Now Here’s a New Medication I haven’t seen in a while

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

First combination spray for the nose!

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? 

But Wait!

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!

#american-college-of-allergy-asthma-immunology, #azelastine, #nasal-spray, #rhinitis

The More Ya Know, the Less Ya Know!

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….

My, how things have changed!

Environmental Tobacco Smoke

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%.

VCD–Vocal Cord Dysfunction

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).

Tiotropium–alias Spiriva

Way too many choices in the treatment of asthma!  Why would you consider Tiotropium or Spiriva for asthma?

Picture says 1,000 words!

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).

Antibiotics

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).

Mold allergy

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: 

Alternaria under a microscope

Alternaria in real life

Immunotherapy

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).

Asthma

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….

Grandpa can’t breathe!

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.

#allergy, #alternaria, #american-college-of-allergy-asthma-immunology, #asthma, #bleeding, #dyspnea, #house-dust-mite, #immunology, #pediatric, #respiratory-disorders, #tiotropium, #union-oyster-house, #united-states, #vocal-cord-dysfunction, #wheeze

What do docs really do?

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

What we do at Allergy meetings!

Debate: After Antihistamines, What’s Best for Next In-Line Treatment” based on his discussion of Hydroxychloroquine/dapsone.

#allergy, #american-college-of-allergy, #american-college-of-allergy-asthma-immunology, #asthma, #boston, #histamine-antagonist, #immunology, #united-states