Asthma - NYSCHA

Asthma - NYSCHA

Asthma An Evidence-Based Peer to Peer Presentation Erin Hall-Rhoades, MD Ithaca College Physician/Assistant Medical Director Why this talk? My partner is one of the many organizers for this conference I was humbled when doing a self-assessment module for my family medicine boards last year The consensus statement from the Expert Panel Report 3 (EPR-3) is too long to expect all practitioners to read, came out in 2007

There are some gold standards of treatment that I learned in residency training that no longer apply I have always wanted to say goblet cell hyperplasia in public What can you expect from this talk? A Pretest with followup explanations peppered through the talk A brief hx of asthma treatment through the ages (b/c Im a liberal arts grad, nonscience major) A review of the 2007 Expert Panel Reports and an evaluation of evidence for some of the findings.

Demographics Pathophysiology Medical evaluation Treatment chronic as well as acute exacerbations What can you expect? (#2) An evidence-based review of answers from the pretest (factoids, myth busters and allaround fun I hope!) A quick review of pertinent topic areas I talk quickly and have a lot to cover!

Disclosures No financial disclosures or conflict of interests Treatment of my shortness of breath with inhaler New found compassion for shortness of breath What Im not: A pulmonologist An allergist An asthma expert A pharmacologist

A pathologist A researcher Im not better or different than you (probably a little more up to date?) Challenges Inherent in Caring for College Students with Asthma Compliance issues Categorization Fractured care High exposure to illnesses Environmental control (Dust mite control?

Really?) Low immunization rates typically Peak flow measurements Medication costs Awesome things about college students Captive audience Follow up appointments Resources Bright/teachable/receptive Ease of follow up Generally healthy Usually have insurance We usually have EHRs that can help us with

quality of care built in assessments for asthma care and exacerbations Pre Test 1) All of the inflammatory mechanisms of asthma can be reversed by inhaled corticosteroids FALSE 2) To know how well asthma is controlled peak flows are a must FALSE 3) All steroid inhalers are all the same and they are very affordable FALSE 4) Steroid inhalers work very quickly, usually within a day or two.

FALSE 5) Asthmatics with an exacerbation need antibiotics, nebulizer treatment, and need their inhaled steroids doubled FALSE Pretest (cont) 6) Everyone needs to be on a combined steroid/LABA FALSE 7) Exercise induced asthma must be treated with preparticipation albuterol FALSE 8) Comorbid conditions are not important to treat to achieve good asthma control FALSE 9) Cockroaches are good for asthma sufferers

FALSE 10) Beer and advil cant make asthma worse FALSE History of Asthma The term asthma comes from the Greek verb aazein to pant, to exhale with the open mouth or sharp breath. Ancient Egyptian remedy on the Georg Ebers Papyrus. One of the remedies consisted of heating a mixture of herbs on bricks and inhaling the fumes. Hippocrates (450 BC) named and described

the medical disorder. Hx of asthma (cont) 1698 One of the first Western medical textbooks, John Floyer described an acute asthma attack as laborious respiration with lifting of the shoulders and wheezing. 1896 Stedmans Twentieth Century Practice, Sir Thomas Granger Steward and George Alexander Gibson wrote the following The treatment of asthma involves the treatment of the patient during fits and between the fits. The general indications are: 1) To allay the spasm during the paroxysm 2) To find out and remove the exciting cause

3) To treat complications and sequelae (Rescue treatment, controller treatment and prevention! Sound familiar?) History of asthma continued Belladonna Alkaloids with bronchodilator properties Relaxes smooth muscle Early 20th century Asthma History Continued Methyl Xanthines Coffee! Aminophylline

