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Lugogo N, O'Connor M, George M, Merchant R, Bensch G, Portnoy J, Oppenheimer J, Castro M. Expert Consensus on SABA Use for Asthma Clinical Decision-Making: A Delphi Approach. Curr Allergy Asthma Rep 2023; 23:621-634. [PMID: 37991672 PMCID: PMC10716188 DOI: 10.1007/s11882-023-01111-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE OF REVIEW A modified Delphi process was undertaken to provide a US expert-led consensus to guide clinical action on short-acting beta2-agonist (SABA) use. This comprised an online survey (Phase 1), forum discussion and statement development (Phase 2), and statement adjudication (Phase 3). RECENT FINDINGS In Phase 1 (n = 100 clinicians), 12% routinely provided patients with ≥4 SABA prescriptions/year, 73% solicited SABA use frequency at every patient visit, and 21% did not consult asthma guidelines/expert reports. Phase 3 experts (n = 8) reached consensus (median Likert score, interquartile range) that use of ≥3 SABA canisters/year is associated with increased risk of exacerbation and asthma-related death (5, 4.75-5); SABA use history should be solicited at every patient visit (5, 4.75-5); usage patterns over time, not absolute thresholds, should guide response to SABA overuse (5, 4.5-5). Future asthma guidelines should include clear recommendations regarding SABA usage, using expert-led thresholds for action.
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Affiliation(s)
- Njira Lugogo
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Maeve O'Connor
- Allergy Asthma and Immunology Relief, Charlotte, NC, USA
| | - Maureen George
- Columbia University School of Nursing, New York, NY, USA
| | - Rajan Merchant
- Woodland Clinic Medical Group, Allergy Department, Dignity Health, Woodland, CA, USA
| | - Greg Bensch
- Allergy Immunology and Asthma Medical Group, Stockton, CA, USA
| | - Jay Portnoy
- Section of Allergy, Asthma & Immunology, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - John Oppenheimer
- Department of Internal Medicine, New Jersey Medical School, Newark, NJ, USA
- Pulmonary and Allergy Associates, Morristown, NJ, USA
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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2
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Krings JG, Sekhar TC, Chen V, Blake KV, Sumino K, James AS, Clover AK, Lenze EJ, Brownson RC, Castro M. Beginning to Address an Implementation Gap in Asthma: Clinicians' Views of Prescribing Reliever Budesonide-Formoterol Inhalers and SMART in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2767-2777. [PMID: 37245736 DOI: 10.1016/j.jaip.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND The Global Initiative for Asthma and National Asthma Education and Prevention Program recently made paradigm-shifting recommendations regarding inhaler management in asthma. The Global Initiative for Asthma now recommends that combination inhaled corticosteroid (ICS)-formoterol inhalers replace short-acting β-agonists as the preferred reliever therapy at all steps of asthma management. Although the most recent guidelines of the National Asthma Education and Prevention Program did not review reliever ICS-formoterol usage in mild asthma, they similarly recommended single maintenance and reliever therapy (SMART) at steps 3 and 4 of asthma management. Despite these recommendations, many clinicians-particularly in the United States-are not prescribing new inhaler paradigms. Clinician-level reasons for this implementation gap remain largely unexplored. OBJECTIVE To gain an in-depth understanding of the facilitators and barriers to prescribing reliever ICS-formoterol inhalers and SMART in the United States. METHODS Community and academic primary care providers, pulmonologists, and allergists who reported regularly caring for adults with asthma were interviewed. Interviews were recorded, transcribed, qualitatively coded, and analyzed using the Consolidated Framework for Implementation Research. Interviews were continued until theme saturation. RESULTS Among 20 interviewed clinicians, only 6 clinicians described regularly prescribing ICS-formoterol inhalers as a reliever inhaler (either alone or within SMART). Significant barriers to new inhaler approaches included concerns surrounding a lack of Food and Drug Administration labeling for ICS-formoterol as a reliever therapy, a lack of awareness regarding a patient's formulary-preferred ICS-long-acting β-agonist choices, the high cost of combination inhalers, and time constraints. Facilitators to using new inhaler approaches included clinicians' beliefs that the latest inhaler recommendations are simpler and more congruent with real-world patients' behavior, and that a potential change in management strategy would offer a valuable opportunity for shared decision making. CONCLUSIONS Although new guidelines exist in asthma, many clinicians described significant barriers to using them including medicolegal issues, pharmaceutical formulary confusion, and high drug costs. Nonetheless, most clinicians believed that the latest inhaler approaches would be more intuitive for their patients and would offer an opportunity for patient-centered collaboration and care. Stakeholders may find these results useful in future attempts to increase the real-world adoption of recent asthma recommendations.
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Affiliation(s)
- James G Krings
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo.
| | - Tejas C Sekhar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Vanessa Chen
- Brown School of Social Work and Public Health, Washington University in St Louis, St Louis, Mo
| | - Kathryn V Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health, Jacksonville, Fla
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Aimee S James
- Occupational Therapy and Surgery (Public Health Sciences), Washington University in St Louis School of Medicine, St Louis, Mo
| | - Amber K Clover
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Eric J Lenze
- Department of Psychiatry, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Ross C Brownson
- Prevention Research Center, Brown School, Washington University in St Louis, St Louis, Mo
| | - Mario Castro
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Kansas, Kansas City, Kan
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Myers AL, Fussell JJ, Moffatt ME, Boyer D, Ross R, Dammann CEL, Degnon L, Weiss P, Sauer C, Vinci RJ. The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children. J Pediatr 2023:13365. [PMID: 36894130 DOI: 10.1016/j.jpeds.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. 65 Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. 66 The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. 67 In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.
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Affiliation(s)
- Angela L Myers
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Jill J Fussell
- Professor, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR
| | - Mary E Moffatt
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Debra Boyer
- DIO/Chief Medical Education Officer, Professor of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Robert Ross
- Children's Hospital of Michigan, Professor of Pediatrics, Central Michigan University College of Medicine, Detroit, MI
| | | | | | - Pnina Weiss
- Professor of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Cary Sauer
- Professor of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Robert J Vinci
- Professor of Pediatrics, Boston University School of Medicine, Boston, MA
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Alyami SM, Alshahwan MI, Alshammari HS, Abugamza FM, Alotaibi SN, Abuoliat OA. Reassessment of the Need for Asthmatic Patients for Biologic Treatment in a Tertiary Care Hospital. Cureus 2023; 15:e36288. [PMID: 36937129 PMCID: PMC10022474 DOI: 10.7759/cureus.36288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Asthma is a common chronic inflammatory airway condition. In difficult-to-treat asthma, poor control can be linked to multiple factors like the presence of uncontrolled comorbidities (e.g. gastroesophageal reflux and allergic rhinitis), as well as to poor inhaler use techniques and adherence. In this study we wanted to evaluate our severe asthma patients already on a biologic treatment with regard to presence of any of these factors. Method: A questionnaire-based study, filled by investigators through direct interview with patients. We included all asthma patients on biologic treatment at King Abdul Aziz Medical City, Riyadh, KSA. Started in October 2020 and ended in December 2020. The questionnaire had a demographic section and sections for asthma symptoms, compliance, inhaler techniques, and comorbidities. RESULT Case series of N=38 severe asthma patients showed that majority had partially controlled or uncontrolled asthma (66%). Some 42% had intermediate/high risk for obstructive sleep apnea (OSA) based on the common screening tool "STOPBANG" score. Some 47% of our patients had uncontrolled gastro-esophageal reflux disease (GERD), and majority (80%) had uncontrolled allergic rhinitis. Only half of them demonstrated appropriate inhaler technique. And none of them was found exposed to asthma triggers at the time of interview. CONCLUSION Significant number of severe uncontrolled asthmatic patients were shown to be associated with at least one comorbid condition that might be interfering with patients' improvement in asthmatic symptoms. By taking appropriate measures toward management and controlling of those comorbid conditions and also educating patients about technique to use inhalers might show notable improvement in asthmatic patients' condition.
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Affiliation(s)
| | - Mosaad I Alshahwan
- Pulmonary Medicine, King Saud Bin Abdul Aziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Hamad S Alshammari
- Pulmonary Medicine, King Saud Bin Abdul Aziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Faisal M Abugamza
- Pulmonary Medicine, King Saud Bin Abdul Aziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Sultan N Alotaibi
- Pulmonary Medicine, King Saud Bin Abdul Aziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Omar A Abuoliat
- Pulmonary Medicine, King Saud Bin Abdul Aziz University for Health Sciences College of Medicine, Riyadh, SAU
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5
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Krings JG, Wojcik KM, Chen V, Sekhar TC, Harris K, Zulich A, Sumino K, Brownson R, Lenze E, Castro M. Symptom-driven inhaled corticosteroid/long-acting beta-agonist therapy for adult patients with asthma who are non-adherent to daily maintenance inhalers: a study protocol for a pragmatic randomized controlled trial. Trials 2022; 23:975. [PMID: 36471430 PMCID: PMC9720948 DOI: 10.1186/s13063-022-06916-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/11/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND While inhaled corticosteroids (ICS) are considered the essential foundation of most asthma therapy, ICS inhaler nonadherence is a notoriously common problem and a significant cause of asthma-related morbidity. Partially acknowledging the problem of nonadherence, international organizations recently made paradigm-shifting recommendations that all patients with mild-to-moderate persistent asthma be considered for symptom-driven ICS-containing inhalers rather than relying on adherence to traditional maintenance ICS inhalers and symptom-driven short-acting beta-agonists (SABA). With this new approach, asthma patients are at least exposed to the important anti-inflammatory effects of ICS-containing inhalers when their symptom reliever inhaler is deployed due to acute symptoms. METHODS This study will (Part 1) complete a pragmatic randomized controlled trial to evaluate if an inhaler strategy that utilizes symptom-driven ICS inhalers is particularly beneficial in maintenance ICS inhaler non-adherent asthma patients, and (Part 2) use a dissemination and implementation (D&I) science conceptual framework to better understand patients' and providers' views of inhaler nonadherence. This study, which will have an option of taking place entirely remotely, will use a Food and Drug Administration (FDA)-approved electronic sensor (Hailie® sensor) to monitor inhaler adherence and includes semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR). DISCUSSION This study is assessing the problem of nonadherence using a D&I implementation science research lens while testing a new inhaler approach to potentially ameliorate the detrimental consequences of maintenance inhaler nonadherence. We hypothesize that the use of a symptom-driven ICS/LABA management strategy, as compared to traditional maintenance ICS treatment and symptom-driven SABA, will lead to improved adherence to an asthma treatment strategy, decreased asthma-related morbidity, less cumulative ICS exposure, and greater patient satisfaction with an inhaler approach. TRIAL REGISTRATION ClinicalTrials.gov NCT05111262. Registered on November 8, 2021.
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Affiliation(s)
- James G Krings
- Division of Pulmonary and Critical Care Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, MO, 63110, USA.
| | - Kaitlyn M Wojcik
- Brown School of Social Work and Public Health, Washington University in Saint Louis, Saint Louis, MO, 63110, USA
| | - Vanessa Chen
- Brown School of Social Work and Public Health, Washington University in Saint Louis, Saint Louis, MO, 63110, USA
| | - Tejas C Sekhar
- Division of Pulmonary and Critical Care Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, MO, 63110, USA
| | - Kelly Harris
- Program in Occupational Therapy, Washington University in Saint Louis School of Medicine, Saint Louis, MO, 63110, USA
| | - Abigail Zulich
- Division of Pulmonary and Critical Care Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, MO, 63110, USA
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, MO, 63110, USA
| | - Ross Brownson
- Brown School of Social Work and Public Health, Washington University in Saint Louis, Saint Louis, MO, 63110, USA
| | - Eric Lenze
- Division of Psychiatry, Washington University in Saint Louis School of Medicine, Saint Louis, MO, 63110, USA
| | - Mario Castro
- Division of Pulmonary Critical Care and Sleep Medicine, University of Kansas, Kansas City, KS, 66103, USA
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Codonopsis laceolata Water Extract Ameliorates Asthma Severity by Inducing Th2 Cells’ and Pulmonary Epithelial Cells’ Apoptosis via NF-κB/COX-2 Pathway. Processes (Basel) 2022. [DOI: 10.3390/pr10071249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Asthma is an incurable pulmonary disease with several symptoms, including abnormal breathing, coughing, and sleep apnea, which can lead to death, and the population of asthma patients has been increasing worldwide. There are many adverse effects in current drugs, and thus, we have tried to develop anti-asthmatic agents from natural products such as Codonopsis laceolata. To define the anti-asthmatic effect and the mechanism of Codonopsis laceolata, an animal study was conducted considering different cell counts of BALF, serum IgE levels, morphological changes in the pulmonary system, the Th2 cell transcription factor (GATA-3), and the apoptotic pathway (NF-κB/COX-2). Codonopsis laceolata significantly suppressed the representative asthmatic changes, such as airway remodeling, mucous hypersecretion, epithelial hyperplasia, and inflammatory cell infiltration, in the respiratory system. It suppressed the levels of GATA-3, IL-4, and IL-13. The down-regulation of Th2-related factors, such as GATA-3, IL-4, and IL-13, results from the stimulated apoptosis of Th2 cells and epithelial cells via a decrease in the levels of NF-κB and COX-2. We concluded that Codonopsis laceolata might be a promising anti-asthmatic drug.
