I know you’ve been there before….waiting in the doctor’s office for your appointment and some smartly dressed man or woman barely has to say hello to the receptionist and walks right by your seat, straight to the doctor’s office. “Hey, that’s not fair,” you say to yourself as you dig your nose into that outdated magazine trying to mask the irritation. “My time is just as valuable as theirs is, put me to the front of the line!” As a patient, my frustration with the #health care system only percolates at the injustice. Isn’t the cost of #medication so high in America because of all the drug companies? If there were no drug reps, wouldn’t my doctor have a better and certainly more unbiased selection of medications? Granted, the goal of any #pharmaceutical company (employer of drug reps) is to make profit, but they can’t do that unless a product (medication) works well and is taken as directed. In the end, drug companies want you to be adherent to medications prescribed so they’ll work, you get better, all of which is good for the bottom line. Almost sounds too good to be true when everybody wins, but hang on and I’ll show you how this is possible. Continue reading
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.
All that wheezes isn’t asthma! Ever heard that before? A common finding in our clinic is “wheezing” or difficulty breathing not due to asthma, but as a result of large tonsils/adenoids. A typical history is as follows:
- Snoring at night
- He wheezes–(it’s not really wheezing, but loud noises coming from the lungs is often labeled as such)
- I can never breathe through my nose
- Examination reveals no wheezing in the chest, but coarse rhonchi transmitted to the chest from the upper airway
- Look at these tonsils that are almost completely obstructing the back of the throat–
ENT doctors are the surgeons that perform T & A’s as they are popularly called. (tonsillectomy/adenoidectomy) The enthusiasm for removing tonsils in young children as a “routine” procedure as decreased because of intraoperative complications, but if it’s needed, the risks outweigh the benefits.
Intermittent budesonide therapy for children with recurrent wheezing
Here’s the issue: my doctor prescribes budesonide (or Pulmicort™) for my child’s asthma and tells me to use it EVERYDAY. Is this really necessary? Conventional wisdom says to use inhaled steroids or anti-inflammatory medications for asthma everyday or they don’t work well. That attitude may now be challenged with this new study from the prestigious New England Journal of Medicine.
This summary appears in the February issue of Journal of Clinical Allergy & Immunology. Wow–that’s a mouthful!
Concerns over adherence and growth suppression in children with wheeze who are regularly treated with inhaled corticosteroids have prompted re-examination of some clinical guidelines by the National Heart, Lung, and Blood Institute‘s Childhood Asthma Research and Education Network. Zeiger et al (N Engl J Med 2011;365:1990-2001) compared low-dose, daily inhaled budesonide with intermittent budesonide therapy initiated at the beginning of respiratory tract infection and continued for 1 week in 278 children between the ages of 12 and 53 months with frequent, episodic wheezing at risk for asthma exacerbation.
The authors found that daily low-dose budesonide therapy did not differ significantly from the intermittent regimen with respect to the frequency of exacerbations. Although the difference in growth measures was not statistically significant between the 2 groups, they noted that the mean exposure to budesonide was greater in those undergoing the daily low-dose regimen.
Zeiger et al commented that their findings of lack of superiority of daily low-dose budesonide to high-dose intermittent budesonide might be an important consideration in future clinical guidelines.
Lead author, Robert Zeiger, MD, PhD, at Kaiser Permanente and University of California, San Diego, gave us this comment: “Our study offers a treatment option for wheezing preschoolers. . .while the study may benefit many preschoolers who wheeze during respiratory illnesses, it did not evaluate children who have more severe disease or persistent symptoms.
Bottom line? Maybe doctors can treat preschoolers who wheeze with intermittent inhaled steroids and avoid year-round use of budesonide. Stay tuned.
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.
As physicians, we have the unpleasant task of learning the differential diagnosis for the diseases we treat. Patients don’t understand it, I have unpleasant memories of using it during rounds as an intern, but this exercise can be helpful for patient care and will keep us out of trouble! Not everything that wheezes is asthma–what are some danger signals that I
might want to modify my original diagnosis of asthma?
Asthma invariably causes symptoms during exercise. If your patient has no symptoms (pre-treatment) during exercise, rethink your asthma diagnosis. How about wheezing at night? Same story…no nocturnal symptoms, not likely to be asthma. Finally, response to therapy is a good clue if co-morbidity is contributing to persistent symptoms. For instance, I prescribe combination therapy (LABA/ICS), yet no improvement in wheezing. Only the most severe asthma patient will not respond to this treatment & I’d start down the path of an alternative diagnosis.
So what is the list for differential diagnosis of wheezing, coughing and suspected asthma? I’ll include links where I have some level of expertise 🙂
1. Left ventricular failure, mitral stenosis–I love cardiology consults! Pedal edema with dyspnea is a red flag even if they’re in your office for “asthma.”
2. Bronchiectasis, cystic fibrosis. Sweat chloride or genetic testing will suffice for CF, but bronchiectasis is often missed during the evaluation for asthma. High resolution CT of chest is the study of choice….
3. Paradoxical vocal cord motion–This one I have to tell you can stump providers even if asthma is present. The best link for this is American Academy of Allergy.
4. GERD or recurrent aspiration
5. Chronic obstructive pulmonary disease (COPD)–don’t forget about the use of Daliresp™ (500mcg/day)
6. α-1 antitrypsin deficiency–Yes this is rare, but treatment is available and diagnosis is as easy as three drops of blood on a postcard!
7. Interstitial lung disease or hypersensitivity pneumonitis–Again, high-resolution CT of chest is very helpful in this scenario…it’s worth fighting insurance to get the study approved.
8. Allergic Bronchopulmonary Aspergillosis (ABPA)–These are usually patients dependent on corticosteroids to breathe. Check total IgE & with ABPA, values are usually >1,000.
9. Pulmonary embolism–usually shows up in the ER, but you never know.
10. Laryngotracheomalacia–If you cough more when upset or crying with a “barky” cough, think tracheomalacia. Usually present before one year of age. Stridor may not always be present. This video is quite informative.
11. Airway neoplasm, foreign body. Found a peanut, found a peanut…..unilateral wheezing is always a concern here. Must keep a high index of suspicion even if there is no history of choking.
12. Rhinosinusitis–Even if it is asthma, sinusitis is ALWAYS a trigger for asthma flares. Don’t bother with plain sinus x-rays…false negative rate can be as high as 30-40%.
13. Churg-Strauss vasculitis or Hyper-Eosinophilic Syndrome–I won’t say more, just go to the link.