We all know the cost and hassle of taking care of asthma, especially for children. And yes, we’ve tried many different methods to get kids to use their inhalers at all, much less to get them to use their inhalers correctly.
Don’t think you have asthma….try the following:
1. Reflux can mimic symptoms of asthma with cough & wheeze
2. You might need a Aridol challenge test to be sure.
3. Don’t forget about sinus infection which can mimic coughing.
4. Make sure you’ve performed lung function! (PFTs)
5. Vocal Cord Dysfunction can sneak in as a cause of cough & wheeze.
Without a doubt, driving on ice and snow should be reserved for the experienced drivers only. We don’t need more wrecks on Hwy 169 that what we already have to endure. But when the forecast for a winter storm brings on a run for bread and milk, we may have gone a bit too far. We have our own version of Black Friday…it’s called snow storm panic! Here I was shopping at Target to get a few items I really did need. Usually, my wait at the pharmacy is very short, but last night I guess EVERYONE thought it was important to get their medications filled before the storm arrived in case medications would no longer be available. Come on, pharmacies stay open even in Minnesota. Did you happen to go down the bread aisle? Nothing left and not a snowflake on the ground. No wonder you can’t yell fire in a theatre. The most shocking behavior, however, found in Oklahoma in preparation for a winter storm is to cancel school before it even starts to snow. Will you catch us off guard and unprepared? Not a chance. No wonder our kids have never seen snow or had a chance to make those lovely snow angels. They’re never in it. All joking aside, we did have a pretty nasty snowstorm 2 years ago with almost 20 inches in one night. That amount of snow shut the city of Tulsa down for a week! Could it happen again? Sure could, but the video below is enough for me:
Now, you’re probably wondering if I always pontificate about a totally irrelevant topic such as how Tulsans prepare for snow storms. Fortunately, this can have some relevance to cold weather illness:
- Asthma can be a real problem during the cold weather. Inhaling cold air causes drying of the airway wall and more severe bronchospasm that moderate temperatures. Don’t think that coughing and shortness of breath is just cold air; it may be your asthma getting out of control. Learn how to cover your nose and mouth with a scarf or mask, even if you’re outside for a short period of time. And most of all, use your regular inhaler (controller) during the winter months if cold air or upper respiratory infections are triggers for your asthma.
- Another problem with the winter season is trying to figure out if I have a cold, flu, sinus, or allergy problems. Let me make this much easier for you. Most ragweed is done pollinating by the end of October, so without much pollen in the air, your sneezing and coughing is probably not due to allergy (no exposure). A cold usually lasts < 1 week and any congestion or runny nose that doesn’t resolve from one Saturday to the next is probably a sinus infection. Why does this matter? Sinus infections should be treated with the “all or nothing” approach as any infection left in the sinuses will only result in more infection. Catching the flu makes you feel terrible and you’re already coughing. What could be worse? Add a fever with muscle aches and your diagnosis is most likely some type of influenza. Good motivation to get your flu shot!
- Am I Allergic to the Cold? I’m glad you asked. Cold-induced hives stays hidden for most of the year and comes out with a vengeance during cold weather. Some instances can be life-threatening and this condition is nothing to take lightly. Cold-induced urticaria of course, responds best to a vacation at Key West, but if you don’t have the luxury or flexibility to do that, antihistamines are still the backbone of treatment. Be careful when shoveling snow as shortness of breath and chest tightness may be associated with hives and a cold-induced reaction.
Although you must be careful with cold weather illness, you have to do something outside or you’ll get cabin fever. The link below is from AAAAI on how to control your asthma and still participate in winter activities. It’s a good read in front of the fireplace with a cup of hot chocolate. In the meantime, I’m heading for the slopes!
Europe and the United States differ on many things including how we look at war and how often we pick our noses…yes it’s true about rhinotillexomania (nose picking). Perhaps this is why Europeans will reach for a nose spray FIRST to treat allergies and then go for antihistamines. Yes, there’s even a Dr Oz video on the subject: http://www.oprah.com/oprahshow/Dr-Oz-on-Health-and-Hygiene
So what is the point of all this nonsense? Treatment of asthma also differs between the United States and Europe.
The Misuse of Asthma Drugs
Gene L Colice Expert Rev Resp Med. 2013;7(3):307-320.
There are three major problems with asthma care in the USA today and misuse of asthma drugs contributes to each.