1914, Theophylline Adrenergic Bronchodilators 1910 Lancet Adrenalin chloride injected subq/ epi and later nebulized and then inhaler Oral corticosteroids 1940s and later inhaled corticosteroids History (cont) A Diversion 1930s-50s Asthma was considered as being one of the holy seven psychosomatic illnesses. Etiology considered to be psychological. The asthmatic wheeze was interpreted to be the suppressed cry of the child

for its mother. WHOOPS! The others of theholy seven: HTN, RA, peptic ulcer, neurodermatitis, ulcerative colitis, thyrotoxicosis. History (cont) Specifically targeted asthma treatments began in 1960s and continues today Nedocromil/cromolyn Leukotriene Anti

(mast cells) modifiers Ig-E Inflammation theory 1960s Advancing theories and knowledge since then. Better understanding of the inflammation cascade and that the primary problem with asthma is that it is an inflammatory process. Summary of history

Weve come a long way in treatment and understanding of this fairly common and chronic condition! Asthma Demographics # of adults with asthma in U.S. 16.4 mil (7%) # of children with asthma in U.S. 7 mil (9.5%) and increasing (some estimates of up to 25% among urban kids) 5/10/06 Asthma is declared the most common chronic childhood disease # of visits with asthma as primary diagnosis 13.3 mil Mortality about 4000 per year

Deaths per 100000 population 1.1 CDC stats from current website 9/2010 Demographics (the upside) The number of deaths due to asthma has declined, even in the face of an increasing prevalence of the disease (NHIS 2005) Fewer patients who have asthma report limitations to activities Goal for Therapy for Asthma The Whole

Point Reduce Impairment Prevent chronic and troublesome sxs (coughing or breathlessness) Maintain (near) normal pulmonary function Maintain normal activity levels Reduce risk Prevent recurrent exacerbations of asthma Prevent progressive loss of lung function Provide optimal pharmacotherapy with minimal or no adverse effects Quality of Life Better lung function OR less symptoms??

LESS SYMPTOMS Diagnosis 19 yo woman comes in with chief complaint of nighttime coughing awakening her from sleep 2 times per month for the past 2 months, occasional wheezing during the day, worse with exercise, a couple of times per week. No current illness. ROS is otherwise completely negative. DOES SHE HAVE ASTHMA? No hx of wheezing illness. No seasonal allergies, no atopy. No family hx of asthma. No smoking (not even socially on the weekend). No other comorbid conditions. DOES SHE HAVE ASTHMA?

Diagnosis (cont) Exam is completely normal. DOES SHE HAVE ASTHMA? Peak Flows normal. DOES SHE HAVE ASTHMA? DOES IT MATTER? YES Severity Daytime Symptoms

Nighttime Symptoms Lung Fxn (Peak flow rate [PEF] or FEV1) Long-term control >5 years old

Mild Intermitte nt <2 d/wk < 2 nights/ Exacerbations mo brief > 80% pred PEF variability <20% No daily med Monitor inhaler use Mild Persistent >2/wk but >2 <1/d nights/mo Exacerbations may affect activity >80% pred PEF variability 20-30% Low-dose inhaled steroids (alt Moderate Persistent

Daily use SABA; exacerbations > 2/week, affects activity >1 night/wk 61-80% pred >30% PEF variability

Low to med dose inhaled corticosteroi ds AND LABA Severe Persistent Continual Frequent

< 60% pred PEF High-dose inhaled cromolyn or LTR) 19 yo woman comes in with chief complaint of nighttime coughing awakening her from sleep 2 times per month for the past 2 months, occasional wheezing during the day, worse with exercise, a couple of times per week. No current illness.

Data from the case: > 2/week daytime sxs > 2 nights/mo nighttime sxs normal PEF not ill no other medical reasons for symptoms Diagnosis (cont) Whats the treatment? Prn Albuterol? Mild Persistent Asthma = Inhaled Corticosteroid Whats my point? Asthma is a clinical

diagnosis!! Inflammatory treatment is the cornerstone of therapy. Dx of asthma Episodic symptoms of airflow obstruction are present. Airflow obstruction is at least partially reversible. Alternative diagnoses are excluded. Is spirometry necessary? No. It can help in categorizing asthma and optimizing treatment if asthma is more severe or resistant to treatment. However, most of our students have mild

asthma. Spirometry is recommended by EPR3. Pathophysiology CLINICAL SYMPTOMS Pathophysiology Mediators: T helper cells (Th1, Th2), Histamine, leukotrienes, GM-CSF, IL-4, IL-5, IL-9, IL-13, mast cells, TNF-a Basically allergic inflammation promotes rapid contraction of airway smooth muscle.