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Cheong AT, Lee PY, Shariff-Ghazali S, Salim H, Hussein N, Ramli R, Pinnock H, Liew SM, Hanafi NS, Abu Bakar AI, Mohd Ahad A, Pang YK, Chinna K, Khoo EM. Implementing asthma management guidelines in public primary care clinics in Malaysia. NPJ Prim Care Respir Med 2021; 31:47. [PMID: 34845205 PMCID: PMC8630037 DOI: 10.1038/s41533-021-00257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 10/27/2021] [Indexed: 11/09/2022] Open
Abstract
Implementing asthma guideline recommendations is challenging in low- and middle-income countries. We aimed to explore healthcare provider (HCP) perspectives on the provision of recommended care. Twenty-six HCPs from six public primary care clinics in a semi-urban district of Malaysia were purposively sampled based on roles and experience. Focus group discussions were guided by a semi-structured interview guide and analysed thematically. HCPs had access to guidelines and training but highlighted multiple infrastructure-related challenges to implementing recommended care. Diagnosis and review of asthma control were hampered by limited access to spirometry and limited asthma control test (ACT) use, respectively. Treatment decisions were limited by poor availability of inhaled combination therapy (ICS/LABA) and free spacer devices. Imposed Ministry of Health programmes involving other non-communicable diseases were prioritised over asthma. Ministerial policies need practical resources and organisational support if quality improvement programmes are to facilitate better management of asthma in public primary care clinics.
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Affiliation(s)
- Ai Theng Cheong
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia.
| | - Ping Yein Lee
- UM eHealth Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sazlina Shariff-Ghazali
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- Malaysian Research Institute on Ageing™, Universiti Putra Malaysia, Serdang, Malaysia
| | - Hani Salim
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Norita Hussein
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Rizawati Ramli
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Hilary Pinnock
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Su May Liew
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nik Sherina Hanafi
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Azainorsuzila Mohd Ahad
- Klinik Kesihatan Lukut, Ministry of Health Malaysia, Port Dickson, Negeri Sembilan, Malaysia
| | - Yong Kek Pang
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Karuthan Chinna
- School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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8
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Rosman Y, Gabay L, Landau T, Confino-Cohen R. Childhood Asthma - The Effect of Asthma Specialist Intervention on Asthma Control: A Retrospective Review. J Asthma Allergy 2021; 14:1367-1373. [PMID: 34785910 PMCID: PMC8591108 DOI: 10.2147/jaa.s334560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Childhood asthma is the most common chronic disease throughout the western world. Improving asthma control is a leading health management goal. Purpose To evaluate the effect of an intervention by a visit to an asthma specialist on asthma control in children. Materials and Methods This retrospective study was conducted using the electronic database of Maccabi Health Services. All members ages 5-16 with an asthma diagnosis during 2000-2016, and at least one visit to a specialist were included. Asthma outcomes during the 2 years before and after the visit to the asthma specialist were compared. Results A total of 37,066 children were diagnosed with asthma. Among them, 13,533 (36.5%) had at least one visit to an asthma specialist and were included. Children with asthma visited their primary care physician more often in the period before the specialist visit (4.4± 4.4 vs 3.16± 3.9 visits, respectively; p<0.01). After visiting a specialist, average number of visits to emergency departments (0.52± 1.3 vs 0.45±1), all cause hospitalizations (0.13±0.45 vs 0.08±0.4) and hospitalizations due to asthma exacerbations (0.08±0.345 vs 0.05±0.3) decreased (p<0.01 for all comparisons). Prescription of short-acting beta agonists decreased (2.85±3.6 vs 2.2 ±3.7, p<0.01) and inhaled steroid prescriptions increased (1.9±2.9 vs 2.7±3.7, p<0.01), respectively, after the intervention. A substantial reduction in the prescription of corticosteroids (0.81±1.9 vs 0.43±1.4, p<0.01) after specialist visit was also noted. Conclusion We found significant positive outcomes after a single consultation with an asthma specialist. Referring pediatric asthma patients to an asthma specialist should be one of the goals of an asthma management plan.
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Affiliation(s)
- Yossi Rosman
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Linoy Gabay
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Tami Landau
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Ronit Confino-Cohen
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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9
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Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated with Pediatric Intensive Care Use for Life-threatening Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:981-991.e1. [PMID: 34775118 DOI: 10.1016/j.jaip.2021.10.065] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Social determinants of health are associated with asthma prevalence and healthcare use in children with asthma, but are multifactorial and complex. Whether social determinants similarly influence exacerbation severity is not clear. OBJECTIVE Composite measures of social determinants of health and readmission outcomes were evaluated in a large regional cohort of 1,403 school-age children admitted to a pediatric intensive care unit (PICU) for asthma. METHODS Residential addresses were geocoded and spatially joined to census tracts. Composite measures of social vulnerability and childhood opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots, where PICU admission rates per 1,000 children are at or above the 90th percentile, versus non-hot spots. RESULTS A total of 228 children resided within a neighborhood hot spot (16%). Hot spots were associated with a higher (ie, poorer) composite Social Vulnerability Index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a lower (ie, poorer) composite Childhood Opportunity Index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower childhood opportunity were associated with PICU readmission. Residing within a hot spot was further associated with a longer duration of hospital stay, individual inpatient bed days, and total census tract inpatient bed days. CONCLUSIONS Social determinants of health identified by geospatial analyses are associated with more severe asthma exacerbation outcomes in children. Outpatient strategies that address both biological and social determinants of health are needed to care for and prevent PICU admissions optimally in children with asthma.
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10
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Canonica GW, Paggiaro P, Blasi F, Musarra A, Richeldi L, Rossi A, Papi A. Manifesto on the overuse of SABA in the management of asthma: new approaches and new strategies. Ther Adv Respir Dis 2021; 15:17534666211042534. [PMID: 34587829 PMCID: PMC8488406 DOI: 10.1177/17534666211042534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The risks of overusing short-acting β2-agonists (SABA), including an
increase in asthma-related deaths, are many and well known. The Global
Initiative on Asthma (GINA) 2019 and 2020 updates recommend as-needed inhaled
corticosteroid (ICS)/formoterol as the preferred rescue medication in mild
asthma as monotherapy and also in moderate to severe asthma when the maintenance
and reliever therapy (MART) strategy is used. Using SABA for symptom relief,
however, was the standard of treatment for many years, and consequently this
practice persists, particularly in patients not taking ICS regularly. Here, we
examine the rationale for this shift from a long-standing recommendation for
as-needed SABA treatment to the use of as-needed ICS/formoterol and consider
clinical evidence on strategies for asthma treatment and patient management.
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Affiliation(s)
- Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Personalized Medicine, Asthma and Allergy, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Italy
| | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Rossi
- Pulmonary Unit, Azienda Ospedaliera Universitaria Integrata and University of Verona, Verona, Italy
| | - Alberto Papi
- Research Center on Asthma and COPD, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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11
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Romão M, Godinho AR, Teixeira PM, Mendes Z, Bernardo F, Teixeira Rodrigues A, Correia de Sousa J. Characteristics of Reliever Inhaler Users and Asthma Control: A Cross-Sectional Multicenter Study in Portuguese Community Pharmacies. J Asthma Allergy 2021; 14:943-954. [PMID: 34354362 PMCID: PMC8331120 DOI: 10.2147/jaa.s315678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/24/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE SABA overuse might indicate poorly managed or uncontrolled asthma and be responsible for poor health outcomes. The aim of this study integrated in new fourth multi-design SABINA+ pillar was to characterize the population using short-acting β2-agonists for asthma and examine the patterns of its use among community pharmacy customers in Portugal, as well as identify characteristics associated with disease control and explore potential differences between GINA treatment steps. PATIENTS AND METHODS This cross-sectional multicenter study was conducted in Portuguese community pharmacies between 29 May 2018 and 15 August 2018. Participants were adults (age ≥18 years) self-reporting asthma diagnosis recruited in the context of a short-acting β2-agonist dispense. A two-part questionnaire (pharmacist interview and self-administered) was used to collect information about sociodemographic characteristics, comorbidities, reliever inhaler use, healthcare resource consumption and self-reported disease control (assessed by the Control of Allergic Rhinitis and Asthma Test - CARAT®). Descriptive statistics was done to characterize the study sample. After categorizing patients according to GINA steps, based on their therapeutic regimen, we performed an exploratory subgroup analysis to evaluate if there were any differences between such groups in terms of the variables collected. A logistic regression was used to identify the potential determinants of overall disease control. RESULTS Around 50.8% of patients were male, and the average age was 52 years old. Half of the patients never smoked, and 51.9% were employed. More than half of the patients report inhaler overreliance - purchasing more than 1 pack in 3 months (65.0%) or using the inhaler on more than 8 days over the previous 4 weeks (50.2%). Of the total number of patients in the study, 79.1% had poorly controlled asthma symptoms, and 78.7% had overall poorly controlled respiratory symptoms. We found statistically significant differences between GINA treatment steps in all sociodemographic characteristics (sex, mean age, education level, employment status); maximum number of SABA uses in 24h, CARAT score (total an asthma sub-score); history of exacerbations requiring ED visits or treatment with OCS for at least 3 days in the previous 12 months. Logistic regression revealed that patients reporting SABA use in more than 8 days in the previous 4 weeks and patients with at least 1 exacerbation requiring treatment with OCS for at least 3 days in the previous 12 months have greater odds of poor disease control [adjusted OR (95% CI): 2.6 (1.3-5.2) and 3.0 (1.3-6.6)]. CONCLUSION Based on the results of this study, it can be inferred that the asthma population using SABA is largely uncontrolled and uses reliever inhalers excessively.
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Affiliation(s)
- Mariana Romão
- Centre for Health Evaluation & Research/Infosaude – National Association of Pharmacies (CEFAR/IS-ANF), Lisbon, Portugal
| | - Ana Rita Godinho
- Centre for Health Evaluation & Research/Infosaude – National Association of Pharmacies (CEFAR/IS-ANF), Lisbon, Portugal
| | - Pedro M Teixeira
- Life and Health Sciences Research Institute (ICVS)/3B’s-PT Government Associate Laboratory, University of Minho, Braga, Portugal
| | - Zilda Mendes
- Centre for Health Evaluation & Research/Infosaude – National Association of Pharmacies (CEFAR/IS-ANF), Lisbon, Portugal
| | | | - António Teixeira Rodrigues
- Centre for Health Evaluation & Research/Infosaude – National Association of Pharmacies (CEFAR/IS-ANF), Lisbon, Portugal
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS)/3B’s-PT Government Associate Laboratory, University of Minho, Braga, Portugal
- Horizonte Family Health Unit, ULS Matosinhos, Matosinhos, Portugal
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12
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Wagner NM, Ritzwoller DP, Raebel MA, Goodrich GK, Cvietusa PJ, King DK, Shoup JA, Bender BG. Can digital communication technology reduce health system personnel time? An evaluation of personnel requirements and costs in a randomized controlled trial. Transl Behav Med 2021; 11:863-869. [PMID: 33449120 DOI: 10.1093/tbm/ibaa130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Use of digital communication technologies (DCT) shows promise for enhancing outcomes and efficiencies in asthma care management. However, little is known about the impact of DCT interventions on healthcare personnel requirements and costs, thus making it difficult for providers and health systems to understand the value of these interventions. This study evaluated the differences in healthcare personnel requirements and costs between usual asthma care (UC) and a DCT intervention (Breathewell) aimed at maintaining guidelines-based asthma care while reducing health care staffing requirements. We used data from a pragmatic, randomized controlled trial conducted in a large integrated health system involving 14,978 patients diagnosed with asthma. To evaluate differences in staffing requirements and cost between Breathewell and UC needed to deliver guideline-based care we used electronic health record (EHR) events, provider time tracking surveys, and invoicing. Differences in cost were reported at the patient and health system level. The Breathewell intervention significantly reduced personnel requirements with a larger percentage of participants requiring no personnel time (45% vs. 5%, p < .001) and smaller percentage of participants requiring follow-up outreach (44% vs. 68%, p < .001). Extrapolated to the total health system, cost for the Breathewell intervention was $16,278 less than usual care. The intervention became cost savings at a sample size of at least 957 patients diagnosed with asthma. At the population level, using DCT to compliment current asthma care practice presents an opportunity to reduce healthcare personnel requirements while maintaining population-based asthma control measures.
