Breaking new ground: challenging existing asthma guidelines

Ginger and its constituents in asthma: a mini-review

OBJECTIVE

The primary objective of this review is to focus on research findings that aim to determine the immunomodulatory action of ginger's active components and the molecular mechanisms that reduce asthma. The study aims to provide an overview of the scientific literature available on ginger's efficacy in treating allergic asthma.

DATA SOURCE

The mouse model of asthma has been used to investigate the actions of ginger and its active compounds on allergies and asthma. Various studies and scientific literature on ginger's health-improving qualities and its traditional use have been examined.

RESULTS

The findings indicate that ginger and its active ingredients have anti-asthmatic features and a suppressive impact on mast cell production of histamine. Animals given ginger and compounds derived from ginger demonstrate a notable reduction in allergic response, suggesting a significant role in lowering the allergic reaction.

CONCLUSION

While ginger shows promise as a potential treatment for allergies and asthma due to its anti-inflammatory, antibacterial, antidiabetic, anticancer, and antioxidant effects, further examination, extrapolation, and confirmation of these results are necessary before utilizing ginger and its active components in human treatments. This review highlights the need for additional research and provides an overview of the current scientific literature on ginger's efficacy in treating allergic asthma.

Differences in Baseline Characteristics and Access to Treatment of Newly Diagnosed Patients With IPF in the EMPIRE Countries

Idiopathic pulmonary fibrosis (IPF) is a rare lung disease with poor prognosis. The diagnosis and treatment possibilities are dependent on the health systems of countries. Hence, comparison among countries is difficult due to data heterogeneity. Our aim was to analyse patients with IPF in Central and Eastern Europe using the uniform data from the European Multipartner IPF registry (EMPIRE), which at the time of analysis involved 10 countries. Newly diagnosed IPF patients (N = 2,492, between March 6, 2012 and May 12, 2020) from Czech Republic (N = 971, 39.0%), Turkey (N = 505, 20.3%), Poland (N = 285, 11.4%), Hungary (N = 216, 8.7%), Slovakia (N = 149, 6.0%), Israel (N = 120, 4.8%), Serbia (N = 95, 3.8%), Croatia (N = 87, 3.5%), Austria (N = 55, 2.2%), and Bulgaria (N = 9, 0.4%) were included, and Macedonia, while a member of the registry, was excluded from this analysis due to low number of cases (N = 5) at this timepoint. Baseline characteristics, smoking habit, comorbidities, lung function values, CO diffusion capacity, high-resolution CT (HRCT) pattern, and treatment data were analysed. Patients were significantly older in Austria than in the Czech Republic, Turkey, Hungary, Slovakia, Israel, and Serbia. Ever smokers were most common in Croatia (84.1%) and least frequent in Serbia (39.2%) and Slovakia (42.6%). The baseline forced vital capacity (FVC) was >80% in 44.6% of the patients, between 50 and 80% in 49.3%, and <50% in 6.1%. Most IPF patients with FVC >80% were registered in Poland (63%), while the least in Israel (25%). A typical usual interstitial pneumonia (UIP) pattern was present in 67.6% of all patients, ranging from 43.5% (Austria) to 77.2% (Poland). The majority of patients received antifibrotic therapy (64.5%); 37.4% used pirfenidone (range 7.4–39.8% between countries); and 34.9% nintedanib (range 12.6–56.0% between countries) treatment. In 6.8% of the cases, a therapy switch was initiated between the 2 antifibrotic agents. Significant differences in IPF patient characteristics and access to antifibrotic therapies exist in EMPIRE countries, which needs further investigation and strategies to improve and harmonize patient care and therapy availability in this region.

Perspectives and Management of Atypical Asthma in Chinese Specialists and Primary Care Practitioners-A Nationwide Questionnaire Survey

Background and objective: To evaluate the awareness/knowledge and clinical practice for the treatment of atypical asthma among respiratory specialists and primary care practitioners (PCPs) in China.

Methods: A total number of 1,997 physicians participated in the survey via WeChat. The questionnaire included six main items: physician demographic characteristics, awareness, diagnosis, medical prescription, assessment/education, and proposal.

Results: Cough variant asthma (CVA) was recognized by 97.51% of physicians (1,166 respiratory specialists and 799 PCPs), followed by chest tightness variant asthma (CTVA, 83.72%) and occult asthma (73.54%). Specialists were more likely to follow diagnostic recommendations than PCPs (P < 0.01); however, 34.15% of physicians reported the utility of bronchodilation tests, airway provocation tests, and peak expiratory flow monitoring. A total of 91.70% and 92.01% of physicians prescribed inhaled corticosteroids (ICS) or ICS plus long-acting beta-agonists (LABA) for CVA and CTVA, respectively. Physicians prescribed an ICS or ICS/LABA for 4 (2–8) or 8 (4–12) weeks for CVA and 4 (2–8) or 5 (4–12) weeks for CTVA, and the prescription durations were significantly shorter for PCPs than for specialists (P < 0.01). Further, 52.42% and 35.78% reported good control of CVA and CTVA, respectively, with significantly lower control rates for PCPs than for specialists (P < 0.01). Additionally, specialists exhibited better assessment and educational habits than PCPs.