Then pro-inflammatory proteins are activated which then mediate both acute and chronic inflammation. Pathophysiology (cont) Current theories (at least in 2007) postulate that the allergic inflammation in asthma arises from an imbalance between Th1 and Th2 cells. Th2 are the destructive cascade mediators. They release cytokines which promote eosinophil growth and migration as well as mast cell differentiation and IgE production. Inhaled antigens activate mast cells and Th2 cells in the airway, causing release of histamine and cysteinyl leukotrienes (including leukotriene C4), leading to a rapid contraction of airway smooth muscles. Th1 produces cyctokine interferon-gamma which inhibits the

synthesis of IgE and the differentiation of precursor cells to Th2. Also theorized that a relative deficiency of interferon-gamma induces the Th2 cytokine pathway and promotes allergic inflammation responsible for asthma. WHEW say that fast 10 times! Illustration of TH1/TH2 THelper1 Cell THelper2 Cell Good Guy Bad Guy Pretest #1 1) All of the inflammatory mechanisms of

asthma can be reversed by inhaled steroids FALSE Asthmatic acute and chronic changes to bronchiole Obstruction of lumen of bronchiole by mucoid exudate Goblet cell metaplasia Epithelial basement membrane thickening Severe inflammation of bronchiole Potentially irreversible airway remodeling Subepithelial collagen deposition

Smooth muscle hypertrophy Microvascular hypertrophy Goblet cell hyperplasia Incomplete Reversal Good RCTs Findings of these studies can be summarized by the following: Most of the inflammatory processes of asthma are reversible, but not all in all people. The smooth muscle wall remodeling in some people does not respond to antiinflammatory treatments. Bateman et al 2004, OByrne and Paraneswaran 2006, Holgate and Polosa 2006 The Evolution of Expert Panel Reports

Consensus statements from the National Asthma Education and Prevention Program (NAEPP) EPR EPR EPR EPR 1 2 2 3 1991

1997 update 2002 2007** **Available in download PDF format from the website: www.nhlibi.nih.gov/guidelines/asthma/index.htm Evolution of EPRs Use of objective measures (including patient symptoms) of lung function to assess the severity of asthma and to monitor the course of therapy Environmental control measures to avoid or eliminate

factors that precipitate asthma symptoms or exacerbations Patient education that fosters a partnership among the patient, his or her family, and clinicians Comprehensive pharmacologic therapy for long-term management designed to reverse and prevent the airway inflammation characteristic of asthma as well as pharmacologic therapy to manage asthma exacerbations SORT Criteria Strength of Recommendation Taxonomy Evidence-grading scale 2004, AAFP PRIMARY CARE!

Patient-oriented recommendations instead of only disease- oriented or focused SORT Criteria (Strength of Recommendation Taxonomy) Evidence Category A: Randomized controlled trials (RCTs), rich body of data. Evidence Category B: RCTs, limited body of data. Evidence Category C: Nonrandomized trials and observational studies. Evidence Category D: Panel consensus judgment.

