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!
Maternal Asthma Medication Use May Cause Certain Birth Defects
Approximately 4% to 12% of pregnant women have asthma. Current clinical guidelines recommend that women with asthma maintain asthma therapy use during pregnancy. These medications act in 2 ways: as bronchodilators or anti-inflammatories. Few studies have examined the effects of maternal asthma medication use on birth defects.
The aim of this study by Lin and colleagues was to examine whether maternal asthma medication use during early pregnancy increases the risk for selected birth defects. (Pediatrics. Published online January 16, 2012)
Study Synopsis and Perspective
A recent study found a statistically significant increase in the risk for isolated esophageal atresia, isolated anorectal atresia, and omphalocele in infants whose mothers used asthma medications within the month before conception or during the first 3 months of pregnancy.
Shao Lin, PhD, from the Center for Environmental Health, New York State Department of Health, Troy, and colleagues reported their study results in an article published online January 16 in Pediatrics.
The researchers used data collected for the National Birth Defects Prevention Study, an ongoing, multicenter, population-based, case-control study of the causes of birth defects that has been collecting data from 10 states in the United States since 1997 by conducting interviews with mothers and analyzing DNA obtained from cheek swabs from family members. That study includes both infants with 1 or more specified birth defects (diaphragmatic hernia, esophageal atresia, small intestinal atresia, anorectal atresia, neural tube defects, omphalocele, or limb deficiencies) and control infants without those birth defects.
For this study, the researchers analyzed data from a case group consisting of 2853 live births, stillbirths, or elective terminations with estimated dates of delivery from October 1, 1997, through December 31, 2005, and with 1 or more of the identified birth defects. The control group comprised 6726 infants born alive and without birth defects during the same period, randomly selected from birth hospital information or birth certificates.
Dr. Lin’s team concentrated on periconceptional use of anti-inflammatory medications, bronchodilators, or both. They defined exposure as use of asthma medication once or more from 1 month before conception through the third month of gestation. Mothers who described their medication use as only “as needed” and who could not provide an exact time frame for use were excluded from the study. (This is a good study design to exclude these patients…doesn’t give you biased results for minimal exposure)
The study found a statistically significant association between isolated esophageal atresia and bronchodilator use only (adjusted odds ratio [aOR], 2.39; 95% confidence interval [CI], 1.23 – 4.66). The aORs for esophageal atresia and anti-inflammatory use only (aOR, 1.61; 95% CI, 0.69 – 3.76) and for use of both bronchodilators and anti-inflammatory medications (aOR, 2.93; 95% CI, 0.88 – 9.75) were elevated, but were not statistically significant.
There was a statistically significant increase in the risk for isolated anorectal atresia associated with anti-inflammatory use only (aOR, 2.12; 95% CI, 1.09 – 4.12).
Use of both bronchodilators and anti-inflammatory medications was associated with a statistically significant increase in the risk for isolated omphalocele (aOR, 4.13; 95% CI, 1.43 – 11.95).
The results are not all bad however. The medications studied were not significantly associated with 6 other birth defects studied (neural tube defects, anencephaly, spina bifida, small intestinal atresia, limb deficiency, and diaphragmatic hernia).
The researchers performed a stratified analysis by time of medication use, using the periconceptional period and the period from the fourth through ninth month of gestation. The positive associations were found only in infants of women who took the medications during the periconceptional period, and not in infants whose mothers took the medications only in the fourth through ninth months of pregnancy.
My comment—>by the time you know you’re pregnant, you’ve had the exposure!
The authors write that from 60% to 67% of mothers of infants with esophageal atresia, anorectal atresia, and omphalocele used bronchodilators during their entire pregnancy, although these data were not shown.
This is a key point–“With the interview information available for analysis, we were unable to distinguish between the effects of asthma and those of asthma medications; however, we did observe that mothers with possible indicators of uncontrolled asthma or severe asthma episodes (eg, use of multiple bronchodilators) were at higher risk for delivering a child with 1 of the defects studied than those who used 1 bronchodilator,” the authors write.
“When regular use of bronchodilators is required, an activated inflammatory process is implied; thus, use of bronchodilators throughout pregnancy might indicate that these mothers had frequent or ongoing inflammatory exacerbations during pregnancy,” they add.
Noting the importance of controlling asthma during pregnancy, the authors write, “The current clinical guidelines and specific recommendations for aggressive asthma management during pregnancy should remain unchanged.”
“Given the low baseline prevalence of these defects, if the observed association proved to be causal, the absolute risks of asthma medications on these rare defects would be small,” they conclude.
The study was supported by the Centers for Disease Control and Prevention. The authors have disclosed no relevant financial relationships.
- Clinical guidelines recommend that women with asthma maintain asthma medication use during pregnancy.
