As-Needed Inhaled beta(2)-Adrenoceptor Agonists in Moderate-to-Severe Asthma : Current Recommendations.

Cockcroft DW.

Division of Respiratory Medicine, Department of Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada.

Intermediate-acting inhaled beta(2)-agonists (e.g. albuterol [salbutamol]), once recommended for round-the-clock bronchodilation, are now recommended to be used exclusively as-needed. Guidelines advise that asthma should be controlled with anti-inflammatory therapeutic strategies so that the as-needed requirement for inhaled beta(2)-agonists should be infrequent; ideally less than several times per week, up to once a day for exercise, and none at night. These recommendations are based upon the recognition that asthma is primarily an inflammatory condition and that the major thrust of therapy should be anti-inflammatory, including environmental control and administration of inhaled corticosteroids (ICS), leukotriene-receptor antagonists, and possibly oral theophylline and inhaled cromones; the cromones include cromolyn sodium (sodium cromogylcate) and nedocromil. While this is the primary rationale behind the as-needed infrequent prescription of the inhaled beta(2)-agonist paradigm, there are a number of detrimental effects that can be seen with regularly scheduled (or frequent as-needed) use of inhaled beta(2)-agonists. These include tolerance to the bronchodilator and particularly the bronchoprotective effects, increased airway responsiveness to allergen, worsened asthma control, and, probably most importantly, over-reliance on an excellent symptom reliever leading to undertreatment. Any or all of these could be responsible for the demonstrated dose-response relationship between inhaled beta(2)-agonist overuse and death from asthma. Several controlled clinical trials, which have included many patients with at least moderately severe asthma, have failed to demonstrate any obvious advantage to the regular scheduled use of inhaled beta(2)-agonists compared with as-needed inhaled beta(2)-agonists. On the other hand, despite no obvious advantage, regular use of albuterol 1000-1200 mug/day appears to be well tolerated and reasonably safe. When asthma is treated using an as-needed, infrequent inhaled beta(2)-agonist, the requirements for beta(2)-agonists become a useful marker of whether or not the asthma is adequately controlled. When inhaled beta(2)-agonists are required inordinately frequently (i.e. when asthma is not adequately controlled), after ensuring compliance with ICS, the most common strategy is to add one of the long-acting inhaled beta(2)-agonists twice daily. On the basis of the available evidence, the as-needed intermediate-acting inhaled beta(2)-agonist therapeutic strategy appears appropriate for patients with moderate-to-severe asthma.

Online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15987233&dopt=Abstract asthma, asthma drug, asthma medicine




Burden of rhinitis in children with asthma.

Sekerel BE.

Pediatric Allergy and Asthma Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Although the clinical association of allergic rhinitis and asthma has been recognized for centuries, in recent years the association appears to be stronger than was reported previously. However, data for children are less clear, and some studies indicate that results observed in developing countries may differ from those observed in Western populations. We therefore intended to document the association of rhinitis with pediatric asthma in terms of caregivers' perception, physician practice, and file records. Asthmatic children aged 3-16 years with at least 1-year follow-up in an allergy-asthma outpatient clinic were invited to participate in the study during a 10-month interval. In addition to a face-to-face questionnaire-based interview, file records were evaluated retrospectively to obtain information relating to asthma and rhinitis. Of 396 patients included in the study, 369 with consistent replies were included in the analyses. The mean age of the study group was 10.6 +/- 0.2 (mean +/- SEM) years, and a greater proportion of the respondents were male (63.7%), atopic (78.3%), and mildly asthmatic (50.7%). House dust mite and grass pollens were the most commonly sensitized allergens (50.7% and 46.9%, respectively). Although only 5.4% of our study population regarded themselves as rhinitic and 23.8% had been diagnosed with allergic rhinitis according to the file records, almost 57.7% of patients had required medications for rhinitis within the last year, and 68.8% had findings consistent with allergic rhinitis. Furthermore, 41.2% and 58.8% reported that their rhinitis symptoms caused a significant burden in their daily life and exacerbated their asthma, respectively, and almost 50% felt that their rhinitis had not been given significant consideration by their physician. In conclusion, although we report a large discrepancy between caregivers' perception of rhinitis, documentation in file records, and treatments for rhinitis, the allergic rhinitis prevalence determined in the survey and the medication use for rhinitis appeared to be in agreement. We recommend a greater effort be made to identify, label, and educate children with rhinitis and their families in asthma outpatient clinics. Pediatr Pulmonol. (c) 2005 Wiley-Liss, Inc.

Online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15988738&dopt=Abstract asthma, asthma drug, asthma medicine




Cost and Management of Asthma Exacerbations in Spanish Hospitals (COAX Study in Hospital Services).

[Article in English, Spanish]

Lumbreras Garcia G.

Servicio de Neumologia. Hospital San Jorge. Huesca. Espana.