SORT example Example : While a number of observational studies suggested a cardiovascular benefit from vitamin E, a large, well-designed, randomized trial with a diverse patient population showed the opposite. The strength of recommendation against routine, long-term use of vitamin E to prevent heart disease, based on the best available evidence, should be A. Evidence Category A: RCT, rich body of data. EPR 3 Key Recommendations for Practice

Chosen by Me 1) Managing asthma long term (Evidence A) Reducing impairment Reducing risk 2) Step up/down (Evidence A) 3) Inhaled Corticosteroids (Evidence A) Just mentioning the following findings: Written action plans (Evidence B) Patient education about inadequate control (Evidence C) Validated sx checklists exist and are useful in following control (Evidence C)

Topics from the pretest Inhaled corticosteroids (Evidence A) Asthma exacerbation management how to keep students out of the emergency room (Evidence A recommendations) LABA use (Evidence A) Exercise-induced bronchospasm (Evidence A treatment) Comorbid condition evaluation and treatment(B-D) Dust mites (A) & Cockroaches (B) Sulfite sensitivity (C) & Aspirin sensitivity (C)

EPR 3 2007 Number of pages = 417 (not including the table of contents BUT lots of pages of references) 56 individuals noted to be on the committee Using past EPR 2 and update in 2004 they divided up topic areas into 4 main ones: 1) Assessment and monitoring 2) Patient education 3) Control of factors contributing to asthma severity 4) Pharmacologic treatment EPR 3 (2007)

Whats different Severity is determined by CURRENT impairment Severity and control determines level of treatment Current impairment and future risk guide treatment choices 4 severity levels of chronic asthma Mild intermittent Mild persistent Moderate persistent Severe persistent

Pretest #2 2) To know how well asthma is controlled peak flows are a must FALSE Severity Daytime Symptoms Nighttime Symptoms

Lung Fxn (Peak flow rate [PEF] or FEV1) Long-term control >5 years old Mild Intermitte nt

<2 d/wk < 2 nights/ Exacerbations mo brief > 80% pred PEF variability <20% No daily med Monitor

inhaler use Mild Persistent >2/wk but >2 <1/d nights/mo Exacerbations may affect activity >80% pred

PEF variability 20-30% Low-dose inhaled steroids (alt Moderate Persistent Daily use SABA; exacerbations

> 2/week, affects activity >1 night/wk 61-80% pred >30% PEF variability Low to med dose inhaled

corticosteroi ds AND LABA Severe Persistent Continual Frequent < 60% pred PEF High-dose inhaled cromolyn or LTR) Step Up/Down Chart SORT criteria Inhaled corticosteroids improve asthma control more effectively than any other single long-term controller medication. Evidence A Randomized controlled trials (RCTs), rich body of data.

Pedersen S, OByrne P. A comparison of the efficacy and safety of inhaled steroids in asthma. Allergy. 1997; 52(39 suppl): 1-34 Hawkins G, McMahon AD, Twaddle S, Wood SF, Ford I, Thomson NC. Stepping down inhaled corticosteroids in asthma; randomised controlled trial. BMJ. 2003; 326(7399): 1115 Expert Panel 3 2007 Pretest #3 3) All steroid inhalers are all the same and they are very affordable FALSE Inhaled Corticosteroids

The most effective long-term treatment for control of symptoms in all age groups Should be used with a spacer if possible or rinse mouth after use Can take up to 1-2 months to achieve full benefit More effective than leukotriene modifiers, longacting beta-2 agonists, cromolyn or theophylline in improving Pulmonary Fxn Preventing symptoms and exacerbations Reducing the need for emergency treatment Decreasing deaths due to asthma

Long Term Therapy (from FPM Jan/Feb 2010) Drug Low Daily Dose Med Daily Dose High Daily Dose

Fluticasone MDI 44,110,22o mcg/puff Flovent BID 88-284 mcg 264-660 mcg >660 mcg Budesonide DPI 200-600 mcg 200 mcg/inhal

Pulmicort BID 600-1200 mcg > 1200 mcg Fluticasone/ salmeterol DPI 100, 250, 500 mcg/50 mcg Advair BID 300-600 mcg (fluticasone)

> 600 mcg (fluticasone) 100-300 mcg (fluticasone) Steroid strengths and bioavailability (FPM Jan/Feb 2010) Relative strengths: Fluticasone (Flovent) > Budesonide (Pulmicort) = Beclomethasone (QVAR) > Flunisolide (AeroBid) =