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Affiliation(s)
- Nicole M Wagner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Adult and Child Consortium for Outcomes Research and Dissemination Science, University of Colorado Denver, Denver, CO, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Marsha A Raebel
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Glenn K Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Peter J Cvietusa
- Department of Asthma, Allergy and Immunology, Kaiser Permanente Colorado, Denver, CO, USA
| | - Diane K King
- Center for Behavioral Health Research and Services, Institute of Social and Economic Research, University of Alaska Anchorage, Anchorage, AK, USA
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Bruce G Bender
- Division of Pediatric Behavioral Health, National Jewish Health, Denver, CO, USA
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13
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Baron AJ, Flokstra-de Blok BMJ, Kerstjens HAM, Koopmans-Klein G, Price DB, Sellink AA, Tsiligianni I, Kocks JWH. High Use of SABAs is Associated with Higher Exacerbation Rate in Dutch Patients with Asthma. J Asthma Allergy 2021; 14:851-861. [PMID: 34285512 PMCID: PMC8285233 DOI: 10.2147/jaa.s292943] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 06/11/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Many patients with asthma still have insufficient disease control, despite the availability of effective treatment options. A substantial proportion of patients appear to rely more on short-acting beta2-agonist (SABA) rather than on anti-inflammatory maintenance treatment. The aim of this study was to describe differences in indicators of asthma symptoms and exacerbations among patients using more or less SABA than the guideline-recommended threshold of <3 times/week. Patients and Methods Data from Dutch respondents in the European REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey were used in this post hoc analysis. The survey included asthma patients aged 18-50 years with at least two prescriptions for their asthma in the past two years. SABA use was categorized into two groups: <3 (low-SABA users) or ≥3 (high-SABA users) times in the last week. Results Of the 736 asthma patients, 21% did not use SABA and 19% used SABA 1 to 2 times (all low SABA users) and 60% used SABA ≥3 times (high SABA users) in the last week. The majority of high and low SABA users also reported using an ICS-containing treatment. Significant differences were found for all indicators related to exacerbations (p<0.001): high SABA users more frequently used antibiotics and oral steroids, more frequently visited the emergency departments or needed an overnight hospital stay. Indicators of asthma symptoms were not significantly different between both groups. Conclusion The majority of a Dutch asthmatic population reported high SABA use and had frequent moderate/severe exacerbations. More effective interventions are needed to change healthcare providers' and patients' behaviours to improve care and reduce SABA (over)use.
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Affiliation(s)
- Anna Jetske Baron
- General Practitioners Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands
| | - Bertine M J Flokstra-de Blok
- General Practitioners Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Pulmonology and Pediatric Allergology, Groningen, the Netherlands
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands
| | | | - David B Price
- Observational and Pragmatic Research Institute, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Ioanna Tsiligianni
- Health Planning Unit, Department of Social Medicine, University of Crete, Crete, Greece
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands.,Observational and Pragmatic Research Institute, Singapore
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14
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Worth H, Criée CP, Vogelmeier CF, Kardos P, Becker EM, Kostev K, Mokros I, Schneider A. Prevalence of overuse of short-acting beta-2 agonists (SABA) and associated factors among patients with asthma in Germany. Respir Res 2021; 22:108. [PMID: 33863317 PMCID: PMC8051057 DOI: 10.1186/s12931-021-01701-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 03/31/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Overuse of short-acting beta-2 agonists (SABA), which do not treat the underlying inflammation of asthma, is linked to poor clinical outcomes such as increased exacerbation risk. This study, as part of the SABINA program, estimated the prevalence of SABA overuse and associated variables in outpatients in Germany. METHODS This retrospective study used anonymized electronic healthcare data from the Disease Analyzer database (IQVIA). A total of 15,640 patients aged ≥ 12 years with asthma who received ≥ 1 SABA prescription(s) between July 2017 and June 2018 in 924 general physician and 22 pneumologist (PN) practices were included. SABA overuse was defined as ≥ 3 prescribed inhalers (~ 200 puffs each) during the study period. The associations between SABA overuse and physician specialty, Global Initiative for Asthma (GINA) steps (based on asthma medications), age, sex, and inhaled corticosteroid (ICS)/long-acting beta agonist (LABA) use were estimated using multivariable regression for patients with probable moderate (GINA step 2) and probable severe (GINA steps 3-5) asthma. RESULTS Annually, 36% of all patients (GINA steps 1-5) in general and 38% in PN practices received ≥ 3 SABA inhalers. The risk of SABA overuse was 14% higher in patients treated by a general practitioner vs. a PN; 34% and 85% higher in GINA steps 4 and 5, respectively, vs. GINA step 3; and 40% higher in male vs. female patients. CONCLUSIONS SABA overuse is prevalent among patients with asthma across all GINA steps in Germany, which may indicate suboptimal asthma control. Further studies are needed to investigate the reasons behind SABA overuse.
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Affiliation(s)
- Heinrich Worth
- Facharzt Forum Fürth, Bahnhofplatz 6, 90762, Fürth, Germany.
| | | | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Peter Kardos
- Lungenpraxis am Maingau Krankenhaus, Frankfurt am Main, Germany
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15
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The Role of ICS/LABA Fixed-Dose Combinations in the Treatment of Asthma and COPD: Bioequivalence of a Generic Fluticasone Propionate-Salmeterol Device. Pulm Med 2021; 2021:8881895. [PMID: 33815843 PMCID: PMC7994080 DOI: 10.1155/2021/8881895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/25/2021] [Accepted: 02/28/2021] [Indexed: 11/17/2022] Open
Abstract
Both asthma and chronic obstructive pulmonary disease (COPD) are inflammatory chronic respiratory conditions with high rates of morbidity and mortality worldwide. The objectives of this review are to briefly describe the pathophysiology and epidemiology of asthma and COPD, discuss guideline recommendations for uncontrolled disease, and review a new generic option for the treatment of asthma and COPD. Although mild forms of these diseases may be controlled with as-needed pharmacotherapy, uncontrolled or persistent asthma and moderate or severe COPD uncontrolled by bronchodilators with elevated eosinophilia or frequent exacerbations may require intervention with combination therapy with inhaled corticosteroids (ICS) and long-acting beta agonists (LABAs), according to international guidelines. Fixed-dose combinations of ICS/LABA are commonly prescribed for both conditions, with fluticasone propionate (FP) and salmeterol forming a cornerstone of many treatment plans. An oral inhalation powder containing the combination of FP and salmeterol has been available as Advair Diskus® in the United States for almost 20 years, and the first and only substitutable generic version of this product has recently been approved for use: Wixela™ Inhub™. Bioequivalence of Wixela Inhub and Advair Diskus has been established. Furthermore, the Inhub inhaler was shown to be robust and easy to use, suggesting that Wixela Inhub may provide an alternative option to Advair Diskus for patients with asthma or COPD requiring intervention with an ICS/LABA.
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16
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Perkins A, Bradley A, Magaldi J. Case analyses of state-sponsored asthma quality improvement interventions - benefits and technical assistance efforts. J Asthma 2021; 59:616-627. [PMID: 33287598 DOI: 10.1080/02770903.2020.1861625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE A cross-case analysis was used to discover how two states benefited from expanded use of evaluation for asthma quality improvement initiatives. If an asthma quality improvement (QI) initiative is successfully evaluated, data can inform how to effectively integrate clinical practice guidelines and circumvent non-clinical reasons that interrupt QI projects such as low staff interest. This article addresses a gap in the literature on quality of evaluation support needed to improve and sustain asthma QI at local health care organizations by describing the similar discoveries observed at two independent QI statewide initiatives in Indiana and Montana. METHODS As part of a larger review, two states funded through the National Asthma Control Program at the Centers for Disease Control and Prevention were identified based on similarities in evaluation approaches. Each state used an iterative stakeholder-driven evaluation approach, mixed methods, process evaluation indicators, and active use of evaluation findings. The asthma QI initiatives and evaluations in Indiana and Montana were coordinated independent of each other. RESULTS Although both states found that asthma QI initiatives improved health outcomes, evaluation data were able to further pinpoint areas that would improve quality of technical support to health care organizations and identify markers of sustainability, such as nontraditional benefits to staff, and intervention sites. CONCLUSION Findings suggest that when evaluation is used to guide implementation, data are available to develop site-specific assistance and identify sustainability markers to prevent interruption of positive health outcomes associated with an asthma QI initiative.
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Affiliation(s)
- Ayana Perkins
- Asthma and Community Health Branch, Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anna Bradley
- Montana Department of Public Health and Human Services, Public Health and Safety Division, Helena, MT, USA
| | - Judith Magaldi
- Cancer Control Section, Division of Chronic Disease, Primary Care and Rural Health, Indiana State Department of Health, Indianapolis, IN, USA
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17
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A call to action for improving clinical outcomes in patients with asthma. NPJ Prim Care Respir Med 2020; 30:54. [PMID: 33277487 PMCID: PMC7718279 DOI: 10.1038/s41533-020-00211-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 10/15/2020] [Indexed: 11/23/2022] Open
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18
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Azzi E, Kritikos V, Peters M, Price D, Cvetkovski B, Alphonse PS, Bosnic-Anticevich S. Perceptions, attitudes, and behaviors of short-acting beta 2 agonist users: an Australian cross-sectional community pharmacy-based study. J Asthma 2020; 59:178-188. [PMID: 33086885 DOI: 10.1080/02770903.2020.1841223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND High use of short-acting beta-2-agonist (SABA) medication is a significant problem. Attitudes and perceptions toward asthma of over-the-counter (OTC) reliever users are unknown. The study aimed to describe the asthma attitudes, perceptions, medication knowledge and information gathering behavior of people with asthma with recent high SABA use (i.e. SABA use > twice a week in the last 4 weeks) and compare them to people with asthma with no recent high SABA use. METHOD A real-world cross-sectional observational study in Australian community pharmacies was conducted; surveying patients ages ≥ 16 years requesting SABA medication OTC. Data collected included; demographics, medication usage, asthma control, asthma-related perceptions and behaviors. Data were summarized by using descriptive analyses. RESULTS 375 participants completed the survey, 73.9% were high SABA users. Of the 375, 90.4% reported that their asthma symptoms were controlled or somewhat controlled and 56.0% felt that their asthma was not serious. However, only 17.6%, had controlled asthma according to GINA-defined criteria. High SABA users tended to be more anxious about their asthma and worried about its impact in the future (50.5% vs. 28.6%, p < 0.001). High SABA users were more likely to agree with the statements suggesting that asthma impacted on activities of daily living (46.6% vs. 16.3%, p < 0.001); were socially conscious about their asthma and more likely to feel embarrassed carrying (21.3% vs 9.2%, p = 0.007) and using (29.2% vs 18.4%, p = 0.036) their asthma inhaler. CONCLUSION This study revealed the extent of uncontrolled asthma and uncovered an anxious and socially conscious group of OTC SABA users. There is a need to better understand patient perceptions and their relationships to high-SABA use, to ensure targeted educational interventions are developed and implemented.