Conclusion: While atypical asthma was identified by most specialists and PCPs, there remains a gap between management in real clinical practice and guideline recommendations, especially for PCPs. Further training of PCPs and clinical studies of atypical asthma are required to improve practice.

Asthma action plan for proactive bronchial asthma self-management in adults: a randomized controlled trial

Background

Written personalized asthma action plans are recommended as part of patient education and self-management.

Objectives

To enable asthmatic adults to proactively self-manage bronchial asthma and sustain asthma quiescent status through utilization of the Asthma Action Plan (AAP), and to establish a feasible asthmatic/care taker-health care provider communication.

Design

Randomized controlled trial with cluster sampling by pulmonologists.

Setting and participants

The study comprised 320 chronic asthmatic patients attending the chest department at the main health insurance hospital in Alexandria that were randomly allocated as the intervention group (AAIG; n=160) that received standard care and intervention by the AAP and a control group (AACG; n=160) that received the routine standard of care. Data were collected through an interviewing questionnaire. The study continued over a 6-month period and passed into three phase stations. During the preparatory phase the health care provider managed to explain, fill and simplify the use of the Arabic version of the AAP, to explain the correct utilization of the weekly follow-up form and to emphasize the weekly communication/visit with the health care provider (HCP) to update their weekly follow-up records. Follow-up was done on the 90th and 180th days from the launch of the study, respectively. The study asthmatics were subjected to history-taking of their asthma symptoms, signs and triggers, and a review of their medical/peak expiratory flow records, as well as his/her daily activity and exercise.

Results

The AAIG experienced superiority of the average of the green zone days ('doing well') with significantly more episodes of early asthma flare-up self-management concomitant with prominent fewer emergency department visits, hospitalization, admission at the ICU, private health facility, and days of sickness leaves and absenteeism. A preponderance of the high and medium adherence levels to asthma medications, avoidance of asthma triggers and smoking was achieved by the AAIG.

Conclusions

AAP was the basis for effective patient-health care provider communication and patient real time asthma flare-up self-management to achieve and sustain better asthma control in asthmatic adults.

Evaluation of inhaler technique and achievement and maintenance of mastery of budesonide/formoterol Spiromax® compared with budesonide/formoterol Turbuhaler® in adult patients with asthma: the Easy Low Instruction Over Time (ELIOT) study

BACKGROUND

Incorrect inhaler technique is a common cause of poor asthma control. This two-phase pragmatic study evaluated inhaler technique mastery and maintenance of mastery with DuoResp® (budesonide-formoterol [BF]) Spiromax® compared with Symbicort® (BF) Turbuhaler® in patients with asthma who were receiving inhaled corticosteroids/long-acting β2-agonists.

METHODS

In the initial cross-sectional phase, patients were randomized to a 6-step training protocol with empty Spiromax and Turbuhaler devices. Patients initially demonstrating ≥1 error with their current device, and then achieving mastery with both Spiromax and Turbuhaler (absence of healthcare professional [HCP]-observed errors), were eligible for the longitudinal phase. In the longitudinal phase, patients were randomized to BF Spiromax or BF Turbuhaler. Co-primary endpoints were the proportions of patients achieving device mastery after three training steps and maintaining device mastery (defined as the absence of HCP-observed errors after 12 weeks of use). Secondary endpoints included device preference, handling error frequency, asthma control, and safety. Exploratory endpoints included assessment of device mastery by an independent external expert reviewing video recordings of a subset of patients.

RESULTS

Four hundred ninety-three patients participated in the cross-sectional phase, and 395 patients in the longitudinal phase. In the cross-sectional phase, more patients achieved device mastery after three training steps with Spiromax (94%) versus Turbuhaler (87%) (odds ratio [OR] 3.77 [95% confidence interval (CI) 2.05-6.95], p < 0.001). Longitudinal phase data indicated that the odds of maintaining inhaler mastery at 12 weeks were not statistically significantly different (OR 1.26 [95% CI 0.80-1.98], p = 0.316). Asthma control improved in both groups with no significant difference between groups (OR 0.11 [95% CI -0.09-0.30]). An exploratory analysis indicated that the odds of maintaining independent expert-verified device mastery were significantly higher for patients using Spiromax versus Turbuhaler (OR 2.11 [95% CI 1.25-3.54]).

CONCLUSIONS

In the cross-sectional phase, a significantly greater proportion of patients using Spiromax versus Turbuhaler achieved device mastery; in the longitudinal phase, the proportion of patients maintaining device mastery with Spiromax versus Turbuhaler was similar. An exploratory independent expert-verified analysis found Spiromax was associated with higher levels of device mastery after 12 weeks. Asthma control was improved by treatment with both BF Spiromax and BF Turbuhaler.