Triamcinolone (Azmacort) Systemic bioavailability (contributes to side effects): 20% - Triamcinolone, Flunisolide and Beclomethasone; 11% - Budesonide; 1% Fluticasone Inhaled Steroids Adverse Effects Oral candidiasis Dysphonia (hoarseness) Reflex cough and bronchospasm

No clinically relevant changes occur in hypothalmic-pituitary-adrenal axis function at low and medium doses They cost a lot!! 2008 Medical Letter cost estimates for Some Inhaled Corticosteroids 1 month supply Medication Cost Beclomethasone HFA MDI (QVAR)

71.25 Budesonide DPI (Pulmicort) 134.88 Fluticasone HFA/MDI (Flovent) 187.20/95.82 Mometasone DPI (Asmanex) 113.92

Triamcinolone (Azmacort) 145.20 Ciclesonide HFA (Alvesco) 139.08 Flunisolide MDI (AeroBid) 90.51 WOW

Medical Letter Vol. 6 (Issue 76) December 2008 True/False 1) Best choice for a 6 year old with mild persistent asthma is an inhaled corticosteroid 2) Best choice for an 18 year old with mild persistent asthma is an inhaled corticosteroid 3) Best choice for a pregnant woman with mild persistent asthma is an inhaled corticosteroids 4) Inhaled corticosteroids at a low dose do not cause any of the following: Glaucoma Bone

loss Growth reduction Cataracts True/False (continued) Inhaled corticosteroids CAN prevent airway wall remodeling (we already talked about this!) During an asthma exacerbation doubling the inhaled corticosteroid dose may be of value Pretest #4 4) Steroid inhalers work very quickly, usually

within a day or two. FALSE Inhaled corticosteroids Can take up to 1-2 months to achieve full benefit Not particularly helpful in acute exacerbations Pretest #5 5) Asthmatics with an exacerbation need antibiotics, nebulizer treatment, and need their inhaled steroids doubled FALSE

Treatment of Asthma Exacerbations at Home Summarizing EPR 3 results and recommendations 1) Home treatment begins with peak flow measurements 2) Increase the frequency of SABA (Evidence A) 3) Initiate oral systemic corticosteroid treatment under certain circumstances (Evidence A) 4) Doubling the ICS dose is not sufficient (Evidence B) [ see next page] 5) Continue more intensive treatment for several days. For asthma exacerbations antibiotics are not helpful

unless a bacterial infection is suspected! (A) The data on doubling inhaled steroids (Myth-Busting) Flagship study: Lancet 2004 Harrison, et al 390 subjects with asthma who were at risk for exacerbation, monitored peak flows When peak flows deteriorated or when increase in sxs, given either placebo or steroid inhaler; outcome was number of people starting prednisolone. Risk was 11% for steroid inhaler and 12% for placebo, statistically no difference. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial, TW Harrison, J Oborne, S Newton, AE Tattersfield. Lancet, Vol 363 (9405) Pgs 271-275 Current available data suggests that quadrupling the dosage of

inhaled corticosteroids may be of value in mild to moderate exacerbations. Not enough data at this time to recommend. Pretest #6 6) Everyone needs to be on a combined steroid/ LABA FALSE Other pharmacologic management Most common treatments for patients with asthma are as follows: 1) LABAs (last up to 12 hours) 2) Leukotriene modifiers (montelukast, zafirlukast, zileuton) Montelukast = Singulair

Zafirlukast = Accolate Zileuton = Zyflo ER (not readily available) 3) chronic oral corticosteroids (only for most refractory disease pts) Others: Immune Modulator/IgE antibody: Xolair for persistent allergic asthma ($600/month). For moderate to persistent asthma that is not well controlled on an inhaled corticosteroid with or without LABA. Other pharmacologic treatment Mast cell stabilizer: Cromolyn (nedocromil no longer available). Relatively ineffective compared to inhaled corticosteroids