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Affiliation(s)
- Elizabeth Azzi
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, Australia.,School of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Vicky Kritikos
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, Australia
| | - Matthew Peters
- Respiratory Medicine, Concord Repatriation General Hospital, Concord, Australia.,Emphysema Centre, Woolcock Institute of Medical Research, Glebe, Australia
| | - David Price
- Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom of Great Britain and Northern Ireland
| | - Biljana Cvetkovski
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, Australia
| | - Pamela Srour Alphonse
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, Australia
| | - Sinthia Bosnic-Anticevich
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, Australia
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19
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Lee SY, Kim MH, Kim SH, Ahn T, Kim SW, Kwak YS, Cho IH, Nah SY, Cho SS, Park KM, Park DH, Bae CS. Korean Red Ginseng affects ovalbumin-induced asthma by modulating IL-12, IL-4, and IL-6 levels and the NF-κB/COX-2 and PGE 2 pathways. J Ginseng Res 2020; 45:482-489. [PMID: 34295208 PMCID: PMC8282494 DOI: 10.1016/j.jgr.2020.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/16/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022] Open
Abstract
Background Asthma is an incurable hyper-responsive disease of the pulmonary system that is caused by various allergens, including indoor and outdoor stimulators. According to the Global Asthma Network, 339 million people suffered from asthma in 2018, with particularly severe forms in children. Numerous treatments for asthma are available; however, they are frequently associated with adverse effects such as growth retardation, neurological disorders (e.g., catatonia, poor concentration, and insomnia), and physiological disorders (e.g., immunosuppression, hypertension, hyperglycemia, and osteoporosis). Methods Korean Red Ginseng has long been used to treat numerous diseases in many countries, and we investigated the anti-asthmatic effects and mechanisms of action of Korean Red Ginseng. Eighty-four BALB/c mice were assigned to 6 treatment groups: control, ovalbumin-induced asthma group, dexamethasone treatment group, and 3 groups treated with Korean Red Ginseng water extract (KRGWE) at 5, 25, or 50 mg/kg/day for 5 days. Anti-asthmatic effects of KRGWE were assessed based on biological changes, such as white blood cell counts and differential counts in the bronchoalveolar lavage fluid, serum IgE levels, and histopathological changes in the lungs, and by examining anti-asthmatic mechanisms, such as the cytokines associated with Th1, Th2, and Treg cells and inflammation pathways. Results KRGWE affected ovalbumin-induced changes, such as increased white blood cell counts, increased IgE levels, and morphological changes (mucous hypersecretion, epithelial cell hyperplasia, inflammatory cell infiltration) by downregulating cytokines such as IL-12, IL-4, and IL-6 via GATA-3 inactivation and suppression of inflammation via NF-κB/COX-2 and PGE2 pathways. Conclusion KRGWE is a promising drug for asthma treatment.
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Affiliation(s)
- Soon-Young Lee
- College of Korean Medicine, Dongshin University, Naju, Jeonnam, Republic of Korea
| | - Min-Hee Kim
- College of Agriculture and Life Science, Chonnam National University, Gwangju, Republic of Korea
| | - Seung-Hyun Kim
- College of Veterinary Medicine, Chonnam National University, Gwangju, Republic of Korea
| | - Taeho Ahn
- College of Veterinary Medicine, Chonnam National University, Gwangju, Republic of Korea
| | - Sung-Won Kim
- Korea Ginseng Corporation, Daejeon, Republic of Korea
| | - Yi-Seong Kwak
- Korea Ginseng Corporation, Daejeon, Republic of Korea
| | - Ik-Hyun Cho
- College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Seung-Yeol Nah
- Ginsentology Research Laboratory and Department of Physiology, College of Veterinary Medicine and Bio/Molecular Informatics Center, Konkuk University, Seoul, Republic of Korea
| | - Seung-Sik Cho
- Department of Biomedicine, Health & Life Convergence Sciences, BK21 Four, College of Pharmacy, Mokpo National University, Jeonnam, Republic of Korea
| | - Kyung Mok Park
- College of Korean Medicine, Dongshin University, Naju, Jeonnam, Republic of Korea
| | - Dae-Hun Park
- College of Korean Medicine, Dongshin University, Naju, Jeonnam, Republic of Korea
- Corresponding author. College of Korean Medicine, Dongshin University, 67 Donsghindae-gil, Naju, Jeonnam, 58245, Republic of Korea.
| | - Chun-Sik Bae
- College of Veterinary Medicine, Chonnam National University, Gwangju, Republic of Korea
- Corresponding author. College of Veterinary Medicine, Chonnam National University, Gwangju, 61186, Republic of Korea.
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20
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Bloom CI, Cabrera C, Arnetorp S, Coulton K, Nan C, van der Valk RJP, Quint JK. Asthma-Related Health Outcomes Associated with Short-Acting β 2-Agonist Inhaler Use: An Observational UK Study as Part of the SABINA Global Program. Adv Ther 2020; 37:4190-4208. [PMID: 32720299 DOI: 10.1007/s12325-020-01444-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Patients with asthma typically increase short-acting β2-agonists (SABA) use with worsening symptoms. Excessive SABA use may lead to a higher risk of adverse outcomes. We evaluated, in a large population cohort, an association between SABA inhaler use and asthma exacerbations and healthcare utilization. METHODS As part of the SABINA (SABA use IN Asthma) global program, we conducted a retrospective longitudinal observational study (SABINA I) using UK primary care electronic healthcare records (Clinical Practice Research Datalink; 2007-2017) from asthma patients aged ≥ 12 years. SABA inhaler use was classified as 'high use', ≥ 3 canisters/year versus 'low use', 0-2 canisters/year. Taking into consideration all their asthma prescriptions, patients were categorized into a treatment step according to 2016 British Thoracic Society (BTS) asthma management guidelines. Multivariable regression assessed the association of SABA inhaler use by BTS treatment steps (grouped as BTS steps 1/2 and 3-5), separately, and with outcomes of exacerbations or asthma-related healthcare utilization (primary care and hospital outpatient consultations); only patients with linked hospital data were included in this analysis. RESULTS Of the 574,913 patients included, 218,365 (38%) had high SABA inhaler use. Overall, 336,412 patients had linked hospital data. High SABA inhaler use was significantly associated with an increased risk of exacerbations [adjusted hazard ratio, 95% confidence interval (CI): BTS steps 1/2 = 1.20, 1.16-1.24; BTS steps 3-5 = 1.24, 1.20-1.28], asthma-related primary care consultations [adjusted incidence rate ratio (IRR), 95% CI: BTS steps 1/2 = 1.24, 1.23-1.26; BTS steps 3-5 = 1.13, 1.11-1.15], and asthma-related hospital outpatient consultations (adjusted IRR, 95% CI: BTS steps 1/2 = 1.19, 1.12-1.27; BTS steps 3-5 = 1.19, 1.13-1.26). CONCLUSION High SABA inhaler use was frequent across BTS steps and was associated with a significant increase in exacerbations and asthma-related healthcare utilization.
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Affiliation(s)
- Chloe I Bloom
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Claudia Cabrera
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Sofie Arnetorp
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Karen Coulton
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Cassandra Nan
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | | | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK.
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Socheongryongtang Modulates Asthma-Related Changes via Modulation of TNF-α and T-bet as well as IFN-γ in an Asthma Murine Model. Processes (Basel) 2020. [DOI: 10.3390/pr8091167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In 2017 the World Health Organization (WHO) reported that 235 million people suffered from asthma, and that 383,000 deaths were due to asthma in 2015. Asthma cannot be completely eradicated and the medications for asthma are associated with many adverse effects. Socheongryongtang is one of the prescriptions which has traditionally been used for the treatment of pulmonary disease, but the anti-asthmatic mechanism is unclear. To investigate the anti-asthmatic mechanism of socheongryongtang, BALB/c mice were divided into five groups: control, asthma-induced control, dexamethasone treatment, and 150 mg/kg or 1500 mg/kg socheongryongtang treatment and several biomarkers were analyzed, such as white blood cell (WBC) and differential counts in broncheoalveolar fluid (BALF), immunoglobulin E (IgE) in serum, and morphological changes/helper T cell-related cytokines/transcription factor in the lung. The therapeutic ingredients were also analyzed. Socheongryongtang inhibited the neutrophils differentiation in BALF, controlled interleukin (IL)-12p40 releasing, down-regulated not only GATA-3 and helper 2 T (Th2) cell transcription factors but also IL-4, and also decreased the level of tumor necrosis factor (TNF)-α in the lung. In addition, through high-performance liquid chromatography (HPLC) analysis, we confirmed that the therapeutic ingredients in socheongryongtang were paeoniflorin, liquiritin, and glycyrrhizin. The oral intake of 7.3 g of socheongryongtang is beneficial for suppressing the possibility of the occurrence of asthma via modulation of TNF-α and T-bet as well as IFN-γ.
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Hosoki K, Chakraborty A, Sur S. Molecular mechanisms and epidemiology of COVID-19 from an allergist's perspective. J Allergy Clin Immunol 2020; 146:285-299. [PMID: 32624257 PMCID: PMC7331543 DOI: 10.1016/j.jaci.2020.05.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
The global pandemic caused by the newly described severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused worldwide suffering and death of unimaginable magnitude from coronavirus disease 2019 (COVID-19). The virus is transmitted through aerosol droplets, and causes severe acute respiratory syndrome. SARS-CoV-2 uses the receptor-binding domain of its spike protein S1 to attach to the host angiotensin-converting enzyme 2 receptor in lung and airway cells. Binding requires the help of another host protein, transmembrane protease serine S1 member 2. Several factors likely contribute to the efficient transmission of SARS-CoV-2. The receptor-binding domain of SARS-CoV-2 has a 10- to 20-fold higher receptor-binding capacity compared with previous pandemic coronaviruses. In addition, because asymptomatic persons infected with SARS-CoV-2 have high viral loads in their nasal secretions, they can silently and efficiently spread the disease. PCR-based tests have emerged as the criterion standard for the diagnosis of infection. Caution must be exercised in interpreting antibody-based tests because they have not yet been validated, and may give a false sense of security of being "immune" to SARS-CoV-2. We discuss how the development of some symptoms in allergic rhinitis can serve as clues for new-onset COVID-19. There are mixed reports that asthma is a risk factor for severe COVID-19, possibly due to differences in asthma endotypes. The rapid spread of COVID-19 has focused the efforts of scientists on repurposing existing Food and Drug Administration-approved drugs that inhibit viral entry, endocytosis, genome assembly, translation, and replication. Numerous clinical trials have been launched to identify effective treatments for COVID-19. Initial data from a placebo-controlled study suggest faster time to recovery in patients on remdesivir; it is now being evaluated in additional controlled studies. As discussed in this review, till effective vaccines and treatments emerge, it is important to understand the scientific rationale of pandemic-mitigation strategies such as wearing facemasks and social distancing, and implement them.
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Affiliation(s)
- Koa Hosoki
- Department of Medicine, Immunology Allergy and Rheumatology, Baylor College of Medicine, Houston, Tex
| | - Abhijit Chakraborty
- Department of Medicine, Immunology Allergy and Rheumatology, Baylor College of Medicine, Houston, Tex
| | - Sanjiv Sur
- Department of Medicine, Immunology Allergy and Rheumatology, Baylor College of Medicine, Houston, Tex.
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Health and cost impact of stepping down asthma medication for UK patients, 2001-2017: A population-based observational study. PLoS Med 2020; 17:e1003145. [PMID: 32692744 PMCID: PMC7373267 DOI: 10.1371/journal.pmed.1003145] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 06/09/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Guidelines recommend stepping down asthma treatment to the minimum effective dose to achieve symptom control, prevent adverse side effects, and reduce costs. Limited data exist on asthma prescription patterns in a real-world setting. We aimed to evaluate the appropriateness of doses prescribed to a UK general asthma population and assess whether stepping down medication increased exacerbations or reliever use, as well as its impact on costs. METHODS AND FINDINGS We used nationwide UK primary care medical records, 2001-2017, to identify 508,459 adult asthma patients managed with preventer medication. Prescriptions of higher-level medication: medium/high-dose inhaled corticosteroids (ICSs) or ICSs + add-on medication (long-acting β2-agonist [LABA], leukotriene receptor antagonist [LTRA], theophylline, or long-acting muscarinic antagonist [LAMA]) steadily increased over time (2001 = 49.8%, 2017 = 68.3%). Of those prescribed their first preventer, one-third were prescribed a higher-level medication, of whom half had no reliever prescription or exacerbation in the year prior. Of patients first prescribed ICSs + 1 add-on, 70.4% remained on the same medication during a mean follow-up of 6.6 years. Of those prescribed medium/high-dose ICSs as their first preventer, 13.0% already had documented diabetes, cataracts, glaucoma, or osteopenia/osteoporosis. A cohort of 125,341 patients were drawn to assess the impact of stepping down medication: mean age 50.4 years, 39.4% males, 39,881 stepped down. Exposed patients were stepped down by dropping their LABAs or another add-on or by halving their ICS dose (halving their mean-daily dose or their inhaler dose). The primary and secondary outcomes were, respectively, exacerbations and an increase in reliever prescriptions. Multivariable regression was used to assess outcomes and determine the prognostic factors for initiating stepdown. There was no increased exacerbation risk for each possible medication stepdown (adjusted hazard ratio, 95% CI, p-value: ICS inhaler dose = 0.86, 0.77-0.93, p < 0.001; ICS mean daily = 0.80, 0.74-0.87, p < 0.001; LABA = 1.01, 0.92-1.11, p = 0.87, other add-on = 1.00, 0.91-1.09, p = 0.79) and no increase in reliever prescriptions (adjusted odds ratio, 95% CI, p-value: ICS inhaler dose = 0.99, 0.98-1.00, p = 0.59; ICS mean daily = 0.78, 0.76-0.79, p < 0.001; LABA = 0.83, 0.82-0.85, p < 0.001; other add-on = 0.86, 0.85-0.87, p < 0.001). Prognostic factors to initiate stepdown included medication burden, but not medication side effects. National Health Service (NHS) indicative prices were used for cost estimates. Stepping down medication, either LABAs or ICSs, could save annually around £17,000,000 or £8,600,000, respectively. Study limitations include the possibility that prescribed medication may not have been dispensed or adhered to and the reason for stepdown was not documented. CONCLUSION In this UK study, we observed that asthma patients were increasingly prescribed higher levels of treatment, often without clear clinical indication for such high doses. Stepping down medication did not adversely affect outcomes and was associated with substantial cost savings.
