and dream of dining with JFK (he has a booth in his name there).
On to what’s new in allergy & asthma….
Smoking bans in Tulsa have stirred some vigorous debate this year (see link). Most importantly, do they work? Information presented last week would suggest a resounding YES! In the U.S. more than 200,000 asthma admissions per year are attributed to Environmental Tobacco Smoke (ETS). Smoking bans can prevent this complication! The Scottish health system has the database to measure the effects of a community-wide smoking ban and their intervention was associated with an 18% reduction in hospital admissions for asthma (NEJM 2010). Wow
If you have to smoke inside, HEPA filters reduced asthma visits in 6-12-year-old children by 18%.
I have a post on this blog describing VCD or paradoxical vocal cord motion. Our terminology is now changing and instead of VCD, I like the term” irritable larnyx syndrome (WILS).” The vocal cords are “housed” in the larynx and many structures and muscles have to work correctly in order for the vocal cords to allow air in and out of the lungs. This implies that multiple triggers will cause an attack and patients with difficult asthma may have a laryngeal dysfunction not just VCD. If you don’t believe me, look at this study. World-wide recognition (AJRCCM, a study from Australia).
Way too many choices in the treatment of asthma! Why would you consider Tiotropium or Spiriva for asthma?
1. Tiotropium works as step-up therapy in adult asthma. Some patients just can’t tolerate albuterol or Xopenex™ because of tremor and other side effects. Now you have an alternative: There were similar improvements in lung function and symptom-free days with Spiriva as adding long acting bronchodilator (NEJM 2011).
2. Tiotropium does fit into the Asthma Guidelines (2007) and works better than increasing the dose of inhaled steroids (yea, less steroids) and is equal to salmeterol (Serevent).
3. This report is from England, so BEWARE! The Respimat inhaler isn’t used in the United States and should you read about this study, it doesn’t apply to patients in the US. (Recent BMJ meta-analysis showed increased cardiovascular mortality with that formulation in COPD) (BMJ, 2011).Anti IL-13 (lebrikuzumab)–Did you say leprechaun?
There is one take home message with the use of lebrikuzumab:
1. Personalized medicine is here! In this study, patients that improved with anti IL-13 also had elevated levels of periostin in blood tests. Periostin is a marker of airway remodelling and gives us a clue as to why and how IL-13 contributes to asthma. Lebrikizumab improved FEV1, but there was no improvement in symptoms or medication use (NEJM 2011).
This comes from the literature review at the College meeting—1 of every 6 children with asthma seen the ED are prescribed antibiotics. Don’t you think this is high for a “practice” that is supposed to be very selective in who gets antibiotics? Generally, antibiotics are not helpful in asthma anyway. More than 2 courses of antibiotics for cough in a 6-month time frame should warrant consideration of asthma as a cause (Pediatrics, 2011).
In a study in Arizona, Fernandez et al. showed skin testing to Alternaria to be surprisingly accurate. Ninety-six percent of patients with a positive skin test to this mold had a positive bronchial provocation test with Alternaria. In Arizona, Alternaria has surpassed dust mite as number one allergen in asthma (due to dry climate). I wonder what results would be in Oklahoma? Here’s what alternaria looks like:
Come on now, do allergy shots REALLY work? Shots with dust mite allowed for inhaled steroid reduction by 50% in children with asthma vs. 30% in controls. Not bad! Do I have to take my medication with shots? Adding dust mite shots to pharmacologic treatment was an effective and safe strategy to reduce corticosteroid doses while maintaining disease control in children with mite-induced allergic asthma (JACI 2011).
Which inhaled steroid to use? Does it matter? QVAR™ & Alvesco™ have said for quite some time that small particles penetrate the airways of an asthmatic better than the competition. They may be right– small particle size inhaled steroids may allow for equal efficacy (benefit) with 1/2 to 1/3 the dose of a larger size of same steroid. Marketing isn’t bad, sometimes it’s just delayed results.
SABA update: Levalbuterol (Xopenex™) may not have any real-life advantages over albuterol. Even in the Xopenex™ package insert, there is mention that there was no difference in heart rate or tremor. In patients who swear by Xopenex™, there’s no reason to change, just start out with cheaper albuterol.
Antihistamines for asthma?
Many patients take antihistamines every day like vitamins. They feel better if an antihistamine is “on-board.” Once again, learn from your patient….they will often give you clues to what medications work. Symptom scores in asthma patients show comparable improvement when given desloratadine (antihistamine) compared to montelukast. Use of antihistamine may prevent the development of asthma in some predisposed children. Well I’ll be….
Asthma in the elderly
The majority of asthma deaths are in patients older than 65.
Asthma in adults/elderly is still predominantly an atopic disease. This means, it’s still due to allergy. Don’t forget to test your older population. In a University of Michigan study, 77% of adult asthma patients were skin test positive.
Depression is definitely underdiagnosed in our loved ones who have retired (ie, grandma & grandpa). Why? They should have a carefree life during retirement, but they don’t. Depression is a significant factor for poor asthma quality of life in the elderly. You are 10x more likely to suffer from psychological dysfunction if you have more than 3 exacerbation of asthma in a single year.
Just goes to show you that allergic respiratory disease is a very complicated condition and every year I’m challenged with new treatments! I can’t ask for anything more.
Most patients never know what doctors do when they’re NOT in the office. One of those activities is attending national meetings in our chosen specialty. For me, the American College of Allergy, Asthma, and Immunology is a yearly highlight. You ask why? Who wouldn’t want to see a distinguished doctor dress up and discuss hives? Seriously, the ACAAI in Boston was a great opportunity to network and stay up to date on changing treatments for allergy & asthma! It’s posted here.
Attendees of the ACAAI Annual Meeting voted Dr. David Khan winner of “The Great Chronic Idiopathic Urticaria Raft
Debate: After Antihistamines, What’s Best for Next In-Line Treatment” based on his discussion of Hydroxychloroquine/dapsone.
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