TRIAL REGISTRATION

EudraCT 2013-004630-14 (registration date 23 January 2014); NCT02570425 .

The effect of a holding chamber on albuterol metered-dose inhaler product differences

BACKGROUND

Three albuterol sulfate metered-dose inhaled (MDI) products (Ventolin HFA, Proventil HFA, and ProAir HFA) are marketed in the United States to provide the same total dose of albuterol sulfate. However, it is widely known that the fine particle dose (<5 μm) is the portion of the particle distribution that actually reaches the lungs and provides therapeutic benefit.

OBJECTIVE

To examine the differences in particle size between products and how a valved holding chamber (VHC) can mitigate possible adverse effects.

METHODS

Particle size distributions in each product were measured, with and without a VHC, and were analyzed by high-performance liquid chromatography.

RESULTS

The only significant mean (SD) difference in total dose was between Proventil (75 [21] μg) and ProAir (107 [12] μg) (P < .01). The fine particle doses of all 3 products were significantly different: 21 (5) μg of albuterol sulfate for Ventolin, 40 (4) μg of albuterol sulfate for Proventil, and 64 (7) μg of albuterol sulfate for ProAir (P < .001 for all 3 cases). The VHC successfully removed the larger particle dose delivered by all 3 products (P ≤ .01) without reducing the fine particle dose (P > .05).

CONCLUSION

Ventolin, Proventil, and ProAir should not be considered interchangeable products. In this study, the dose of albuterol sulfate likely to reach the lungs with Proventil or ProAir is 2 to 3 times that of Ventolin. As such, patients with asthma may require 3 additional puffs of Ventolin to achieve a clinical benefit similar to Proventil or ProAir. Because all 3 products contain 200 actuations, it also follows that Proventil or ProAir products may last a user 2 to 3 times longer than Ventolin.

Introduction of a new paediatric asthma guideline: Effects on asthma control levels

BACKGROUND

In 2008, a new national paediatric asthma management guideline based on the international Global Initiative for Asthma (GINA) guideline was launched in the Netherlands. We studied whether asthma control and treatment regimens improved after introduction of the guideline by comparing survey data before and after the guideline introduction.

METHODS

Two comparable groups of children (6-16 years) with asthma were included before (2004) and after (2013) the introduction of the guideline. Children, parents and paediatricians completed questionnaires about asthma symptoms, medication and healthcare use. Spirometry was performed.

RESULTS

Data of 209 patients were analysed. Level of asthma control did not improve between 2004 and 2013 with a proportion of (partly) controlled asthmatics of 51% in 2004 and 59% in 2013 (p = 0.28). In 2013, paediatricians characterized 76% of children as (partly) controlled, while 59% of children was (partly) controlled according to GINA criteria (p < 0.05). Step-down treatment in controlled patients was more applied by paediatricians in 2013 compared to 2004 (from 8 to 40%, p < 0.05). Step-up treatment in uncontrolled patients did not improve.

CONCLUSIONS

Asthma control did not improve after the introduction of the new guideline. Compared to 2004, an improvement was observed in step-down treatment in patients with controlled disease.

An assessment of adherence to asthma medication guidelines: findingsfrom a tertiary care center in the state of Penang, Malaysia

BACKGROUND/AIM

Multiple asthma guidelines have been developed to reduce asthma mortality, morbidity, and cost associated with asthma worldwide. In Malaysia, within this context, it is relatively unknown to what extent doctors adhere to the asthma guidelines. This study aimed to assess guideline adherence and calculate the cost of adhered and nonadhered prescriptions by medical doctors in a public tertiary health care facility.

MATERIALS AND METHODS

A cross-sectional study was carried out at Hospital Pulau Pinang, Malaysia. One hundred and eighty patients, a total of 30 patients per doctor, were enrolled to assess guideline adherence. The patients were followed for a second visit to assess their lung function. The costs of adhered and nonadhered prescriptions were calculated.

RESULTS

One hundred and forty-three patients (79%) received guideline (Global Initiative for Asthma 2011)-adhering pharmacotherapy. In the majority of patients (n = 133, 73.9%) asthma control was classified as partially controlled. There was no significant association observed between patient asthma control and patient demographics; however, there was a significant difference (P < 0.001) between lung function values from the first and second visits. The cost of adhered prescription was higher (70.1 Malaysian ringgit) than that of nonadhered prescription (13.74 Malaysian ringgit).

CONCLUSION

Fair levels of guideline adherence were observed. Emphasis should be placed on identifying appropriate cost-effective medication regimens based on patient asthma control and constant feedback from patients.

Comparison of serious inhaler technique errors made by device-naïve patients using three different dry powder inhalers: a randomised, crossover, open-label study

BACKGROUND

Serious inhaler technique errors can impair drug delivery to the lungs. This randomised, crossover, open-label study evaluated the proportion of patients making predefined serious errors with Pulmojet compared with Diskus and Turbohaler dry powder inhalers.