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Amin S, Soliman M, McIvor A, Cave A, Cabrera C. Usage Patterns of Short-Acting β 2-Agonists and Inhaled Corticosteroids in Asthma: A Targeted Literature Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2556-2564.e8. [PMID: 32244024 DOI: 10.1016/j.jaip.2020.03.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/26/2020] [Accepted: 03/05/2020] [Indexed: 01/14/2023]
Abstract
Despite the availability of effective asthma treatments, some patients are poorly controlled because of overreliance on short-acting β2-agonists (SABAs) and underuse of inhaled corticosteroids (ICSs). To identify patient characteristics and outcomes associated with SABA overreliance and ICS underuse, we conducted a targeted literature review of the quantitative evidence on asthma medication use. Articles evaluating SABA and/or ICS use in patients with asthma (aged ≥12 years), published between January 2012 and March 2018, were identified using MEDLINE and EMBASE. We observed that studies classified SABA usage as "overuse," "high use," "excess use," "extreme overuse," "suboptimal use," and "inappropriate use." Multiple thresholds were used to define overuse of SABA (≥3 to ≥12 canisters/y). SABA overreliance was prevalent, with approximately 20% of adults using 3 or more canisters per year (≥12 inhalations/wk). Similarly, inappropriate ICS use, classified as "suboptimal," "high use," "underuse," and "unlicensed use," was defined by varying thresholds. Specific patient populations, such as older adults, smokers, and patients with low income, were more susceptible to SABA overreliance and ICS underuse. Overreliance on SABAs was associated with increased risk of severe exacerbations, asthma-related hospitalizations, emergency department visits, and asthma-related costs. These findings emphasize the prevalence and related burden of SABA overreliance at the potential expense of appropriate ICS use.
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Affiliation(s)
| | - Mena Soliman
- BioPharmaceuticals Medical, AstraZeneca, Mississauga, ON, Canada
| | - Andrew McIvor
- Firestone Institute for Respiratory Health, St Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
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Grunwell JR, Gillespie S, Morris CR, Fitzpatrick AM. Latent Class Analysis of School-Age Children at Risk for Asthma Exacerbation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2275-2284.e2. [PMID: 32198127 DOI: 10.1016/j.jaip.2020.03.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/07/2020] [Accepted: 03/01/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Factors responsible for asthma exacerbations in children are complex and may differ from those that drive asthma severity. OBJECTIVE To identify latent classes of children at risk for asthma exacerbation and determine whether latent class assignment is useful in the prediction of future exacerbation. METHODS Latent class analysis was performed on 513 children aged 6 to 17 years at risk for asthma exacerbation, with 31 variables encompassing demographics, medical history, treatment, symptoms, lung function, sensitization, and type 2 inflammation. Primary and secondary outcomes included exacerbation occurrence by 12 months and time to first exacerbation, respectively. RESULTS Four latent classes were identified with differing demographic features, sensitization and type 2 inflammatory markers, prior exacerbation severity and health care utilization, and lung function. Exacerbations occurred in 22.4% of class 1 ("lesser sensitization with normal lung function"), 27.9% of class 2 ("lesser sensitization with prior severe exacerbation and normal lung function"), 45.3% of class 3 ("multiple sensitization with reversible airflow limitation"), and 64.3% of class 4 ("multiple sensitization with partially reversible airflow limitation") (P < .001). Time to exacerbation also followed similar trends and was shortest in the latent classes with multiple sensitization and airflow limitation (P < .001). Outcomes were driven largely by children with exacerbation-prone asthma (defined as ≥3 exacerbations in the prior year), who were present in each class but most strongly represented in classes 3 and 4. CONCLUSIONS Children at risk for asthma exacerbation are a heterogeneous group. Sensitization, prior exacerbation severity, and lung function variables may be particularly useful in identifying children at greatest risk for future exacerbation.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Clinical and Translational Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Claudia R Morris
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Clinical and Translational Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Clinical and Translational Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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Single inhaler maintenance and reliever therapy in pediatric asthma. Curr Opin Allergy Clin Immunol 2020; 19:111-117. [PMID: 30640210 DOI: 10.1097/aci.0000000000000518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Asthma affects more than 25 million people worldwide and continues to grow in prevalence. According to a center for disease control and prevention (CDC) report, the total annual cost of asthma in the United States between 2008 and 2013, including medical care, absenteeism, and mortality, was $81.9 billion. Although the National Institute of Health guidelines recommend fixed inhaled corticosteroid (ICS) dosing, the 2008-2010 Medical Expenditure Panel Survey showed that asthma is still poorly controlled. Single inhaler maintenance and reliever therapy (SMART) offers a possible alternative management plan. This is a review of SMART vs. current treatment guidelines. RECENT FINDINGS SMART addresses variable inflammation with symptom-driven dosing of ICS. It relies on a combination inhaler that has a long-acting β-agonist, which has an immediate onset of action to provide quick relief, in combination with an ICS. Recent studies show that SMART decreases the frequency and severity of asthma exacerbations when compared to fixed ICS dosing. In addition, intermittent use of ICS gave a reduced effect on growth and permitted a lower total amount of ICS to be delivered. SUMMARY SMART appears to outperform treatment that is based on current guidelines in the United States. As inhalers capable of being used for SMART are already approved, what is needed is Food and Drug Administration approval of the SMART strategy.
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Haselkorn T, Szefler SJ, Chipps BE, Bleecker ER, Harkins MS, Paknis B, Kianifard F, Ortiz B, Zeiger RS. Disease Burden and Long-Term Risk of Persistent Very Poorly Controlled Asthma: TENOR II. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2243-2253. [PMID: 32173511 DOI: 10.1016/j.jaip.2020.02.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 01/30/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe/difficult-to-treat disease occurs in 5% to 10% of patients with asthma, but accounts for more than 50% of related economic costs. Understanding factors associated with persistent very poorly controlled (VPC) asthma may improve outcomes. OBJECTIVE To characterize persistent VPC asthma after more than 10 years of standard of care. METHODS The Epidemiology and Natural history of asthma: Outcomes and treatment Regimens (TENOR) II (N = 341) was a multicenter, observational study of patients with severe/difficult-to-treat asthma with a single, cross-sectional visit more than 10 years after TENOR I. Persistent VPC asthma was defined as VPC asthma at TENOR I and TENOR II enrollment; without VPC asthma was defined as well- or not well-controlled asthma at either or both visits. Multivariable logistic regression assessed long-term predictors of persistent VPC asthma using TENOR I baseline variables. RESULTS Of 327 patients, nearly half (48.0%, n = 157) had persistent VPC asthma. Comorbidities and asthma triggers were more frequent in patients with persistent VPC asthma than in patients without VPC asthma. Total geometric mean IgE was higher in patients with persistent VPC asthma (89.3 IU/mL vs 55.7 IU/mL); there was no difference in eosinophil levels. Lung function was lower in patients with persistent VPC asthma (mean % predicted pre- and postbronchodilator FEV1, 63.0% vs 82.8% and 69.6% vs 87.2%, respectively). Exacerbations in the previous year were more likely in patients with persistent VPC asthma (29.7% vs 9.0%, respectively). Predictors of persistent VPC asthma were black versus white race/ethnicity, allergic trigger count (4 vs 0), systemic corticosteroid use, and postbronchodilator FEV1 (per 10% decrease). CONCLUSIONS The burden of persistent VPC asthma is high in severe/difficult-to-treat disease; management of modifiable risk factors, maximization of lung function, and trigger avoidance may improve outcomes.
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Affiliation(s)
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colo
| | - Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Eugene R Bleecker
- Department of Medicine, Division of Pharmacogenomics, Center for Applied Genetics and Genomics Medicine, University of Arizona Health Sciences, Tucson, Ariz
| | - Michelle S Harkins
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico, Albuquerque, NM
| | | | | | | | - Robert S Zeiger
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif
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Fitzpatrick AM, Bacharier LB, Jackson DJ, Szefler SJ, Beigelman A, Cabana M, Covar R, Guilbert T, Holguin F, Lemanske RF, Martinez FD, Morgan W, Phipatanakul W, Pongracic JA, Raissy HH, Zeiger RS, Mauger DT. Heterogeneity of Mild to Moderate Persistent Asthma in Children: Confirmation by Latent Class Analysis and Association with 1-Year Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2617-2627.e4. [PMID: 32156610 DOI: 10.1016/j.jaip.2020.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Compared with adults, phenotypic characterization of children with asthma is still limited and it remains difficult to predict which children with asthma are at highest risk for poor outcomes. OBJECTIVE To identify latent classes in a large population of treatment-adherent children with mild to moderate asthma enrolled in clinical trials and determine whether latent class assignment predicts future lung function abnormalities and exacerbation rate. METHODS Latent class analysis was performed on 2593 children with mild to moderate asthma aged 5 18 years, with 19 variables encompassing demographic characteristics, medical history, symptoms, lung function, allergic sensitization, and type 2 inflammation. Outcomes included lung function and the annualized exacerbation rate at 12 months of follow-up. RESULTS Five latent classes were identified with differing demographic features, asthma control, sensitization, type 2 inflammatory markers, and lung function. Exacerbation rates were 1.30 ± 0.12 for class 1 (multiple sensitization with partially reversible airflow limitation), 0.90 ± 0.05 for class 2 (multiple sensitization with reversible airflow limitation), 0.87 ± 0.08 for class 3 (lesser sensitization with reversible airflow limitation), 0.87 ± 0.05 for class 4 (multiple sensitization with normal lung function), and 0.71 ± 0.06 for class 5 (lesser sensitization with normal lung function). Lung function abnormalities persisted in class 1 at 12 months. CONCLUSIONS Children with mild to moderate asthma are a heterogeneous group. Allergic sensitization and lung function may be particularly useful in identifying children at the greatest risk for future exacerbation. Additional studies are needed to determine whether latent classes correspond to meaningful phenotypes for the purpose of personalized treatment.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Daniel J Jackson
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stanley J Szefler
- Children's Hospital Colorado and Department of Pediatrics, University of Colorado, Aurora, Colo
| | - Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Michael Cabana
- Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York, NY
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Theresa Guilbert
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | | | - Robert F Lemanske
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Wayne Morgan
- Department of Pediatrics, The University of Arizona, Tucson, Ariz
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital and Harvard Medical School Department of Pediatrics, Boston, Mass
| | | | | | - Robert S Zeiger
- Kaiser Permanente, Southern California Region and Department of Pediatrics, University of California San Diego, San Diego, Calif
| | - David T Mauger
- Department of Public Health Sciences, Penn State University, Hershey, Pa
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Bateman ME, Oakland H, Oral E, Nuss H, Fisher P, Udemgba C, Walker C, Daigrepont N, Parada NA. Evaluation of a Multidisciplinary Disease Management Program to Achieve Asthma Control in Seven Safety Net Hospitals in Louisiana. Popul Health Manag 2020; 24:133-140. [PMID: 32096685 DOI: 10.1089/pop.2019.0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The objective was to evaluate a multidisciplinary guideline-driven disease management program focused on achievement of asthma control among sustained patients with confirmed asthma in Louisiana and to assess factors affecting achievement of asthma control. Data were extracted from the electronic health records of 1596 adults with confirmed asthma, sustained care for >1 year in the outpatient setting, and ≥2 recorded Asthma Control Test (ACT) scores. Multivariable logistic regression modeling was used to assess the association of demographic variables, comorbidities, and process measures with the best achieved asthma control as represented by the highest ACT score. Most subjects were female (81.1%) and African American (63.9%). Approximately half of them (48.9%) were able to achieve asthma control (ACT ≥20). The most prevalent comorbidities were hypertension (79.8%), rhinitis (55.3%), and obesity (50.5%). Most patients received pulmonary function testing (PFT) (88.6%), controller medication therapy (85.5%), or written asthma action plans (92.7%). Asthma control was positively associated with presence of PFT (OR = 1.63, 95% CI: 1.13, 2.37) and being a "never" smoker (OR = 1.49, 95% CI: 1.08, 2.04). Asthma control was less likely to be achieved by patients who were African American (OR = 0.68, 95% CI: 0.52, 0.87), had more comorbidities (OR = 0.89, 95% CI: 0.83, 0.96), or were on more medications (OR = 0.79, 95% CI: 0.72, 0.88). Asthma control was achieved in 48.9% of an adult, primarily African American population with the implementation of comprehensive guideline-driven care. Furthermore, this is the first study to observe that the presence of PFT may be associated with asthma control.