First, multiple sources document that symptom control of most Americans with asthma in the general population does not meet standards established in the National Asthma Education and Prevention Program Expert Panel Report III (EPR3). In the CHOICE survey, 1000 patients with asthma randomly chosen across the USA were asked about their care and burden of disease. Almost half of these patients (49%) reported that they did not use asthma controller medications, although 79% had evidence of persistent disease. Of the 51% of the patients reporting the use of asthma controller medications in this survey, 85.7% had not well controlled or very poorly controlled disease. Numerous previous surveys of asthma patients in the USA and Europe, using either telephone interviews or questionnaires, have reported similarly high levels of uncontrolled disease. In the Exercise-Induced Bronchospasm Landmark Survey, 78.8% of the children with asthma and 83% of adults with asthma described respiratory symptoms with exercise. Children and adults with asthma commonly described being limited in their ability to perform sports and outdoor activities by their disease in this survey.
I know most patients would like to stop their asthma medications ASAP, but it comes at the cost of losing asthma control. I’ve previously discussed when to stop asthma medications…I’d like to know what you think? Are doctors prescribing unneccesary medications?
Second, in addition to difficulties with symptom control on a daily basis, patients with asthma in the USA frequently suffer exacerbations.
In the CHOICE survey, 5% of the patients reported being hospitalized and 14.4% described either an emergency department (ED) or urgent outpatient visit for an asthma exacerbation in the past year. Patients interviewed in this survey with more severe, persistent or uncontrolled asthma were more likely to have suffered asthma exacerbations. Previous surveys have reported similarly high rates of asthma exacerbations resulting in ED visits and hospitalizations. Data from the US CDC confirm that nationwide rates of ED visits and hospitalizations for asthma exacerbations remain unacceptably high.
So what are parents to do? The choice between giving your child steroids and having to rush to the emergency room for an asthma flare can be a “no win” proposition.
Third, asthma is an expensive disease.
The CDC has recently estimated that asthma costs the US economy approximately US$56 billion annually. On average, an asthma patient has been calculated to generate approximately US$2000–$4000 more in healthcare costs per year than a nonasthma control patient. Indirect costs due to work loss, school absenteeism, reduced productivity and so on, further contribute to the economic impact of asthma. Healthcare costs of asthma increase in patients with more severe disease. In patients with moderate and severe persistent asthma, exacerbations will further substantially increase healthcare costs.
I know the most common reason that patients stop their medication is simple: medications are too expensive. Here are some tips to reduce the cost of your prescribed medications for asthma:
- Make sure the medications you are picking up at your pharmacy are needed year round. Some patients need asthma inhalers only during the cold winter months.
- Educate yourself…know your triggers for asthma attacks to keep you out of the ER and better yet to use inhalers as prevention! (I have links to the American College of Allergy and the American Academy of Allergy, Asthma, and Immunology)
- Monitor your symptoms with a peak flow meter and pay attention to how much exercise you can do, and how well you sleep. Both of these indicators will tell you several days in advance if your asthma is flaring.
- Use coupons for your inhalers. In years past, pharmacy reps would leave samples for us to hand out to get patients started on asthma prevention. This is no longer the case because of health care reform. But….coupons are available for a similar value. Just don’t forget to take the coupon in to your pharmacist when you pick up your inhaler.
In summary, having reviewed the data, the EPR3 predisposes to under treatment of asthma. The tendency is for healthcare providers to underestimate asthma severity and to correspondingly undertreat the disease. In most asthma patients, the result will be persistent asthma symptoms. In important subsets of asthma patients, particularly smokers, the efficacy of ICS seems impaired. For a given categorization of asthma severity (even if accurately calculated by the healthcare provider), the corresponding recommended treatment with ICS in the EPR3 might be insufficient in smoking and obese asthma patients. Again, the consequence will be persistent asthma symptoms. Asthma tragedies occur all the time…let’s make sure it doesn’t happen to someone you know!
Asthma sufferers may benefit more from inhaling vitamin D than the steroids usually prescribed for the condition. And besides, aren’t we all concerned with side effects from steroids? A new study from the U.K. identifies a mechanism through which the vitamin can significantly reduce asthma symptoms and suggests it may offer a new method of treatment. Continue reading Why Does Vitamin D work?
Oh, if I only knew of a more interesting subject for MY next cocktail party. When kids’ drama, and the latest neighborhood gossip just won’t do, try your luck at the newest asthma mediation!
A special thanks to Reuters for their excellent reporting…my comments will be in RED.