METHODS

Patients ≥18 years old with asthma and/or COPD who were current users of an inhaler but naïve to the study devices were assigned to inhaler technique assessment on Pulmojet and either Diskus or Turbohaler in a randomised order. Patients inhaled through empty devices after reading the patient information leaflet. If serious errors potentially affecting dose delivery were recorded, they repeated the inhalations after watching a training video. Inhaler technique was assessed by a trained nurse observer and an electronic inhalation profile recorder.

RESULTS

Baseline patient characteristics were similar between randomisation arms for the Pulmojet-Diskus (n = 277) and Pulmojet-Turbohaler (n = 144) comparisons. Non-inferiority in the proportions of patients recording no nurse-observed serious errors was demonstrated for both Pulmojet versus Diskus, and Pulmojet versus Turbohaler; therefore, superiority was tested. Patients were significantly less likely to make ≥1 nurse-observed serious errors using Pulmojet compared with Diskus (odds ratio, 0.31; 95 % CI, 0.19-0.51) or Pulmojet compared with Turbohaler (0.23; 0.12-0.44) after reading the patient information leaflet with additional video instruction, if required.

CONCLUSIONS

These results suggest Pulmojet is easier to learn to use correctly than the Turbohaler or Diskus for current inhaler users switching to a new dry powder inhaler.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01794390 (February 14, 2013).

Managing chronic rhinosinusitis and respiratory disease: a qualitative study of triggers and interactions

OBJECTIVE

The aim of this analysis is to explore views of patients with chronic rhinosinusitis (CRS) about of the aetiology of their respiratory symptoms and the relationship between upper and lower respiratory symptoms.

METHODS

This study is part of a larger mixed methods study investigating the epidemiology of CRS, which comprises a questionnaire study of patients with CRS and controls and a qualitative study of 21 patients with CRS. Semi structured qualitative interviews were undertaken with these patients; 11 males and 10 females. Twelve patients had asthma. Patients were recruited with a tertiary outpatient rhinology clinic. Interviews were transcribed verbatim and analysed using thematic analysis, using Nvivo software (QSR International, Melbourne, Australia). Several important and recurring themes were highlighted.

RESULTS

Patients described many perceived triggering factors and an interaction between upper and lower respiratory tract symptoms. They felt that their symptoms could be managed more holistically.

CONCLUSIONS

Concerns about triggers of respiratory symptoms and interactions between upper and lower respiratory symptoms are of significant concern to patients. These should be appropriately managed and acknowledged in formal treatment pathways, for example, through the use of combined ENT/respiratory clinics.

Knowledge of Asthma among Doctors Practicing in Three South Eastern States of Nigeria

Background:

Asthma is a chronic airway disease that has a significant impact on patients with substantial global socioeconomic burden. Appropriate knowledge by health care practitioners is important in the management of asthma.

Aim:

The aim was to assess the knowledge of asthma among doctors practicing in health care facilities in three South-Eastern states of Nigeria.

Subjects and Methods:

This was a descriptive cross-sectional study. The participants were selected using multi-staged sampling method and interviewed with structured, self-administered questionnaires. Comparison of the different outcome variables using the Chi-square (categorical) and Student's t-test (noncategorical) with the characteristics of the participants were done.

Result:

A total of 283 doctors were interviewed. Eighty-eight percent of them identified asthma as a common disease in our environment, (P = 0.04) but unrelated to socioeconomic status. Knowledge of epidemiology was poor among medical officers and registrars (P = 0.04). Most of the doctors (80%)(226/283) recognized the pathogenic significance of bronchospasm in exacerbation, while 58.6% (166/283) of them considered chronic inflammation as a significant factor in asthma pathogenesis P < 0.001. Majority of the doctors (84.1%) (238/283) were aware of the use of steroids in acute exacerbation, while 59.4% (168/283) considered aminophylline as the first line medication in exacerbation (P = 0.02). Knowledge about the use of steroids as controller medication was noted in 1.7% (5/283) of the respondents. Only 47.3% (134/283) of the participants were aware of the Global Initiative on Asthma guideline, (P = 0.03).

Conclusion:

There was good knowledge of epidemiology and clinical features of asthma, but a small number of the doctors had knowledge of pathophysiology and treatment of the disease. For best practices in asthma management, there is a need for further education.

Small airways dysfunction in asthma: evaluation and management to improve asthma control

The small airways have been neglected for many years, but interest in the topic has been rekindled with recent advances in measurement techniques to assess this region and also the ability to deliver therapeutics to the distal airways. Current levels of disease control in asthmatic patients remain poor and there are several contributory factors including; poor treatment compliance, heterogeneity of asthma phenotypes and associated comorbidities. However, the proposition that we may not be targeting all the inflammation that is present throughout the whole respiratory tree may also be an important factor. Indeed decades ago, pathologists and physiologists clearly identified the importance of small airways dysfunction in asthmatic patients. With improved inhaler technology to deliver drug to target the whole respiratory tree and more sensitive measures to assess the distal airways, we should certainly give greater consideration to treating the small airway region when seeing our asthmatic patients in clinic. The aim of this review is to address the relevance of small airways dysfunction in the daily clinical management of patients with asthma. In particular the role of small particle aerosols in the management of patients with asthma will be explored.