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Affiliation(s)
- Marjorie E Bateman
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Hannah Oakland
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Evrim Oral
- School of Public Health, Biostatistics Program, LSUHSC, New Orleans, Louisiana, USA
| | - Henry Nuss
- School of Public Health, Behavioral and Community Health Sciences Program, LSUHSC, New Orleans, Louisiana, USA
| | - Paige Fisher
- School of Public Health, Biostatistics Program, LSUHSC, New Orleans, Louisiana, USA
| | - Chioma Udemgba
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Carl Walker
- Lousisana State University Health Care Services Division, New Orleans, Louisiana, USA
| | - Nathan Daigrepont
- Lousisana State University Health Care Services Division, New Orleans, Louisiana, USA
| | - Nereida A Parada
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Marozkina N, Zein J, DeBoer MD, Logan L, Veri L, Ross K, Gaston B. Dehydroepiandrosterone Supplementation May Benefit Women with Asthma Who Have Low Androgen Levels: A Pilot Study. Pulm Ther 2019; 5:213-220. [PMID: 32026412 PMCID: PMC6967310 DOI: 10.1007/s41030-019-00101-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Indexed: 01/09/2023] Open
Abstract
Introduction Among individuals with severe asthma, FEV1 is low in individuals with low dehydroepiandrosterone (DHEA) sulfate (DHEAS) levels. In the Severe Asthma Research Program (SARP), no women with DHEAS > 200 μg/dL had an FEV1 < 60% predicted. DHEA has benefited patients with COPD and pulmonary hypertension in small trials. Therefore, we hypothesized that DHEA supplementation may improve FEV1 in asthmatic women with low DHEAS. Methods Premenopausal, nonsmoking, otherwise healthy women, 18-50 years old, with mild or moderate asthma and baseline FEV1 > 60% predicted received 100 mg DHEA orally every 12 h for 2 weeks. Spirometry and DHEAS were measured at the initial visit and 2 weeks later, after completion of DHEA treatment. Based on our previous work, the primary outcome variable for this pilot study was post-albuterol spirometry in the low-DHEAS group. Subjects also continued their other routine asthma management. Results Serum DHEAS increased with DHEA treatment in women with starting DHEAS < 200 µg/dL: this increase was from 71 ± 23 to 725 ± 295 µg/dL (n = 10; p = 0.0001). The increase in the high-DHEAS group was smaller. Post-albuterol FEV1 increased by 51 mL, from 3.026 ± 0.5 to 3.077 ± 0.49 L (n = 10; p = 0.034 by paired t test, significant after Bonferroni), in women with low DHEAS. In the high-DHEAS group (baseline DHEAS ≥ 200 µg/dl), post-albuterol FEV1 did not change significantly (n = 3, p = NS). Three subjects were excluded: one had comorbid COPD, one could not perform spirometry, and one did not take the DHEA. There were no adverse effects of DHEA treatment in this trial. Conclusions Endocrine treatments (corticosteroids) are a mainstay of anti-inflammatory management for moderate and severe asthma. Their use has improved asthma outcomes. Androgens also reduce airway inflammation and promote airway smooth muscle relaxation, but are rarely used clinically for asthma treatment. Our results suggest that the over-the-counter steroid DHEA may improve lung function in asthma outcomes among women with DHEAS < 200 ug/dL.
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Affiliation(s)
| | - Joe Zein
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Laurie Logan
- Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Laura Veri
- Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Kristie Ross
- Case Western Reserve University, Cleveland, OH, USA
- Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Benjamin Gaston
- Case Western Reserve University, Cleveland, OH, USA.
- Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
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Azzi EA, Kritikos V, Peters MJ, Price DB, Srour P, Cvetkovski B, Bosnic-Anticevich S. Understanding reliever overuse in patients purchasing over-the-counter short-acting beta 2 agonists: an Australian community pharmacy-based survey. BMJ Open 2019; 9:e028995. [PMID: 31412998 PMCID: PMC6701672 DOI: 10.1136/bmjopen-2019-028995] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Overuse of asthma relievers is associated with significant adverse consequences. This study aimed to better understand the population purchasing and using short-acting beta agonists (SABA) over the counter (OTC); and compare the demographic, clinical and behavioural characteristics of those who overuse SABA with those who do not. DESIGN AND SETTING Real-world cross-sectional observational study in community pharmacy. PARTICIPANTS Of 412 participants ≥16 years requesting SABA OTC, 289 were SABA overusers (used SABA more than twice per week in the past 4 weeks). MAIN OUTCOME MEASURE Reliever use, Global Initiative for Asthma-defined control, healthcare utilisation, patterns of preventer use. RESULTS 70.1% of participants were classified as SABA overusers, that is, reporting SABA use more than twice a week within the last 4 weeks, 73.6% reported not using a preventer daily and only 81.6% reported a doctor diagnosis of asthma. SABA overusers were more likely to have moderate-severe nasal symptoms (80.8% vs 63.0%, p<0.001) and a diagnosis of depression (11.1% vs 5.7%, p<0.001), when compared with SABA non-overusers. A higher proportion of SABA overusers had uncontrolled asthma (59.0% vs 15.4%, p<0.001), were more likely to use oral corticosteroids to manage worsening asthma symptoms (26.2% vs 13.5%, p<0.01) and visit the doctor for their asthma in the past 12 months (74.5% vs 62.5%, p<0.01), when compared to SABA non-overusers. CONCLUSIONS This study uncovers a hidden population of people who can only be identified in pharmacy with suboptimal asthma, coexisting rhinitis, poor preventer adherence and, in some cases, no asthma diagnosis.
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Affiliation(s)
- Elizabeth A Azzi
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Vicky Kritikos
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Matthew J Peters
- Department of Respiratory Medicine, Concord Hospital, Concord, New South Wales, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - David B Price
- Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | - Pamela Srour
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Biljana Cvetkovski
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sinthia Bosnic-Anticevich
- Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Bok SH, Seo JH, Bae CS, Kang B, Cho SS, Park DH. Allium hookeri root extract regulates asthmatic changes through immunological modulation of Th1/Th2‑related factors in an ovalbumin‑induced asthma mouse model. Mol Med Rep 2019; 20:3215-3223. [PMID: 31432168 PMCID: PMC6755185 DOI: 10.3892/mmr.2019.10560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/26/2019] [Indexed: 12/30/2022] Open
Abstract
In 2013, WHO estimated that approximately 235 million people suffered from asthma worldwide. Asthma is a hyper responsive disorder, which is related to an imbalance between the T-helper type 1 and 2 cells (henceforth, Th1 and Th2, respectively). Allium hookeri is a plant that is widely used for culinary purposes and also in traditional Asian medicine. The present study was conducted to elucidate the anti-asthmatic effects and mechanism of action of A. hookeri root extracts (AHRE) in an ovalbumin (OVA)-induced asthma mouse model. The mice were divided into five groups, namely, the control, the OVA-treated group, the dexamethasone-treated group, the 30 mg/kg AHRE-treated group, and the 300 mg/kg AHRE-treated group. The total WBC count and the differential cell count in the bronchoalveolar fluid, the level of serum IgE, the histopathological changes in the lung, and changes in the cell surface molecules, the asthma-related cytokine levels, and Th cell transcription factors were evaluated. AHRE significantly ameliorated asthmatic changes, such as the total WBC count, eosinophil count, and the level of IgE; in addition, it reduced mucus hypersecretion, epithelial hyperplasia, and eosinophil infiltration in the lungs. AHRE significantly inhibited the expression of CD68+ cells and MHC class II+ molecules, Th1 cell transcription factor (T-bet) activation, Th2 cell transcription factor (GATA-3) activation, and TNF-α in the lung tissue. Furthermore, it suppressed cell surface molecules, such as CD4+and CD8+; Th1-related cytokines, such as IFN-γ and IL-12p40; Th2-related cytokines, such as IL-4 and IL-5; and Th17-related cytokines, such as IL-6 and TNF-α, in a dose-dependent manner. Thus, AHRE may be considered a promising anti-asthmatic drug.
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Affiliation(s)
- So-Hyeon Bok
- College of Oriental Medicine, Dongshin University, Naju, Jeonnam 58245, Republic of Korea
| | - Ji-Hye Seo
- College of Oriental Medicine, Dongshin University, Naju, Jeonnam 58245, Republic of Korea
| | - Chun-Sik Bae
- College of Veterinary Medicine, Chonnam National University, Gwangju 61186, Republic of Korea
| | - Bossng Kang
- Department of Emergency Medicine, College of Medicine, Hanyang University, Guri, Gyunggi 11923, Republic of Korea
| | - Seung Sik Cho
- College of Pharmacy, Mokpo National University, Muan, Jeonnam 58554, Republic of Korea
| | - Dae-Hun Park
- College of Oriental Medicine, Dongshin University, Naju, Jeonnam 58245, Republic of Korea
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Syk J, Vinge I, Sörberg M, Vahteristo M, Rytilä P. A Multicenter, Observational, Prospective Study of the Effectiveness of Switching from Budesonide/Formoterol Turbuhaler ® to Budesonide/Formoterol Easyhaler ®. Adv Ther 2019; 36:1756-1769. [PMID: 30941722 PMCID: PMC6824392 DOI: 10.1007/s12325-019-00940-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Indexed: 11/30/2022]
Abstract
Introduction In real-life practice, asthma remains poorly controlled, with a considerable burden on patients’ quality of life. Budesonide/formoterol (B/F) Easyhaler® has demonstrated similar dose consistency, therapeutic equivalence, and equivalent bronchodilator efficacy to B/F Turbuhaler®, but no real-life comparisons are yet available in patients switching from B/F Turbuhaler® to B/F Easyhaler®. Methods The primary objective of this real-life, non-interventional, observational study was to show non-inferiority of asthma control when adult patients in Swedish primary care with persistent asthma switched from B/F Turbuhaler® to B/F Easyhaler®. At visit 1, baseline demographic and endpoint data were recorded, and eligible patients switched to B/F Easyhaler®. The study comprised a control visit (visit 2) and a concluding examination (visit 3) after 12 weeks. Asthma control was assessed using the Asthma Control Test (ACT). The mini-Asthma Quality of Life Questionnaire (AQLQ) and lung function test were performed, and participants and investigators answered questionnaires about ease-of-use and teaching. Results A total of 117 patients were enrolled in the on-treatment population; 81 (64.8%) were female. At visit 3, B/F Easyhaler® demonstrated non-inferiority to B/F Turbuhaler®; the mean difference in change from baseline ACT was statistically significant (18.9 vs. 20.7, respectively; p < 0.0001) and met the non-inferiority criteria of B/F Easyhaler® being greater than − 1.5 points versus the reference product. Asthma was well controlled in 62 (53.0%) patients at baseline, increasing to 83 patients (70.9%) at visit 3. Patients experienced statistically significant improvements in mini-AQLQ score after B/F Easyhaler® treatment and lung function remained stable across the treatment period. B/F Easyhaler® was easy to learn and prepare for use. Conclusion This real-life, non-interventional, non-inferiority study in adults with persist asthma demonstrates equivalent or better disease control when patients switch from B/F Turbuhaler® to B/F Easyhaler®. A further study with direct comparison between treatments could add to the understanding of inhaler switch. Funding Orion Corporation, Orion Pharma. Electronic supplementary material The online version of this article (10.1007/s12325-019-00940-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jörgen Syk
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Ines Vinge
- Asthma-Allergy-Lung Department, Lidingö Hospital, Lidingö, Sweden
| | | | | | - Paula Rytilä
- Orion Corporation, Orion Pharma, Espoo, Finland.