- In the current study, positive associations were observed for anorectal atresia, esophageal atresia, and omphalocele and maternal periconceptional use of asthma medications, but not for other birth defects studied.
You must want to know how to treat esophageal atresia?
The patient with asthma has special challenges besides learning which inhaler to use at the right time. Obesity makes asthma worse and asthma is a risk factor for obesity. Which came first, the chicken or the egg? Treating obesity will require multiple concurrent strategies….there is no one size fits all!
This is a New Year’s resolution you love to hate. Success rates for smokers may not look all that great, but you triple your chances of being a “quitter” if you use medications combined with counseling. This article has lots of quotes that I left as is.
Despite the known dangers of smoking, about 20 percent of Americans still light up, but almost 70 percent want to quit, a new government report shows.
The percentage of smokers appears to hover around 20 percent as people take up the habit, he said. “But there has been a decline in the last five years in the rate of smoking, and smokers are actually smoking less,” he added.
“Perhaps the most dangerous situation we are in is we have seen over the past five years a flattening of the downward trend in youth initiation. We are very worried that there are a number of things that have been happening in terms of tobacco industry marketing techniques that affect youth,” McAfee said.
The report was published in the Nov. 11 issue of the CDC‘s Morbidity and Mortality Weekly Report.
According to the report, 68.8 percent of current smokers say they want to quit and 52.4 percent tried to quit during the past year.
In addition, 48.3 percent of smokers who saw their doctor in the past year say they got advice to quit. Moreover, 31.7 percent had counseling alone or with drugs to help them quit in the past year. And about 6 percent quit successfully in the past year.
McAfee noted that most smokers who manage to quit do so without the help of drugs or counseling. “About 20 percent of people take medication or sign up for counseling,” he said.
Other factors that are equated with quitting are education, where 11 percent of those with a college degree were able to quit, compared with 3 percent of those who did not graduate from high school, McAfee said.
In addition, blacks had the highest interest in quitting and the highest quit attempt rate than any other group, but blacks also had the lowest rate of successful quitting, McAfee said. Blacks were also less likely to use medication or counseling, he noted.
In addition, blacks were more likely to smoke menthol cigarettes, which decreases the rate of quitting, McAfee said.
If you can’t quit by yourself, the best way to quit is with a combination of counseling and drugs like Zyban, Chantix or other nicotine replacement therapy, the CDC report said.
“Smokers who try to quit can double or triple their chances by getting counseling, medicine or both,” CDC director Dr. Thomas R. Frieden said in a statement.
The CDC is releasing the report as part of the annual Great American Smokeout on Nov. 17. The event is sponsored by the American Cancer Society, and encourages smokers to make a plan to quit, or quit smoking that day.
The report also notes that the growth of smoke-free workplaces and public places offer smokers another incentive to quit.
Smoking is still the leading preventable cause of death and disease, including cancer, chronic obstructive pulmonary disease and other lung diseases. Each year in the United States, smoking and exposure to secondhand smoke kill some 443,000 people, the report noted.
In addition, for every smoking-related death there are 20 people living with a smoking-related disease, the agency said.
Vince Willmore, vice president of the Campaign for Tobacco-Free Kids, said that “the CDC report confirms that most smokers want to quit, but too many don’t get the help they need to succeed.”
“To help more smokers quit, it is critical that all private and government health plans provide affordable and accessible coverage for smoking-cessation medication and counseling, and that states use more of their tobacco revenues to properly fund tobacco prevention and cessation programs,” he said.
States must also continue to enact policies that encourage quitting, including higher tobacco taxes and smoke-free air laws, Willmore said.
In a related move, the U.S. Food and Drug Administration said Thursday that most of the warning letters it recently sent to more than 1,200 tobacco retailers were about illegal sales of cigarettes and smokeless tobacco products to minors.
FDA inspections of tobacco retailers found that most are in compliance with the law, but some still sell tobacco products to youngsters. Retailers who continue to violate the law could face fines.
“It should worry every parent that 20 percent of U.S. high school students smoke cigarettes,” FDA Commissioner Margaret A. Hamburg said in an agency news release.
“For many young people, that first cigarette or use of smokeless tobacco will lead to a lifetime of addiction, and for many, serious disease,” she said. “More than 80 percent of adult smokers begin smoking before 18 years of age. Retailers are vital partners in the FDA’s efforts to prevent tobacco use among kids.”
With all this bad news, is there anything that can be done? Oklahoma State University is now a smoke-free campus since 2008–way to go Pokes!
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.
- 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.
- The recommendation for expanded vaccinations for whooping cough — even for those over 65 — is new from the American Academy of Pediatrics and the U.S. Centers for Disease Control and Prevention. It comes after a nationwide surge in whooping cough infections during 2010.
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!