New Year’s Resolution–Who Should start Controller Meds?

New Year’s resolution!

I don’t like New Year’s Resolutions–if I don’t do something everyday, how is a resolution going to change my priority?  Behold…I bring you good tidings of great joy…taking regular PREVENTATIVE medication works the same way! 

So what’s the issue at hand?  Patients with asthma often want to stop preventive medication for the cough & wheeze.  I often hear…I don’t need it, only to suffer from an asthma attack with their next cold.  What are some useful strategies to improve asthma care in this regard?

 From the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition: Abstract 14793. Presented October 14, 2011: 

American Academy of Pediatrics

  • Pediatricians strongly support the recommendation that emergency department (ED) physicians start asthma controller medications during an acute visit to the ED, according to research presented here at the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition.
  • Why in the emergency room?  It’s the best time to have that one-on-one discussion with asthma patients.  You have their attention.

National asthma guidelines recommend that ED physicians consider initiating long-term controller medications when children present with an acute asthma attack. We all (I mean physicians) follow the guidelines, right?  Think again!

  • Many ED doctors are reluctant to do so, lead author Esther Maria Sampayo, MD, MPH, from the University of Pennsylvania School of Medicine, Philadelphia, said in an oral abstract session.
  • “One AAP study noted that less than 20% of ED doctors actually do this,” Dr. Sampayo told Medscape Medical News. “When you ask them why, they say it’s not their role to be the pediatrician and they shouldn’t be providing long-term management.”

If you don’t know the answer….then let’s find out.  The researchers did a cross-sectional mail survey of a randomly selected national sample of pediatricians involved in providing primary care from the AAP.

  • Of the 527 pediatricians who responded to the survey, 83% reported that they feel it is appropriate for the ED physician to initiate controller medications.
  • Just 23% of pediatricians reported that their patients “almost always” follow-up within 1 month after an ED visit. Makes you wonder what else gets “missed!”
  • Half (51%) of those surveyed believe that having ED physicians prescribe controller meds in the ED will encourage patients to follow-up. 
  • The survey also asked the pediatricians what they consider to be the benefits of having ED physicians initiate asthma controller medications. Most (85%) feel that it is a “teachable moment” and represents an important opportunity to capture patients who are poorly controlled.  Strike it while the iron is hot!

    Strike When the Iron is Hot!

Noah Kondamudi, MD, an asthma specialist in the Pediatric Emergency Department of the University of Medicine & Dentistry of New Jersey in Newark, said that in his experience, more and more ED doctors are prescribing asthma controller medications when children present with acute asthma.

Here in Oklahoma, no data is available on prescribing habits of emergency room physicians for asthma controller meds or the opinion of local pediatricians.  Do I hear a study that needs to be done?

“In general, emergency room doctors would not want to add to or change the primary care doctor’s chronic disease plan. However, more and more data are showing that many asthmatic children are not on controller medication, so initiating controller therapy should make a big difference,” he said.

My thanks to Fran Lowry who is a freelance writer for Medscape.  She has disclosed no relevant financial relationships.

#american-academy-of-pediatrics, #asthma, #emergency-department, #pediatric, #pharmaceutical-drug, #physician, #united-states, #university-of-pennsylvania-school-of-medicine

I’m Worried about Whooping Cough

Grandparents eager to hold the new baby in the family this holiday season should add vaccines to their shopping list.

  • The whooping cough vaccine given to babies and toddlers loses much of its effectiveness after just three years, a lot faster than doctors believed, and that could help explain a recent series of outbreaks in the U.S. among children who are fully vaccinated.The whooping cough vaccine given to babies and toddlers loses much of its effectiveness after just three years, a lot faster than doctors believed, and that could help explain a recent series of outbreaks in the U.S. among children who are fully vaccinated. 
By Rich Pedroncelli, AP
  • Anyone who comes into close contact with infants is now urged to get vaccinated against whooping cough, or pertussis. Getting the vaccine now will provide enough time for it to start working by Christmas weekend, but cost could be a barrier for many people.

Last year (2010), the whooping cough epidemic hit hard in Oklahoma, resulting in several infant deaths from an apparent “benign” disease.  (review News on 6 report)

How do you protect your babies against whooping cough?

Being a “pit bull” for your baby is the right thing to do, according to Dr. Eric Scott Palmer, a Nashville neonatologist .  “Not only is there pertussis or whooping cough, but we are entering the influenza and respiratory syncytial virus seasons,” Palmer said. “These are some viral illnesses and bacterial illnesses, such as whooping cough, that can and do kill infants, particularly former premature infants. At family gatherings, while everyone loves babies, the infection control during those times is of critical importance — particularly as it relates to hand-washing.”

Many adults mistakenly believe they are protected against pertussis because they’ve had whooping cough before, while others walk around with the virus without realizing it, said Dr. Kelly Moore, who directs immunization programs for the Tennessee Department of Health. Also, the vaccine wears off over time, so a booster shot is needed about every 10 years.

“People may assume it’s like measles, where you get it once and you never get it again,” Moore said. “Unfortunately, this is something you can get many times. The problem is the symptoms aren’t as classic as measles or chicken pox. People might not even realize they have it because it is not as obvious.”