Objective: The prevalence and associated health cost of asthma have been increasing in developed countries, and 70% of the overall disease cost is due to exacerbations. The primary objective of this study was to determine the hospital cost of an asthma exacerbation in Spain. The secondary objective was to determine what maintenance treatments patients were using to control asthma before the exacerbation and how the exacerbation was treated. The study formed part of a broader study (COAX II), with the same objectives in each of the 8 participating European countries. Patients and Methods: Prospective observational study that enrolled 126 patients with an asthma exacerbation treated in the usual way in 6 Spanish hospitals over a 3-month period (from January 1 to March 31, 2000). RESULTS: According to the criteria of the Global Initiative for Asthma, 33.3% of the exacerbations were mild, 38.9% moderate, 26.2% severe, and 1.6% were associated with risk of imminent respiratory arrest. Use of corticosteroids was widespread among patients with moderate and severe asthma, but only 68% of the patients with severe asthma used long-acting beta2 agonists. The mean cost was ;1555.70 (95% confidence interval [CI], ;1237.60-;1907.00), of which 93.8% (;1460.60; 95% CI, ;1152.50-;1779.40) was due to direct costs, and 6.2% (;95.10; 95% CI, ;35.50-;177.00) to indirect costs. Cost rose with increasing severity of the exacerbation- ;292.60 for a mild exacerbation, ;1230.50 for a moderate exacerbation, and ;3543.10 for a severe exacerbation. CONCLUSIONS: The mean cost was s1555.70. The costs of moderate and severe exacerbations were 4 and 12 times that of a mild exacerbation, respectively. Long-acting beta2 agonists were less widely used than recommended by the guidelines for treatment of moderate and severe persistent asthma leading to asthma exacerbations.

Online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15989888&dopt=Abstract asthma, asthma drug, asthma medicine




Bronchial Exudate of Serum Proteins During Asthma Attack.

[Article in English, Spanish]

Sanchis J.

Clinica d'Asma i Al.lergia. Departament de Pneumologia. Hospital de la Santa Creu i de Sant Pau. Barcelona. Spain.

Objective: Although altered vascular permeability and edema of the bronchial mucosa are associated with asthma attack, their influence on its severity remains unknown. We address this issue by comparing relative indices for the concentration of albumin (RIAlb) and alpha2-macroglobulin (RIalpha2M) in induced sputum and peripheral blood from patients with exacerbated asthma, patients with stable asthma, and control subjects. Patients and methods: Forty-six volunteers participated in the study: 14 with exacerbated asthma (forced expiratory volume in the first second [FEV1] 74.3% [SD, 20.8%] of reference), 23 with stable asthma (FEV1 93.6% [7.5%]), and 9 controls (FEV1 101.1% [9.9%]). The concentrations of albumin and alpha2-macroglobulin were quantified by immunoturbidimetry and immunonephelometry, respectively. The relative index was then calculated by dividing the concentration in sputum supernatant by the concentration in peripheral blood. RESULTS: The mean RIAlb was 1.2 (1.1) in the control group, 2.9 (3.1) in the stable asthma group, and 6.0 (6.7) in the exacerbated asthma group. The RIalpha2M values were 11.7 (10.9), 11.9 (14.7), and 3.2 (3.8) for the control group and stable and exacerbated asthma groups, respectively. The increases in the RIAlb values between all groups, and the decrease in the RIalpha2M value between the exacerbated asthma and control groups were statistically significant (P<.05). The percentage of neutrophils, but not of eosinophils, in sputum was correlated with the RIAlb (r=0.39; P=.008) but not the RIalpha2M (r=--0.035; P=.82). FEV1 displayed an inverse relationship with the RIAlb (r=--0.43; P=.009) but not with the RIalpha2M (r=--0.206; P=.24). No correlation was found between oxyhemoglobin saturation and either the RIAlb (r=--0.33; P=.19) or the RIalpha2M (r=--0.12; P=.84). CONCLUSIONS: Vascular permeability is altered during asthma exacerbations and appears to be correlated with the presence of neutrophils and the degree of bronchial obstruction.

Online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15989890&dopt=Abstract asthma, asthma drug, asthma medicine




Timing and intensity of early fevers and the development of allergies and asthma.

Johnson CC.

Background Early childhood fevers appear to protect against later allergies and asthma. What is not known is the time in which fevers exert this effect and whether the degree of temperature increase is important. Objective We sought to examine the relationship between the time and degree of early fevers and later allergies and asthma. Methods Eight hundred thirty-five children from southeast Michigan were enrolled at birth. Clinic records from their first 2 years were abstracted for episodes of fever. At age 6 to 7 years, children underwent allergy testing. We examined fevers occurring within 6-month intervals in the first 2 years of life and outcomes at age 6 to 7 years. The primary outcome measures were allergic sensitization, asthma, asthma with allergic sensitization, and asthma without allergic sensitization. Results In the unadjusted analysis each episode of fever between 7 and 12 months of age was associated with a lower odds of allergic sensitization (odds ratio [OR], 0.71; 95% CI, 0.54-0.93) and asthma with allergic sensitization (OR, 0.43; 95% CI, 0.21-0.90) at age 6 to 7 years. Likewise, every 1 degrees C increase in the maximum temperature between 7 and 12 months was associated with a lower odds of allergic sensitization (OR, 0.77; 95% CI, 0.61-0.96) and asthma with allergic sensitization (OR, 0.62; 95% CI, 0.40-0.94). After adjusting for potential confounders, each episode of fever between 7 and 12 months was associated with a lower likelihood of asthma with allergic sensitization (adjusted OR, 0.33; 95% CI, 0.11-0.94) at age 6 to 7 years. Conclusions Both the timing and intensity of childhood fevers appear to be important factors in the development of allergies and asthma.