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Ammari WG, Khalil Mohammad M, Tayyem RF, Martin GP, Royall PG. Delivered Lung Dose and Aerodynamic Particle Size Distribution of Salbutamol Pressurized Metered Dose Inhaler After Living Under Patients' Realistic Retention Environments. J Aerosol Med Pulm Drug Deliv 2019; 32:386-395. [PMID: 31199708 DOI: 10.1089/jamp.2019.1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The impact of inhalers' postdispensing, real-life temperature and relative humidity (RH) environments on their delivered dose (DD) and aerodynamic particle size distribution (APSD) is usually overlooked. This work evaluated the salbutamol DD and APSD of Ventolin® Evohaler® (V) inhalers already been used and stored by respiratory patients. Methods: Adult patients, prescribed V for ≥3 months before study enrollment, were dispensed both new V to use and portable, handheld electronic temperature and RH data loggers to keep close to the given V before returning them both after 2-3 weeks. Patients' enrollment took place during summer (VS) and winter (VW) seasons. The returned V was then in vitro evaluated using the Next Generation Impactor, and compared with control V (VC) counterparts stored under 21°C and 46% RH. Results: The VS survived in fluctuating habitats of 21.2°C-40.4°C and 16.2%-63.2% RH, which significantly (p < 0.05) decreased the salbutamol DD from 80.4 to 70.5 μg compared with VC. This 12.3% DD reduction was accompanied with a decrease in the fine particle dose from 26.2 to 20.4 μg (p < 0.05), and an increase in the mass median aerodynamic diameter from 2.3 to 2.5 μm (p < 0.05). The VW and VC had equivalent DD and APSD. Conclusion: Patients using V are expected to receive smaller lung doses during the hot summer season compared with intentionally well-kept VC. To have equivalent lung deposition, V users should be advised to retain their inhalers around 20°C with minimal daily environmental fluctuations during summer times.
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Affiliation(s)
- Wesam G Ammari
- Faculty of Pharmacy and Medical Sciences, Al-Ahliyya Amman University, Amman, Jordan
| | | | - Rabab F Tayyem
- ACDIMA Centre for Bioequivalence and Pharmaceutical Studies, Amman, Jordan
| | - Gary P Martin
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom
| | - Paul G Royall
- Institute of Pharmaceutical Science, King's College London, London, United Kingdom
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Fishman E, Crawford G, DeVries A, Hackell J, Haynes K, Helm M, Wall E, Agiro A. Association between early-childhood antibiotic exposure and subsequent asthma in the US Medicaid population. Ann Allergy Asthma Immunol 2019; 123:186-192.e9. [PMID: 31158472 DOI: 10.1016/j.anai.2019.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although socioeconomically disadvantaged children have an increased risk of asthma, the association between early-childhood antibiotics and the incidence of asthma among such children has had limited study. OBJECTIVE To examine the association between antibiotic fills in the first 2 years of life and risk of developing asthma among children enrolled in Medicaid plans. METHODS This retrospective cohort study of children with continuous medical and pharmacy coverage from birth to 2.5 years of age was performed from July 1, 2012, to November 31, 2018. We excluded children with a diagnosis of asthma before 2.5 years of age. Hazard ratios (HRs) and 95% CIs were estimated from Cox proportional hazards regression models. Covariates included sex, preterm birth, cesarean delivery, and mother's asthma status. RESULTS There were 79,582 children in the study cohort of whom 29,931 (37.6%) had 0 antibiotic prescriptions filled, 27,403 (34.4%) had 1 or 2 prescriptions filled, and 22,248 (28.0%) had 3 or more prescriptions filled. A total of 2381 new cases of asthma were observed in 89,545 person-years of follow-up. After adjustment, receipt of 1 or 2 antibiotics was associated with an increased risk of developing asthma, relative to 0 antibiotics (HR, 1.34; 95% CI, 1.21-1.49), and receipt of 3 or more antibiotics was associated with greater increased risk relative to 0 antibiotics (HR, 1.71; 95% CI, 1.54-1.90). After adjustment, the absolute risk of developing asthma by age 4.0 years increased from 2.7% (0 antibiotics) to 3.6% (1-2 antibiotics) and 4.5% (≥3 antibiotics). CONCLUSION Antibiotic prescriptions filled in the first 2 years of life were associated with an increased risk of asthma diagnosis from 2.5 to 5 years of age in a Medicaid population.
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Affiliation(s)
| | | | | | | | | | - Mark Helm
- Childhood Health Associates of Salem, Salem, Oregon
| | - Eric Wall
- University of Washington Neighborhood Clinics, Seattle, Washington
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Shah SP, Grunwell J, Shih J, Stephenson S, Fitzpatrick AM. Exploring the Utility of Noninvasive Type 2 Inflammatory Markers for Prediction of Severe Asthma Exacerbations in Children and Adolescents. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2624-2633.e2. [PMID: 31100552 DOI: 10.1016/j.jaip.2019.04.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Noninvasive markers of type 2 inflammation are needed to identify children and adolescents who might benefit from personalized biologic therapy. OBJECTIVE We hypothesized that blood eosinophil counts would predict 1 or more acute visits for asthma and that prediction could be improved with the addition of a second, noninvasive type 2 inflammatory biomarker. METHODS Children and adolescents 5 to 21 years (N = 589) with an asthma exacerbation necessitating systemic corticosteroid treatment in the previous year completed a characterization visit and telephone calls at 6 and 12 months. The primary outcome was an acute visit for asthma with receipt of systemic corticosteroids. Acute visits were verified by medical record review. Exploratory outcomes included time to first acute visit and hospitalization. RESULTS Acute visits occurred in 106 (35.5%) children and 72 (24.8%) adolescents. Elevated blood eosinophils were associated with increased odds and shorter time to first acute visit, but optimal cut-points differed by age (≥150 vs ≥300 cells/μL for children vs adolescents, respectively). The addition of a second marker of type 2 inflammation did not improve prediction in children, but increased the odds and hazard of an acute visit up to 16.2% and 11.9%, respectively, in adolescents. Similar trends were noted for hospitalizations. CONCLUSIONS Blood eosinophils and other noninvasive markers of type 2 inflammation may be useful in the clinical assessment of children and adolescents with asthma. However, features of type 2 inflammation vary by age. Whether children and adolescents also respond differently to management of type 2 inflammation is unclear and warrants further evaluation.
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Affiliation(s)
- Samar P Shah
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jocelyn Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer Shih
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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Lee SY, Bae CS, Seo NS, Na CS, Yoo HY, Oh DS, Bae MS, Kwon MS, Cho SS, Park DH. Camellia japonica oil suppressed asthma occurrence via GATA-3 & IL-4 pathway and its effective and major component is oleic acid. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2019; 57:84-94. [PMID: 30668326 DOI: 10.1016/j.phymed.2018.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/03/2018] [Accepted: 12/09/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND In December 2016, WHO released a report stating that in 2015 there were 383,000 deaths caused by asthma and 235 million people suffering from asthma. As there are many adverse effects associated with the currently-used asthma drugs, new anti-asthmatic drugs need to be developed. PURPOSE In order to find new drug candidates with safe and low side effects, the anti-asthmatic function and mechanism of C. japonica oil were evaluated, and its active ingredients were analyzed for use in an ovalbumin asthma murine model. STUDY DESIGN AND METHODS The study consisted of six groups: control; ovalbumin group; and dexamethasone group as a positive control; and 10, 100, and 500 mg/kg C. japonica oil treatment groups. In order to measure the anti-asthmatic effect of C. japonica oil, WBC and differential cell count in BALF, IgE in serum, morphological changes in pulmonary system, and gene and protein levels such as IFN-γ, IL-12p40, IL-4, IL-5, IL-6, TNF-α, and IL-6 were all evaluated. RESULTS C. japonica oil had an anti-asthmatic effect and significantly controlled eosinophil in BALF, Th2-related factors such as GATA-3 that is Th2 cell transcription factor, IL-4, IL-5, and IL-13, and TNF-α in the lung. It also dose-dependently modulated inflammatory cells, T-bet, IL-12p40, and IL-6. Oleci acid was the major gradient (52.89%) in C. japonica oil and also had anti-asthmatic effects such as the downregulation of inflammatory cells, WBC, and eosinophil in BALF, IgE in serum, and morphological changes in the lung. CONCLUSION We concluded that C. japonica oil is a new anti-asthmatic drug candidate and that oleic acid is the major anti-asthmatic ingredient in C. japonica oil.
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Affiliation(s)
- Soon-Young Lee
- College of Oriental Medicine, Dongshin University, Naju, Jeonnam 58245, South Korea
| | - Chun-Sik Bae
- College of Veterinary Medicine, Chonnam National University, Gwangju 61186, South Korea
| | - Nam-Sook Seo
- College of Oriental Medicine, Dongshin University, Naju, Jeonnam 58245, South Korea
| | - Chang-Su Na
- College of Oriental Medicine, Dongshin University, Naju, Jeonnam 58245, South Korea
| | - Hah Young Yoo
- Department of Biotechnology, Sangmyung University, Seoul 03016, South Korea
| | - Deuk-Sil Oh
- Jeollanam-do Forest Resource Research Institute, Naju, Jeonnam 58213, South Korea
| | - Min-Suk Bae
- College of Engineering, Mokpo National University, Muan, Jeonnam 58554, South Korea
| | - Myung-Sang Kwon
- College of Veterinary Medicine, Kangwon National University, Chuncheon, Gangwon 24341, South Korea
| | - Seung-Sik Cho
- College of Pharmacy and Natural Medicine Research Institute, Mokpo National University, Muan, Jeonnam 58554, South Korea.
| | - Dae-Hun Park
- College of Oriental Medicine, Dongshin University, Naju, Jeonnam 58245, South Korea.
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Shi X, Buysse DJ, Ritterband LM, Sereika SM, Strollo PJ, Wenzel SE, Luyster FS. Solving insomnia electronically: Sleep treatment for asthma (SIESTA): A study protocol for a randomized controlled trial. Contemp Clin Trials 2019; 79:73-79. [PMID: 30825525 PMCID: PMC6563833 DOI: 10.1016/j.cct.2019.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 02/14/2019] [Accepted: 02/26/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Chronic insomnia is associated with poor asthma control. Cognitive-behavioral treatment for insomnia (CBT-I) is an efficacious and durable treatment for comorbid insomnia in medical and psychiatric disorders. However, the efficacy and potential accompanying mechanisms of CBT-I have not been examined in asthma. The purpose of this study is to test the efficacy of a CBT-I intervention on sleep and asthma control in adults with insomnia and asthma. We will also explore airway inflammation (i.e., exhaled nitric oxide, blood eosinophils) as a potential biological mechanism linking improvements in sleep with improvements in asthma control. METHODS The study is a single center, parallel group, randomized controlled trial. Two hundred and ten adults with insomnia and asthma that is not well-controlled will be randomized to either a 9-week Internet-based CBT-I program (Sleep Healthy Using the Internet (SHUTi)) or an enhanced usual care condition which utilizes an online educational video about insomnia. The primary sleep outcome is insomnia severity measured by the Insomnia Severity Index. Secondary sleep outcomes are sleep quality and wrist actigraph-recorded sleep parameters. Asthma control will be assessed by the Asthma Control Test, Asthma Quality of Life Questionnaire, pulmonary function testing, and self-report of asthma exacerbations and asthma-related healthcare utilization. Treatment outcomes will be measured at baseline, 9 weeks, and 6 months. DISCUSSION This trial has the potential to identify a novel strategy for improving asthma control. Findings may advocate for the inclusion of treatment of comorbid insomnia into current asthma management practice guidelines.