Cost considerations of therapeutic options for children with asthma

Asthma is a prevalent health condition in children, with economic implications for the individual and their family, as well as for societies with nationalized healthcare. Pharmaceutical cost is the main driver of healthcare expenditure in asthma. Existent explicit guidelines are meant to guide asthma management across all age groups, but they are failing. Pharmacologic management of asthma consists of a stepwise treatment approach to achieve symptom control. Various studies suggest a significant number of medical practitioners are prescribing inhaled corticosteroids (ICS) and ICS/long-acting beta agonist (LABA) combination inhalers inappropriately, including prescribing high doses of ICS without specialist consultation. ICS/LABA combination inhalers should only be used in persistent asthmatics, which account for approximately 5% of all children with asthma. Despite this, there is an increase in prescribing rates of ICS/LABA combination inhalers in the context of a decrease in the prevalence of asthma. Furthermore, there is inappropriate prescribing of ICS/LABA combination inhalers in children under 5 years of age, and initiation of relatively more expensive ICS/LABA combination inhalers in patients who have not previously been prescribed ICS. There is evidence to suggest that cost is a significant barrier to asthma management, especially for the more expensive ICS/LABA combination inhalers. Hence, prescribing cost-effective asthma medications appropriately is one of the most important strategies in reducing the morbidity and mortality associated with asthma. It is incumbent on every medical practitioner to not prescribe expensive medications if not indicated, both for the sake of the patient and for society.

Comparison of asthma control criteria: importance of spirometry

AIMS

To compare the measurements of asthma control using Canadian Thoracic Society (CTS) Asthma Management Consensus Summary and Global Initiative for Asthma (GINA) guidelines composite indices with and without spirometry.

METHODS

Asthma control parameters were extracted from electronic medical records (EMRs) of patients ≥6 years old at two primary care sites. Asthma control ratings calculated according to CTS and GINA criteria were compared.

RESULTS

Data were available from 113 visits by 93 patients, aged 6-85 years (38.7 ± 24.8; mean ± SD). The proportion of visits at which individuals' asthma was completely controlled was 22.1% for CTS symptoms only and 9.7% for CTS with spirometry (p < .01); and 17.7% versus 14.1% for GINA symptoms only versus symptoms with spirometry (p = .125).

CONCLUSIONS

Asthma control ratings using GINA and CTS criteria are discordant in more than half of the patients deemed "in control" by at least one scale. Differences in the spirometry criterion threshold are primarily responsible for this discordance. Failure to include spirometry as part of the control index consistently overestimates asthma control and may underestimate future risk of exacerbations.

Reassessing the evidence hierarchy in asthma: evaluating comparative effectiveness

Classical randomized controlled trials are the gold standard in medical evidence because of their high internal validity. However, their necessarily strict design can limit their external validity and the ability to extrapolate these data to real world patients. Therefore, alternatively designed studies may play a complementary role in evaluating the comparative effectiveness of therapies in nonidealized patients in more naturalistic, real world settings. Observational studies have high external validity and can evaluate real world outcomes. Their strength lies in hypothesis generation and testing and in identifying areas in which further clinical trials may be required. Pragmatic trials are designed to maximize applicability of trial results to usual care settings by relying on clinically important outcomes and enrolling a wide range of participants. A combination of these approaches is preferable and necessary.

Congruence between international guidelines and mite specific immunotherapy prescribing practices

Both rhinitis (ARIA) and asthma (GINA) guidelines recommend allergen-specific immunotherapy (SIT) tailored to the specific levels of severity of each disease. Real world studies evaluating congruence between these recommendations and prescribing practice in the single patient with comorbidity are lacking. An observational polycentric study was carried out in 518 patients recruited from 34 allergy centers throughout Italy. A questionnaire was administered to each consecutive patient over a span of four months. Taking into account guideline recommendations for both diseases, concomitant in the same patient, three subsets resulted: patients not eligible for SIT (11%); patients eligible for SIT for one disease only (60%); patients eligible for SIT for both diseases (29%). SIT was prescribed in 257 (49.6%) subjects. The level of SIT prescription was about 50% in all three groups. Consistent with the ARIA guidelines, a correlation between the prescription of SIT and the severity of rhinitis was documented (r=0.87; p=0.001). An association with asthma severity was found (p=0.02), but the trend was inconsistent with the GINA recommendations. Young age was the most important factor for SIT prescription both in the eligible for one disease and in the eligible for both diseases subset. The tendency towards worsening of symptoms was a factor for SIT in the eligible for one disease subset. In mite allergic patients with rhinitis and asthma comorbidity, the severity of rhinitis and the young age are the most important factors driving the SIT prescription. The congruence of SIT prescription was better for the ARIA than GINA guidelines.