Online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15990781&dopt=Abstract asthma, asthma drug, asthma medicine




Undiagnosed asthma in older people: an underestimated problem.

Ruffin RE.

Department of Medicine, University of Adelaide, Queen Elizabeth Hospital, Woodville Road, Adelaide, SA 5011, Australia. david.wilson adelaide.edu.au.

WHAT WE NEED TO KNOW Are older people with respiratory symptoms aware this could be asthma? Which explanations for undiagnosed asthma apply most commonly in older Australians with asthma? Can we improve awareness of asthma in older people with undiagnosed asthma? Is the possibility of asthma in older people firmly established on the general practitioners' radar screen? What reasons most often determine whether GPs perform spirometry in their practice? WHAT WE NEED TO DO Conduct a representative population study to assess whether older Australians recognise respiratory symptoms as being asthma and are reporting these symptoms. Conduct and evaluate a pilot asthma health promotion program for older people. Conduct a controlled therapeutic trial of people with undiagnosed asthma to assess treatment benefits and produce treatment recommendations. Identify whether the prominence of asthma in older people can be brought to the attention of GPs. Analyse more carefully the issues associated with innovation of office spirometry.

Online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15992315&dopt=Abstract asthma, asthma drug, asthma medicine




Understanding asthma in older Australians: a qualitative approach.

Douglass JA.

Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital and Monash University, Commercial Road, Prahran, VIC 3181, Australia. d.goeman alfred.org.au.

WHAT WE NEED TO KNOW Are there differences in symptom interpretation in older people with asthma? What are effective drug delivery strategies in older people to maximise adherence and minimise side effects? How do older people with asthma manage their asthma? Are self-management strategies as appropriate as they are in younger age groups? Do older people with asthma take appropriate steps in an emergency? Do they own or act on asthma action plans? WHAT WE NEED TO DO Identify the specific barriers that prevent the optimal care of older people with asthma. Address systematic barriers, such as cost and immobility, that reduce access to effective treatments. Ensure older people with asthma receive appropriate asthma treatment. Explore asthma self-management strategies in older people to develop effective algorithms. Educate health professionals to provide optimal asthma treatments and deliver appropriate education designed specifically for older people.

Online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15992317&dopt=Abstract asthma, asthma drug, asthma medicine




Distinguishing asthma and chronic obstructive pulmonary disease: why, why not and how?

Wood-Baker R.

Woolcock Institute of Medical Research, Royal Prince Alfred Hospital, PO Box M77, Missenden Road, Camperdown, NSW 2050, Australia. crj med.usyd.edu.au.

WHAT WE NEED TO KNOW What are the essential differences in the inflammatory process that lead to different pathological outcomes in asthma and chronic obstructive pulmonary disease (COPD)? What factors cause some patients with asthma to have clinical features indistinguishable from COPD, and should these patients be treated differently from those with early-onset, atopic asthma? What should be added to FEV(1) improvement after bronchodilator to enhance the ability of spirometry to distinguish between asthma and COPD? Why is disturbed gas exchange characteristic of stable COPD but rare in asthma? Why and when does COPD become a systemic disease with multiorgan dysfunction, while asthma generally does not? Does the response to bronchodilators in asthma and COPD predict prognosis and response to other interventions? Do people with asthma (airway obstruction, hyper-responsiveness and atopy) and COPD (fixed airflow limitation) have different natural histories, responses to treatment and prognoses? WHAT WE NEED TO DO Evaluate new diagnostic tools (eg, indirect markers of inflammation) for asthma and COPD. Target older people in epidemiological studies to identify and describe the extent of asthma. Initiate community awareness programs to help older people with dyspnoea recognise they may have symptoms of asthma or COPD that should be assessed by a doctor. Define the clinical and physiological features of asthma and COPD in older people that indicate when and which treatments will achieve maximum benefit with least harm. Develop strategies for better, patient-focused care of people with severe airway disease, concentrating on device use, action plans, side effects, end-of-life decisions, exercise and independence in activities of daily living. Maintain research into new drugs and targets for preventing progressive loss of lung function in asthma and COPD.

Online pharmacy ref source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15992321&dopt=Abstract asthma, asthma drug, asthma medicine