Theophylline: rarely used for persistent asthma Atrovent: has not been approved for use in asthma by FDA. Sometimes used acutely as an adjunct bronchodilator when albuterol itself is ineffective. Whats upcoming? Possibly new on horizon: Bronchial Thermoplasty (Aug 2010 Medical Letter). Severe persistant asthma. 3 trials: modestly effective in improving some asthma-related outcomes. Reduces smooth muscle mass/airway widening? 3 bronchoscopies 3

weeks apart. $2500/catheter and a RF controller ($30000) or leased. SMART trial 2006 Large trial salmeterol or placebo was added to usual asthma treatment. 13 of 13176 salmeterol-treated patients died compared to 3/13179 of placebo-treated patients. Black box warning added about higher risk of asthma-related death for all products containing LABA.

Bottom line combination treatment LABA + ICS is fine. LABA alone for mild persistent EPR3 Additional Findings (briefly) Written action plans (Evidence B) Patient education about inadequate control (Evidence C) Validated sx checklists exist and are useful in following control (Evidence C) Important to know that EHRs can be helpful and that our patients are very educable!! But still EVIDENCE C for symptom checklists and patient education!!

Validated Questionnaires Asthma-Specific Quality of Life Mini Asthma Quality of Life Questionnaire (Juniper et al. 1999a) Asthma Quality of Life Questionnaire (Katz et al. 1999; Marks et al. 1993) ITG Asthma Short Form (Bayliss et al. 2000) Asthma Quality of Life for Children (Juniper et al. 1996) Generic Quality of Life SF-36 (Bousquet et al. 1994) SF-12 (Ware et al. 1996)

Examples can be found on pages 80-81 in EPR3 Questionnaires Questionnaires generally ask about sxs for past 4 weeks; missing school or work; night sxs, SABA use, and about how well controlled they think their asthma is. Some are available online. Most questions can be asked at a routine f/u visit, often aided by an EHR. Pretest #7 7) Exercise induced asthma must be treated with pre-participation albuterol

FALSE Exercise Induced Bronchospasm Treatment Options Exercise may be the only precipitant of asthma sxs in some patients. Diagnosis criteria has been relaxed history of cough, shortness of breath, chest pain or tightness or wheezing with exercise or activity suggests EIB. Management strategies recommended by EPR3

1) Long-term control therapy, if appropriate (Evidence A) 2) Pretreatment before exercise Pretreatment before exercise (cont) Inhaled beta2-agonsists will prevent EIB in more than 80 percent of patients (Evidence A) SABA used shortly before exercise may be helpful for 2-3 hrs, LABAs can be protective for up to 12 hrs but frequent and chronic use of LABAs should be discouraged Leukotriene inhibitors can be helpful (Evidence B). Montelukast decreases exercise-induced bronchospasm in up to 50% with onset of action reported to begin as soon as 2 hrs

after admin and persisting for up to 24 hours. Cromolyn taken shortly before exercise is another alternative (Evidence B) Warmup before exercise may reduce the degree of EIB (Evidence C) A mask or scarf over mouth in the cold may help (Evidence C) Pretest #8 8) Comorbid conditions are not important to treat to achieve asthma control FALSE Comorbid conditions

In patients with inadequately controlled asthma, chronic comorbid conditions should be considered. Bronchopulmonary aspergillosis (Evidence A) GERD (Evidence B) Obesity (Evidence B) Obstructive sleep apnea (Evidence C) Rhinitis/sinusitis (Evidence B) Chronic stress/depression (Evidence C) EPR 3 panel