A survey of allergic rhinitis in Taiwanese asthma patients

BACKGROUND

Allergic rhinitis (AR) often coexists with and can significantly worsen bronchial asthma (BA). We evaluated the proportion of patients with BA and concomitant AR (BA+AR) diagnosed and treated in an average clinical practice.

METHODS

A cross-sectional study methodology was used to determine the prevalence of AR in patients more than 15 years of age with a documented history of asthma who experienced wheezing during the prior 12 months. The International Study of Asthma and Allergies in Childhood standardized written questionnaire was used and therapeutic class choices were recorded.

RESULTS

Among 750 surveyed asthma patients, 524 patients (69.9%) experienced AR. Of those with BA and AR, there were 44 patients (8.4%) who were not diagnosed with AR, and the treatment rate for AR was 62.1%. The most frequent severity level of BA and AR were moderate persistent (38.9%) and intermittent mild (52.5%), respectively. There were no significant differences between patients with AR and without AR.

CONCLUSIONS

The prevalence of AR in patients with asthma was 69.9% in this study. Despite Allergic Rhinitis and its Impact on Asthma guideline recommendations encouraging evaluation and treatment of AR among asthmatics, nearly 8.4% of asthmatics with AR were undiagnosed, and 37.9% of asthmatics with AR were untreated for AR.

Prescribing patterns of asthma controller therapy for children in UK primary care: a cross-sectional observational study

Background

Asthma management guidelines recommend a stepwise approach to instituting and adjusting anti-inflammatory controller therapy for children with asthma. The objective of this retrospective observational study was to describe prescribing patterns of asthma controller therapies for children in a primary care setting.

Methods

Data from the UK General Practice Research Database were examined for children with recorded asthma or recurrent wheezing who, from September 2006 through February 2007, were ≤ 14 years old at the time of a first asthma controller prescription after ≥ 6 months without a controller prescription. We evaluated demographic characteristics, asthma duration, comorbidities, asthma-related health care resource use, and prescribed daily dose of controller medication. In addition, physicians for 635 randomly selected patients completed a survey retrospectively classifying asthma severity at the prescription date and describing therapy and health care utilization for 6 prior months.

Results

We identified 10,004 children, 5942 (59.4%) of them boys, of mean (SD) age of 8.0 (3.8) years. Asthma controller prescriptions were for inhaled corticosteroid (ICS) monotherapy for 9059 (90.6%) children; ICS plus long-acting β2-agonist (LABA) for 698 (7.0%); leukotriene antagonist monotherapy for 91 (0.9%); ICS plus leukotriene antagonist for 55 (0.6%); and other therapy for 101 (1.0%), including 45 (0.45%) children who were prescribed LABA as monotherapy. High doses of ICS (> 400 μg) were prescribed for 44/2140 (2.1%) children < 5 years old and for 420/7452 (5.6%) children ≥ 5 years. Physicians reported asthma severity as intermittent for 346/635 (55%) patients and as mild, moderate, and severe persistent for 159 (25%), 71 (11%), and 11 (2%), respectively (severity data missing for 48 [8%]). The baseline characteristics and controller therapy prescriptions of the survey cohort were similar to those of the full cohort.

Conclusions

Physician classifications of asthma severity did not always correspond to guideline recommendations, as leukotriene receptor antagonists were rarely used and high-dose ICS or add-on LABA was prescribed even in intermittent and mild disease. In UK primary care, monotherapy with ICS is the most common controller therapy at all levels of asthma severity.

Quality of care of Egyptian asthmatic children: clinicians adherence to asthma guidelines

BACKGROUND

Despite the development and dissemination of guidelines for the diagnosis and management of asthma, a gap remains between current recommendations and actual practice.

OBJECTIVES

To assess the physicians attitude towards asthma guidelines and their adherence to its recommendations.

METHODS

Three hundred and fifty two clinicians (101 General practitioners, 131 pediatric specialists, 35 pediatric consultants and 85 doctors did not report the qualification) engaged in direct childhood asthma care in Cairo, Egypt were subjected to a self-administered questionnaire with 35 questions of which most were multiple choices, aiming at assessment of three important aspects about the involved physicians; physician's knowledge, practice and attitude. 165 of the clinicians were working in governmental hospitals, 68 clinicians work in private clinics and 119 clinicians work in both.

RESULTS

Agreement with asthma guidelines was present in 76.2% of the studied physicians, however those who not in agreement with the guidelines claimed that this was mainly due to patient factors, firstly the poor socioeconomic standard of the patient (18.1%) and secondly due to poor patient compliance (16%). Poor knowledge was found in 28.5%, poor practice was found in 43.6% and poor attitude was found in 14.4% of the studied physicians. There was positive highly significant correlation between qualification and knowledge, (p<0.01), positive highly significant correlation between qualification and practice, (p<0.01), and positive highly significant correlation between qualification and attitude, (p<0.01).