Medscape Medical News from the American Thoracic Society (ATS) 2013 International Conference
Regeneron, Sanofi Asthma Drug Seen as Potential Game Changer
By Ransdell Pierson
(Reuters) – A new type of asthma drug meant to attack the underlying causes of the respiratory disease slashed episodes by 87% in a mid-stage trial, making it a potential game changer for patients with moderate to severe disease, researchers said on Tuesday.
Slashing episodes by 50% is pretty dramatic, much less results of 87%. Too good to be true always lurks in the background with medical studies. Am I cynical? Unfortunately, I’ve been burned by too many drugs, gadgets, and the next best nutritional supplement to accept this news without a grain of salt.
“Overall, these are the most exciting data we’ve seen in asthma in 20 years,” said Dr. Sally Wenzel, lead investigator for the 104-patient study of dupilumab, an injectable treatment being developed by Regeneron Pharmaceuticals Inc and French drugmaker Sanofi.
The drug also met all its secondary goals, such as improving symptoms and lung function and reducing the need for standard drugs called beta agonists.
Although far larger trials will be needed to confirm findings from the “proof of concept” study, researchers expressed optimism. They noted that dupilumab has also shown the ability to tame atopic dermatitis or severe eczema.
The medicine, if approved, could hold promise for patients with moderate to severe persistent asthma that is not well controlled by standard drugs.
“We have been treating asthma with sort of Band-Aid therapies that didn’t get at the underlying causes,” Dr. Wenzel said in an interview, adding that dupilumab could be an important step in going to the root of the problem.
The drug works by simultaneously blocking proteins that have been linked to inflammation, interleukin-4 (IL-4) and interleukin-13 (IL-13).
Dr. Wenzel, director of the Asthma Institute at the University of Pittsburgh, said other drugmakers have tested medicines that block one or both of the proteins, but without success.
The trial recruited patients with high levels of eosinophils. Such patients were deemed likely to benefit from treatment.
This new form of medication, called monoclonal antibodies, targets single molecules to avoid the side effects of steroids. Our prototype for asthma is Omalizumab or Xolair which just celebrated its 10th year out in the market. Other than Xolair, I’m limited to using steroids for severe asthma. 😦
All patients initially stayed on their standard asthma treatments, meaning medium-to-high doses of inhaled glucocorticoids, as well as long-acting beta agonists. But patients gradually tapered off on those drugs and were no longer taking either of them after nine weeks.
Throughout the Phase IIa trial, half the patients also received weekly injections of dupilumab, while half received placebo injections.
After the ninth week, about 25% of those on placebos had experienced exacerbations, i.e., the need to take a beta agonist, a decrease in lung function, the need for an oral or inhaled corticosteroid, or admission to the hospital or emergency room for worsening asthma.
“By end of the trial, after 12 weeks, 44% of those in the placebo group had exacerbations, compared with 5% of those on dupilumab,” Dr. Wenzel said.
That represented an overall 87% reduction in exacerbations, which Dr. Wenzel said was highly statistically significant.
She said dupilumab was well tolerated, with side effects similar to placebo. But she cautioned that longer trials are needed to fully assess the drug.
Regeneron and Sanofi said standard drugs are unable to control asthma well in 10% to 20% of patients. They estimate that inflammation caused by Th2 cells – the type of inflammation among patients they tested – plays a role in half of those moderate to severe cases and affects as many as 2.5 million people in the United States and up to 30 million worldwide.
Dupilumab has also shown strong hints of safety and effectiveness in two early-stage trials that involved 67 patients with atopic dermatitis. Larger studies are slated to begin later this year.
Atopic dermatitis is inherited and involves patches of highly itchy skin on any part of the body. Patients, many of whom also have asthma and hay fever, have compared the sensation to having unending poison ivy.
“This asthma data and the data we already have in atopic dermatitis really raises the possibility the scientific community has finally hit upon the key pathway across all these allergic diseases,” George Yancopoulos, Regeneron’s research chief, said in an interview.
And there you have it….next time don’t be stuck with boring conversation about the weather, talk about Dupilumab!
One over-active gene has been implicated in 20-30 percent of patients with childhood asthma, according to a study in Science Translational Medicine. The gene, according to authors, interrupts the synthesis of lipid molecules sphingolipids, which are part of cell membranes found throughout the body. Reduced sphingolipids was clearly linked to bronchial hyper-reactivity, unrelated to allergens or inflammation, according to the researchers, from New York-Presbyterian Hospital/Weill Cornell Medical Center, Columbia University Medical Center and SUNY Downstate Medical Center.