Comorbid conditions (cont) Not as simple as treat this and it gets better. Example of allergic rhinitis and asthma: Intranasal steroids and nonsedating antihistamines have been reported to decrease ED visits for asthma Adams et al 2002: Corren et al. 2004; Crystal-Peters et al. 2002 Comorbid conditions Of adult patients who have asthma, approximately 5 percent have poorly

controlled asthma, with frequent symptoms and exacerbations despite use of high-dose ICS Little is known about why some patients who have asthma do not respond well to therapy. A high prevalence of comorbidity has been postulated in this group (Heaney et al. 2003). Obesity and Asthma Cross sectional design 1113 members of a large integrated health care organization, 35 years or older. Mini-Asthma Quality of Life Questionnaire, Asthma Therapy Assessment Questionnaire, and self-reported

asthma-related hospitalization. Even after adjusting for demographics, smoking status, oral corticosteroid use, evidence of GERD and inhaled corticosteroid use, obese adults were more likely to report poor asthma-specific quality of life, poor asthma control and a history of asthma-related hospitalizations. Mosen et al 2008 Pretest #9 9) Cockroaches are good for asthma sufferers FALSE

Allergens and Asthma Which of the following allergens is more likely to cause disproportionately higher asthma morbidity among inner-city residents? Tree pollen House Mite Allergen Mold Cat Dander Cockroach Allergen Cockroaches are Bad Evidence: Rosenstreich, DL et al. The role of cockroach allergy and exposure to cockroach allergen in causing

morbidity among inner-city children with asthma. NEJM 1997; 336(19) 1356-1363. RCT trial; 1992-1993, 476 kids ages 4-9 yrs, baseline and 1 year Allergic to cockroach allergen(36.8%), dust mite (35%), cat (22.7%). Highest levels of hospitalization for asthma were for those who had the highest exposure to cockroach allergen in their bedrooms and were allergic. Similar patterns were not found for the combination of allergy to dust mites or cat dander and high levels of the allergen. While were talking about Cockroaches: Dust Mites Evidence A

-Encase the mattress in an allergen-impermeable cover. -Encase the pillow in an allergen-impermeable cover or wash it weekly. -Wash the sheets and blankets on the bed weekly in hot water. -A temperature of >130F is necessary for killing housedust mites. HOW LIKELY ARE OUR PATIENTS TO COMPLY WITH THIS? Pretest #10 10) Beer and advil cant make asthma worse FALSE

Sulfite sensitivity Avoiding sulfite containing products may make some patients have less sxs (Evidence C). Consider in patients with severe persistent asthma Products that can contain sulfites are as follows: Beer Wine Processed Shrimp

Dried fruit potatoes Sulfites (cont) Added sulfites are more common in wine than beer. Sulfite formation can happen naturally as a result of fermentation Sulfites are used as a preservative fairly frequently and they inhibit browning and

discourage bacterial growth FDA estimates that 1/100 people is sulfite- sensitive and that of that group 5% have asthma. Sulfites are required to be labeled Aspirin Sensitivity EPR recommends that clinicians query patient about possible bronchoconstriction by aspirin or NSAIDs (Evidence C) A syndrome that often includes rhinorrhea, nasal polyps, sinusitis, conjunctival edema

and asthma following aspirin ingestion. As many as 20 percent of adults with asthma may have worsening with NSAIDs ASA sensitivity continued Alternatives that typically do not cause bronchospasm includes acetaminophen (7% cross reactivity), salsalate, or highly selective COX-2 inhibitor celecoxib. Cross reactivity can be seen with other NSAIDs including indomethacin, naproxen, ibuprofen, fenoprofen. Treatment of choice for patients with aspirin-induced

asthma = leukotriene modifiers. Drazen et al Treatment of asthma with drugs modifying the leukotriene pathway. NEJM 1999; 340(3) 197-206. Salsalate Weakly inhibits COX-1 In the family of Non-acetyl salicylates Inexpensive (covered for $4 or $5 in most 1 month discount prescriptions) Use 2000 mg/d or less divided bid-tid (500s and 750s) Information from UptoDate Revised 5/10

I was taught that this is a good medication to consider in elderly patients due to lower GI bleed risk and cheaper than COX-2 BUT I cant find a reference so it might be true and it might not be true and we dont treat elderly patients (most of the time!) Risk Factors for Death from Asthma Asthma hx Previous severe exacerbation (intubation or ICU admit) Two or more hospitalizations for asthma in past yr 3 or more ED visits for asthma in past year Using > 2 canisters of SABA per month