CONCLUSION

The attitude of the studied physicians revealed agreement of their majority with the guidelines, while the disagreement was mainly explained by the poor socioeconomic standard of the patients. The degree of poor practice is more marked than that of poor knowledge or poor attitude reflecting resources limitations and applications obstacles in the physician's practice.

Cost effectiveness of leukotriene receptor antagonists versus long-acting beta-2 agonists as add-on therapy to inhaled corticosteroids for asthma: a pragmatic trial

BACKGROUND

Information is lacking on the relative effectiveness and cost effectiveness--in a real-life primary-care setting--of leukotriene receptor antagonists (LTRAs) and long-acting beta2 adrenergic receptor agonists (beta2 agonists) as add-on therapy for patients whose asthma symptoms are not controlled on low-dose inhaled corticosteroids (ICS).

OBJECTIVE

To estimate the cost effectiveness of LTRAs compared with long-acting beta2 agonists as add-on therapy for patients whose asthma symptoms are not controlled on low-dose ICS.

METHODS

An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma insufficiently controlled with ICS (n = 361) were randomly assigned to add-on LTRAs (n = 176) or long-acting beta2 agonists (n = 185). The main outcome measures were the incremental cost per point improvement in the Mini Asthma Quality of Life Questionnaire (MiniAQLQ), per point improvement in the Asthma Control Questionnaire (ACQ) and per QALY gained from perspectives of the UK NHS and society.

RESULTS

Over 2 years, the societal cost per patient receiving LTRAs was pounds sterling 1157 versus pounds sterling 952 for long-acting beta2 agonists, a (significant, adjusted) increase of pounds sterling 214 (95% CI 2, 411) [year 2005 values]. Patients receiving LTRAs experienced a non-significant incremental gain of 0.009 QALYs (95% CI -0.077, 0.103). The incremental cost per QALY gained from the societal (NHS) perspective was pounds sterling 22,589 (pounds sterling 11,919). Uncertainty around this point estimate suggested that, given a maximum willingness to pay of pounds sterling 30,000 per QALY gained, the probability that LTRAs are a cost-effective alternative to long-acting beta2 agonists as add-on therapy was approximately 52% from both societal and NHS perspectives.

CONCLUSIONS

On balance, these results marginally favour the repositioning of LTRAs as a cost-effective alternative to long-acting beta2 agonists as add-on therapy to ICS for asthma. However, there is much uncertainty surrounding the incremental cost effectiveness because of similarity of clinical benefit and broad confidence intervals for differences in healthcare costs.

TRIAL REGISTRATION

UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811.

History of guidelines for the diagnosis and management of asthma: from opinion to control

The Global Initiative on Asthma (GINA) was launched in 1993 in collaboration with the National Heart, Lung, and Blood Institute, the National Institutes of Health (USA) and the WHO. Its first effort was the production of a consensus report on asthma treatment, which aimed to bridge the gap between the various treatment options and the incorporation and implementation of innovative treatment forms into daily clinical practice. The first report published in 1995, A Global Strategy for Asthma Management and Prevention, has been translated into several languages, widely adopted and provided the foundation for several asthma guidelines worldwide. The GINA and other guidelines were primarily based on consensus of expert opinion in order to employ a severity-based classification system as a guide to treatment. However, in the late 1990s, guidelines underwent a major paradigm shift from opinion- to evidence-based classification as the foundation for asthma management. A second major shift involved the classification of asthma according to the level of disease control as a guide to treatment, which was realized for the first time in the revised 2006 GINA guidelines. Since their first appearance, asthma guidelines have played a leading role in disseminating information about asthma. In addition, they have had a substantial impact on standardizing asthma care around the world, which is likely to continue in the future. This article addresses the history of guideline development and issues related to asthma guidelines, with particular emphasis on the GINA guidelines.

Recommendations for treatment of intermittent mild persistent asthma in children and adolescents

Many parents and caretakers of children and adolescents with mild persistent asthma (MPA) do not follow proposed guidelines, namely the daily and continuous administration of inhaled corticosteroids (ICS). Instead, parents and caretakers tend to use ICS and bronchodilators intermittently for short periods and restart such therapy only when symptoms reappear. It is our opinion that intermittent treatment of MPA in children and adolescents might achieve the same level of asthma control as has been achieved in adults. We propose, therefore, that after an initial period of stabilization with age-appropriate doses of oral glucocorticoids or high-dose ICS and short-acting beta-2 agonists (SABA), caretakers can stop treatment once there are no longer signs or symptoms of asthma. When asthmatic symptoms recur, treatment should be restarted with ICS and SABA, or oral corticosteroids if the exacerbation is severe. The perception of developing asthma symptoms remains an unsolved problem. Based on our clinical experience in children and adolescents with asthma, we list a number of signs and symptoms that precede an exacerbation of asthma, allowing for an early re-introduction of treatment to prevent an exacerbation.