  • Doctors start vaccinating infants for pertussis at two months old, but protection requires booster shots. Children need five doses of the vaccine, and three of those occur before the age of 1.
  • Another new recommendation from the CDC is that pregnant women get the shot after the 20th week of gestation if they have not been previously vaccinated.

“What is frightening is that people with an ordinary cough illness might not think they have pertussis and might expose a newborn or infant unknowingly,” Moore said. “Small infants or newborns can stop breathing when they have pertussis.”  Here’s what pertussis sounds like in small infants (watch the video)

“The vast majority of pertussis cases are never diagnosed or confirmed,” Moore said, noting that it takes a more sophisticated lab test than a blood check to detect the bacterium.

Protection is provided by the Tdap vaccine, available in your doctor’s office or at the local health department. Whooping cough is one of several winter illnesses that can cause serious complications for infants and people with compromised immune systems. While you’re getting the pertussis vaccine, get the flu shot while you’re already there! 

“The stoic family member who shows up sick at the family Christmas party is probably not doing anyone any favors,” Moore said.

The full article from USA Today is found here!

#american-academy-of-pediatrics, #centers-for-disease-control-and-prevention, #christmas, #dpt-vaccine, #kelly-moore, #pertussis, #usa-today, #vaccination

Egg Allergy and the Flu shot–Updated recommendations

 Trivalent influenza vaccine (TIV) FLU SHOT is safe to use in children with severe egg allergy, and can be given as a single dose, according to research presented at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting.  I attended this session and the research presented definitely changes recommendations on giving the flu vaccine.

Eggs are delicious: but what about allergy?

This report confirms the recommendation made earlier this year by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) — that egg allergy is no longer a contraindication to vaccination with TIV.

Previously, the AAP Red Book considered anaphylaxis to egg or severe egg allergy a contraindication to receiving the vaccine.  When you grow vaccine in egg yolk this is understandable (see below). 

Growing influenza--beware of egg you know why!

“The benefits of flu shots are well established and clearly outweigh the risks for children with egg allergy,” lead author Matthew J. Greenhawt, MD, from the University of Michigan in Ann Arbor, said in a statement. For the full interview, click on this link

“Children with food allergies are more likely to have asthma, which can increase their chance of respiratory complications from the flu. Expanding the population of children who receive flu shots will play an important role in decreasing influenza associated with hospitalization and in promoting the overall health of our children,” he explained.

Using a 2-step approach, the group randomized 28 children who were contraindicated for TIV according to previous AAP Red Book criteria to receive either a 10%/90% split dose of TIV (n = 13), or to receive normal saline plus 100% TIV (n = 15) to mimic the split dose.

In these 28 children, the mean egg skin test wheal was 7.7 mm, mean egg white ImmunoCAP was 23.1 kuA/L, mean ovalbumin ImmunoCAP was 20.4 kuA/L, and mean ovomucoid ImmunoCAP was 18.1 kuA/L.

There were no differences in these values between the 2 groups, Dr. Greenhawt reported.

In addition, they investigators retrospectively analyzed 32 children with severe egg allergy who were vaccinated by their primary care physician despite the contraindication, for comparison.

This retrospective group consisted of 13 children who received TIV as a split dose as a safety precaution and 19 who received it as a single dose. The mean egg white ImmunoCAP was 18.2 kuA/L, and there was no difference between children who received a single or a 2-step split dose of TIV.

None of the children developed an allergic reaction.

“Use of 2-step split dosing appears unnecessary, as a single dose was well tolerated by those who received this either in an allergy clinic or in the primary care setting,” Dr. Greenhawt concluded.

This change in clinical practice probably needs some reassurance!  Todd A. Mahr, MD, director of pediatric allergy/immunology at Gundersen Lutheran Medical Center in La Crosse, Wisconsin, and clinical professor of pediatrics at the University of Wisconsin Medical School in Madison, was comoderator of the session. He told Medscape Medical News that “the nice thing about this paper is that it reaffirms the ACIP and the AAP recommendations that have come out for administration of TIV in egg-allergic patients. This paper was actually submitted before [those recommendations] came out. It is nice to have it at our meeting to reconfirm the new recommendations.”

“What ACIP and AAP say now is that if the patient can eat egg cooked in things, the general practitioner can just go ahead and give TIV and watch the patient for 30 minutes afterwards,” said Dr. Mahr, who was not part of the current study.

Patients with a history of anaphylactic reaction to egg should be sent to a specialist for vaccination. “That specialist can decide what to do. One option is to do a 2-step dosing; another is to give it in 1 dose and be prepared to handle anaphylaxis,” Dr. Mahr said.

Dr. Greenhawt reports financial relationships with Phadia, Sunovion, and Nutricia. Dr. Mahr reports financial relationships with ISTA, Alcon, AstraZeneca, Genentech, GlaxoSmithKline, Merck, and Novartis.

American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 2. Presented November 6, 2011.

#aap-red-book, #advisory-committee-on-immunization-practices, #american-academy-of-pediatrics, #astrazeneca, #egg-allergy, #glaxosmithkline, #gundersen-lutheran-medical-center, #influenza-vaccine