Risk Factors cont: Asthma Deaths Social Hx Low socioeconomic status or inner-city residence Illicit drug use Major psychosocial problems Comorbidities Cardiovascular dz Other chronic lung dz Chronic psychiatric dz Summary

Its important to treat our patients asthma well so that their life is happier. We have a receptive and interested patient population. Our patients typically have good resources (were lucky). Immunize when able, discourage smoking, think about allergens, sulfites, address comorbid conditions as able, compliance particularly if pts sxs seems refractory to usual treatment. Summary (cont)

Inhaled corticosteroids are the cornerstone of good treatment of mild persistent asthma and above Do use symptoms as a way to measure control Dont double inhaled steroids for exacerbations Dont put everyone on oral steroids for exacerbations Dont put everyone on antibiotics for exacerbations Do look for treatable comorbid conditions Dont use LABAs alone THANK YOU!

Questions? Contact information: [email protected] References National Heart, Lung and Blood Institute. National Asthma Edication and Prevention Program (NAEPP). Expert Report Panel 3 (EPR3). Guidelines for the diagnosis and management of asthma. Full report Bethesda, MD: NHLBI, 2007. Full report: www.nhlibi.nih.gov/guidelines/asthma/index.htm Anderson, HR et al. Bronchodilator treatment and deaths from asthma: a case control study. BMJ 2005; 330:117. (Barnes and Woolcock 1998 Bateman, GD.. Am J of Repiratory Crit Care Med 2004;170(8): 834-44 Chu, EK and Drazen. Asthma: One hundred years of treatment and Onward. Am J of Resp and Crit Care Medicine. 2005; 171: 1202-1208

Drugs for Asthma. Treatment Guidelines from the Medical Letter Vol 6 (Issue 76) December 2008 Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:549-57. FDA Drug Safety Communications: New safety requirements for long-acting inhaled asthma medications called Long-Acting Beta-Agonists (LABAs) References (cont) Grotheer, P, Marshall, M, Simone, A. Sulfites: Separating Fact From Fiction. Publication #FCS8787, Institue of Food and Agricultureal Sciences, University of Florida 2005. Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet, Vol 363 (9405) Pgs 271-275 Hawkins G, McMahon AD, Twaddle S, Wood SF, Ford I, Thomson NC. Stepping down

inhaled corticosteroids in asthma; randomised controlled trial. BMJ. 2003; 326(7399): 1115 Holate and Polosa The mechanism, diagnosis, and management of severe asthma in adults. Lancet 2006;368(9537) 780-93 Review. Mosen, DM et al. The relationship between obesity and asthma severity and control in adults. J Allergy Clin Immunol 2008; 122:507 Nelson, HS et al. The Salmeterol Multicenter Asthma Research Trial: A comparison of the usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest 2006: 129:14. NHIS. National health interview survey (NHIS 2005). Hyattsville, MD: National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, 2005. http://www.cdc.gov/nchs/about/major/nhis/reports_2005.htm. OByrne, PM, Paraneswaran K. Pharmacological management of mild or moderate persistant asthma. Lancet 2006; 368(9537) 794-803. Pedersen S, OByrne P. A comparison of the efficacy and safety of inhaled steroids in asthma.

Allergy. 1997; 52(39 suppl): 1-34 References (cont) Philip, G et all. Single-dose montelukast or salmeterol as protection against exerciseinduced bronchoconstriction. Chest 2007; 132:875. Pollart SM, Elward, KS. Overview of changes to asthma guidelines: Diagnosis and Screening. Am Fam Physician 2009. May 1; 79(9): 761-67. Rosenstreich DL et al. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. NEJM 1997; 336:1356-63. Simon, RA. NSAIDS (including ASA): Allergic and pseudoallergic reactions. UpToDate. May 2010 Wikipedia for some of the asthma history information

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