Feasibility and interpretation of FE(NO) measurements in asthma patients in general practice

BACKGROUND

Exhaled NO (FE(NO)) is a useful biomarker for the monitoring of asthma control and response to therapy. However, there is a lack of data on FE(NO) levels and their interpretation in Primary Care asthma population depending on their treatment and smoking habit. Besides, the majority of current FE(NO) tests have been done by stationary chemiluminescence analysers whose use is limited to research laboratories.

METHODS

FE(NO) measurements by the novel hand-held NO monitoring device (NIOX MINO) were made in 96 asthma patients (32 males, mean age 53+/-12) at five local General Practices during their scheduled 15-20 min visits for lung function assessment.

RESULTS

Success rate was 78% and the intra-subject coefficient of variation was 8.7%. Inhaled corticosteroid treatment had an overall reducing effect on the FE(NO) value (30.5 [19.8-49.8]) vs. patients not on the ICS (26.5 [19-94]) (p<0.044). FE(NO) levels in the ICS treated current or ex-smokers group of patients were still significantly above the normal values (p<0.0001). FE(NO) levels were similar in patients receiving ICS whether there were current, ex-smokers or non-smokers. The highest FE(NO) levels (94 [15.8-151]) were found in asthmatic current smokers and not receiving treatment with ICS. The most "normalised" FE(NO) levels (35.3 [13.5-35.3]) were seen in ex-smokers.

CONCLUSIONS

FE(NO) measurements performed with a new hand-held monitoring device are reproducible and feasible in General Practice in the majority of patients of different ages and asthma severities. A high percentage of patients with different severities of asthma and regardless of their treatment with ICS and current smoking habit (current and/or ex-smokers) had highly elevated FE(NO) values, suggesting that their current therapy was possibly insufficient to control the underlying degree of airway inflammation and asthma symptoms.

Impact of depression and anxiety on quality of life, health behaviors, and asthma control among adults in the United States with asthma, 2006

BACKGROUND

Psychological factors such as anxiety and depression are increasingly being recognized as influencing the onset and course of asthma.

METHODS

We obtained Patient Health Questionnaire 8 depression data from 41 states and territories using the 2006 Behavioral Risk Factor Surveillance System. Heath risk behaviors, social and emotional support, life satisfaction, disability, and four health-related quality-of-life (HRQOL) questions were available for all states and territories (n = 18,856 with asthma). Five additional HRQOL questions were asked in three states (n = 1345 persons with asthma), and questions assessing asthma control were available for nine states (n = 3943 persons with asthma).

RESULTS

Persons with asthma were significantly more likely than those without asthma to have current depression (19.4% vs. 7.7%), a lifetime diagnosis of depression (30.6% vs. 14.4%), and anxiety (23.5% vs. 10.2%). For most domains examined, there was a dose-response relationship between level of depression severity and mean number of days of impaired HRQOL in the past 30 days, as well as an increased prevalence of life dissatisfaction, inadequate social support, disability, and risk behaviors, such as smoking, physical inactivity, and obesity, among those with asthma. Moreover, depression and anxiety were associated with a decreased level of asthma control, including more visits to the doctor or emergency room, inability to do usual activities, and more days of symptoms compared to those without depression or anxiety.

CONCLUSION

This research indicates that a multidimensional, integrative approach to health care should be considered when assessing patients with asthma.

The associations between smoking, physical inactivity, obesity, and asthma severity in the general US population

The purpose of this study was to examine the associations between smoking, physical inactivity, obesity, and asthma severity among US adults. The magnitude of these associations was very strong. For example, those who visited an emergency room in the past year were 60% more likely than those who did not to smoke; those who used an inhaler > or =15 times in the past month (versus those who did not use an inhaler) were 90% more likely to be physically inactive; and those who had asthma symptoms all the time in the past 30 days (versus those with no symptoms) were 80% more likely to be obese.

New perspectives in the treatment of allergic rhinitis and asthma in children

PURPOSE OF REVIEW

Allergic rhinitis and asthma are some of the most prevalent chronic diseases in children. Meticulous evaluations of the therapeutic options and interventions are needed to control this burden. The central pathogenic mechanism is an immediate hypersensitivity reaction, followed by interventions in the allergic cascade. Once inflammation is established, potent anti-inflammatory agents or mediator antagonists could help control the phenomenon and reduce the characteristic symptoms related to severity.

RECENT FINDINGS

Monoclonal antibody against IgE has demonstrated its efficacy in reducing the symptoms of asthma and rhinitis. In difficult-to-treat asthma patients it allows a reduction in the dose of inhaled steroids, the number of exacerbations, emergency visits and hospitalizations. Its broad implementation is limited by its high cost because adverse events are not a concern. Specific sublingual immunotherapy gave promising results in clinical trials, while modifying immunoglobulins and cytokine profiles, also inducing T-cell tolerance. Safety issues of subcutaneous immunotherapy have been surpassed by the sublingual route, with equivalent efficacy. The new inhaled steroid ciclesonide is effective in established inflammation, is activated only in the respiratory system, and has negligible systemic effects.

SUMMARY

Robust evidence on the efficacy and safety of several novel therapies in rhinitis and asthma is available.