Here is the full citation—>Sci Transl Med. 2013 May 22;5(186):186ra67. doi: 10.1126/scitranslmed.3005765.
Impaired sphingolipid synthesis in the respiratory tract induces airway
Worgall TS, Veerappan A, Sung B, Kim BI, Weiner E, Bholah R, Silver RB, Jiang XC,
Department of Pathology and Cell Biology, Columbia University, New York, NY
Asthma is a clinically heterogeneous genetic disease, and its pathogenesis is
incompletely understood. Genome-wide association studies link orosomucoid-like 3
(ORMDL3), a member of the ORM gene family, to nonallergic childhood-onset asthma.
Orm proteins negatively regulate sphingolipid (SL) synthesis by acting as
homeostatic regulators of serine palmitoyl-CoA transferase (SPT), the
rate-limiting enzyme of de novo SL synthesis, but it is not known how SPT
activity or SL synthesis is related to asthma. The present study analyzes the
effect of decreased de novo SL synthesis in the lung on airway reactivity after
administration of myriocin, an inhibitor of SPT, and in SPT heterozygous knockout
mice. We show that, in both models, decreased de novo SL synthesis increases
bronchial reactivity in the absence of inflammation. Decreased SPT activity
affected intracellular magnesium homeostasis and altered the bronchial
sensitivity to magnesium. This functionally links decreased de novo SL synthesis
to asthma and so identifies this metabolic pathway as a potential target for
“The following story uses fictional names to comply with HIPPA regulations and is not intended to offer medical advice. If you have specific questions regarding your asthma, please contact my office or call your regular doctor. ”
“And what medications are you taking now?” This wasn’t my usual style to get right to the point, but I was running behind schedule.
“Oh, the ones that are in my chart”, replied Mr. Williams with a broad grin that always let me know he was glad to see me. Continue reading When Can I Stop My Medicine?
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:
- As noted below, emergency rooms and urgent care clinics often don’t know how many times in one year a patient has been on steroids. Patients often don’t go to the same clinic, and the doctor in that case has no way of monitoring overall steroid use and exposure. The fix: communicate to ANY provider how many times you have used oral steroids. You’ll be pleasantly surprised at the results!
- Inhaled steroids, allergy shots, avoidance of pets are all designed to reduce your need for bursts of oral steroids. I agree, avoiding dust and animal dander can be a hassle, but you’ll have better control of asthma if you do and less of a need for oral steroids. The fix: take preventive medications as prescribed, avoid all known triggers of asthma (perfume included), and measure your peak flow reading at the first sign of coughing or wheezing.
- Who gets tired of repeating the same list of medications every time you go to the doctor? Oh, yes, I get tired of writing them down! There is a reason for the madness….your arthritis doctor, allergist, and ER doctor all prescribe prednisone for different conditions, and unless each prescription is written down and recorded, it’s easy to get an overdose. The fix: try to remember “in-between” medicine that you have received from one doctor visit to the next. This is especially important to review with your “primary care doctor”.
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.”
If you’re anything like me, waking up on Thanksgiving morning brings to mind a flood of memories to truly appreciate. Maybe its the intoxicating smell of turkey (and the tryptophan will make you want a nap) mixed with pumpkin pie, or the anticipation of Christmas that entices us to slow down and reflect on what is truly important in our hectic lives. For me, of course, my delightful family is always a “sweet spot” when I come home from work each day.
Healthcare on the other hand, has come under criticism for many reasons, and my position is no exception. Despite all of the challenges facing health providers, I still love the challenge of caring for patients with respiratory illness! Despite all of the changes proposed by the “powers that be” to make health care better, the following principles remain:
- If you understand the WHY about your condition, you’ll be better prepared to implement the HOW do I feel better!
- Feeling better is a cooperative effort between patients, health care providers, support systems, the right diagnosis and the right treatment. Solutions are never usually simple, easy, or a quick fix.
- I’m reminded of a middle-aged woman who was frequently hospitalized for her asthma. She was frequently on steroids (oral) for wheezing and almost died several times. She made a decision to stop smoking, clean her environment, and took her medications on a regular basis. She also attended classes on asthma and taught herself about what made her asthma so severe in the first place. Was she successful? I never hear from her anymore if that tells you something about her progress.
Enjoy your holiday….and by the way if you get heartburn, I wrote last year about the inevitable! Click on the link below.