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Affiliation(s)
- Xiaojun Shi
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Daniel J Buysse
- Department of Psychiatry and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Lee M Ritterband
- Center for Behavioral Health & Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Susan M Sereika
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Patrick J Strollo
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Sally E Wenzel
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Faith S Luyster
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, United States of America.
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Zhu Y, Zhong T, Ge D, Li Q, Wu J. Multi-Factor Analysis of Single-Center Asthma Control in Xiamen, China. Front Pediatr 2019; 7:498. [PMID: 31850293 PMCID: PMC6901658 DOI: 10.3389/fped.2019.00498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/18/2019] [Indexed: 12/20/2022] Open
Abstract
We evaluated the effects of air pollutants, age, allergic history, family allergic history, treatment, treatment steps, and compliance on uncontrolled childhood asthma in Xiamen, China. The clinical data of children with asthma in the pediatric outpatient department of the First Affiliated Hospital of Xiamen University from January 2016 to June 2018 were analyzed retrospectively. According to the assessment of the patients' outcome including well-controlled, partly-controlled and uncontrolled, 7,211 cases of 3,268 patients were selected. Rank sum test and ordered multi-class logistic regression analysis were used. In the rank sum test, age, allergic history, family allergic history, season, treatment, treatment steps and compliance were found associated with uncontrolled rate (all P < 0.001). Logistic regression analysis showed that PM10, NO2, and SO2 raised uncontrolled-asthma rate (aOR 1.311, aOR 1.281, aOR 1.252, respectively). Older children had lower uncontrolled rate (OR = 0.849, 95% CI: 0.758-0.950), children with higher treatment steps had higher uncontrolled rate (OR = 1.227, 95%CI: 1.040-1.448), and children with better treatment compliance have lower uncontrolled rate (OR = 0.374 95% CI: 0.331-0.424). The order of the uncontrolled rate of asthma from high to low was winter, spring, autumn, and summer. PM10, NO2, SO2, age, season, treatment steps, and treatment compliance have significance for predicting the control rate of childhood asthma in Xiamen, China.
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Affiliation(s)
- Yu Zhu
- Department of Pediatrics, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Taoling Zhong
- National Institute for Data Science in Health and Medicine, School of Medicine, Xiamen University, Xiamen, China
| | - Dandan Ge
- Department of Pediatrics, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Qiyuan Li
- National Institute for Data Science in Health and Medicine, School of Medicine, Xiamen University, Xiamen, China
| | - Jinzhun Wu
- Department of Pediatrics, The First Affiliated Hospital of Xiamen University, Xiamen, China
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Abstract
Respiratory viral infections including human rhinovirus (RV) infection have been identified as the most important environmental trigger of exacerbations of chronic lung diseases. While well established as the most common viral infections associated with exacerbations of asthma and chronic obstructive pulmonary disease, RVs and other respiratory viruses are also now thought to be important in triggering exacerbations of cystic fibrosis and the interstitial lung diseases. Here, we summarize the epidemiological evidence the supports respiratory viruses including RV as triggers of exacerbations of chronic lung diseases. We propose that certain characteristics of RVs may explain why they are the most common trigger of exacerbations of chronic lung diseases. We further highlight the latest mechanistic evidence supporting how and why common respiratory viral infections may enhance and promote disease triggering exacerbation events, through their interactions with the host immune system, and may be affected by ongoing treatments. We also provide a commentary on how new treatments may better manage the disease burden associated with respiratory viral infections and the exacerbation events that they trigger.
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Out of One, Many: Moving beyond a Single Guideline toward Personalized Asthma Care for Obese Children. Ann Am Thorac Soc 2018; 15:16-17. [PMID: 29286850 DOI: 10.1513/annalsats.201710-836ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Kercsmar CM, Sorkness CA, Calatroni A, Gergen PJ, Bloomberg GR, Gruchalla RS, Kattan M, Liu AH, O'Connor GT, Pongracic JA, Szefler SJ, Teach SJ, Wildfire JJ, Wood RA, Zoratti EM, Busse WW. A computerized decision support tool to implement asthma guidelines for children and adolescents. J Allergy Clin Immunol 2018; 143:1760-1768. [PMID: 30529451 DOI: 10.1016/j.jaci.2018.10.060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 09/18/2018] [Accepted: 10/01/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multicenter randomized controlled trials (RCTs) for asthma management that incorporate usual-care regimens could benefit from standardized application of evidence-based guidelines. OBJECTIVE We sought to evaluate performance of a computerized decision support tool, the Asthma Control Evaluation and Treatment (ACET) Program, to standardize usual-care regimens for asthma management in RCTs. METHODS Children and adolescents with persistent uncontrolled asthma living in urban census tracts were recruited into 3 multicenter RCTs (each with a usual-care arm) between 2004 and 2014. A computerized decision support tool scored asthma control and assigned an appropriate treatment step based on published guidelines. Control-level determinants (symptoms, rescue medication use, pulmonary function measure, and adherence estimates) were collected at visits and entered into the ACET Program. Changes in control levels and treatment steps were examined during the trials. RESULTS At screening, more than half of the participants were rated as having symptoms that were not controlled or poorly controlled. The proportion of participants who gained good control between screening and randomization increased significantly in all 3 trials. Between 51% and 70% had symptoms that were well controlled by randomization. The proportion of well-controlled participants remained constant or improved slightly from randomization until the last posttreatment visit. Nighttime symptoms were the most common control-level determinant; there were few (<1%) instances of complete overlap of factors. FEV1 was the driver of control-level assignment in 30% of determinations. CONCLUSION The ACET Program decision support tool facilitated standardized asthma assessment and treatment in multicenter RCTs and was associated with attaining and maintaining good asthma control in most participants.
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Affiliation(s)
- Carolyn M Kercsmar
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Christine A Sorkness
- Department of Medicine, Division of Allergy and Immunology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Peter J Gergen
- Division of Allergy, Immunology, and Transplantation, National Institutes of Health, Bethesda, Md
| | - Gordon R Bloomberg
- Department of Pediatrics, Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Rebecca S Gruchalla
- Department of Internal Medicine/Pediatrics, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Meyer Kattan
- Department of Pediatrics, Division of Pediatric Pulmonology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew H Liu
- Department of Pediatrics, Division of Pulmonary Medicine, Children's Hospital Colorado, Aurora, Colo
| | - George T O'Connor
- Department of Medicine, Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University School of Medicine, Boston, Mass
| | - Jacqueline A Pongracic
- Department of Pediatrics, Division of Allergy and Immunology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Stanley J Szefler
- Department of Pediatrics, Division of Pulmonary Medicine, National Jewish Health and University of Colorado, Denver School of Medicine, Denver, Colo
| | - Stephen J Teach
- Department of Pediatrics, Division of Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC
| | | | - Robert A Wood
- Department of Pediatrics, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Edward M Zoratti
- Department of Pediatrics, Division of Allergy and Immunology, Henry Ford Health System and Wayne State University School of Medicine, Detroit, Mich
| | - William W Busse
- Department of Medicine, Division of Allergy and Immunology, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Yang JF, Chaudhuri R, Thomson NC, Ramparsad N, O'Pray H, Barclay S, MacBride-Stewart S, McCallum C, Sharma V, McSharry C, Murray D, Shepherd M, Lee WTN. Insights into frequent asthma exacerbations from a primary care perspective and the implications of UK National Review of Asthma Deaths recommendations. NPJ Prim Care Respir Med 2018; 28:35. [PMID: 30232329 PMCID: PMC6145932 DOI: 10.1038/s41533-018-0103-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 08/22/2018] [Accepted: 08/28/2018] [Indexed: 02/06/2023] Open
Abstract
The United Kingdom National Review of Asthma Deaths (NRAD) recommends that patients who require ≥3 courses of oral corticosteroids (OCS) for exacerbations in the past year or those on British Thoracic Society (BTS) Step 4/5 treatment must be referred to a specialist asthma service. The aim of the study was to identify the proportion of asthma patients in primary care that fulfil NRAD criteria for specialist referral and factors associated with frequent exacerbations. A total of 2639 adult asthma patients from 10 primary care practices in Glasgow, UK were retrospectively studied between 2014 and 2015. Frequent exacerbators and short-acting β2-agonist (SABA) over-users were identified if they received ≥2 confirmed OCS courses for asthma and ≥13 SABA inhalers in the past year, respectively. Community dispensing data were used to assess treatment adherence defined as taking ≥75% of prescribed inhaled corticosteroid (ICS) dose. The study population included 185 (7%) frequent exacerbators, 137 (5%) SABA over-users, and 319 (12%) patients on BTS Step 4/5 treatment. Among frequent exacerbators, 41% required BTS Step 4/5 treatment, 46% had suboptimal ICS adherence, 42% had not attended an asthma review in the past year and 42% had no previous input from a specialist asthma service. Older age, female gender, BTS Step 4/5, SABA over-use and co-existing COPD diagnosis increased the risk of frequent exacerbations independently. Fourteen per 100 asthma patients would fulfil the NRAD criteria for specialist referral. Better collaboration between primary and secondary care asthma services is needed to improve chronic asthma care.
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Affiliation(s)
- Jieqiong Freda Yang
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Rekha Chaudhuri
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Neil C Thomson
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Nitish Ramparsad
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Hugh O'Pray
- eHealth Strategy & Programmes, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Stephen Barclay
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Craig McCallum
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Varun Sharma
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Charles McSharry
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Dianne Murray
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Malcolm Shepherd
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Wai-Ting Nicola Lee
- Asthma/COPD Clinical Research Centre, Gartnavel General Hospital, Glasgow & Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK.
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Abstract
PURPOSE OF REVIEW The article aims to provide an updated and evidence-based review of the innovative electronic health interventions to monitor and improve inhaler technique and adherence to recommended therapy in asthma. RECENT FINDINGS Out of the 290 articles identified by the search strategy, 23 manuscripts fulfilled the review inclusion criteria. Included studies mainly addressed m-health, electronic reminders, telemedicine, and inhaler tracker interventions. Investigations were performed both in adults and children. Remarkably, the majority of studies were performed in the most recent years, showing a progressively increasing interest for this field. Existing findings appear to be of moderate-high quality. A significant number of papers, however, were published in scientific journals with a low impact factor (<2). Furthermore, extremely high heterogeneity was found in the considered study endpoints. Collected evidence supports a relevant role for e-health in monitoring and improving inhaler use and treatment adherence in asthma. The patients' acceptance and satisfaction towards assessed interventions were also found to be positive. SUMMARY E-health represents a highly valuable tool for achieving optimal and personalized asthma management. Unanimously agreed and adopted standards for conducting trials and reporting results on e-health in asthma are however needed to fully understand its real added value.
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Tamási L, Szilasi M, Gálffy G. Clinical Effectiveness of Budesonide/Formoterol Fumarate Easyhaler ® for Patients with Poorly Controlled Obstructive Airway Disease: a Real-World Study of Patient-Reported Outcomes. Adv Ther 2018; 35:1140-1152. [PMID: 30066185 PMCID: PMC6096955 DOI: 10.1007/s12325-018-0753-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The effectiveness of inhaled therapies can be influenced by many factors, including the type of inhaler, which may have clinical implications. We report a real-world, multicenter, open-label, non-randomized, non-interventional study conducted by 200 pulmonologists across 200 centers in Hungary. The effectiveness of budesonide/formoterol inhalation therapy in daily clinical practice, delivered via the Bufomix Easyhaler®, was evaluated in patients with asthma, chronic obstructive pulmonary disease (COPD) and asthma-COPD overlap (ACO). METHODS Effectiveness was assessed after 12 weeks of treatment by spirometry, the Asthma Control Test, mini-Asthma Quality of Life Questionnaire, COPD Assessment Test and modified Medical Research Council dyspnea scale. Patient satisfaction with the Bufomix Easyhaler® and physicians' assessments (ease of use and time taken to learn the technique) were also assessed. RESULTS A total of 1498 patients with obstructive airway disease were evaluated (asthma: n = 621; COPD: n = 778; ACO: n = 99), of whom 455 (30.4%) were newly diagnosed inhaler-naïve patients and 1043 (69.6%) were switching from other inhalers. Significant improvements in lung function, disease control and health-related quality of life measures (all p ≤ 0.002) were reported after 12 weeks of Bufomix Easyhaler® use. Improvements were observed in both inhaler-naïve patients and those who switched to a Bufomix Easyhaler® from other devices. After switching, 72.4% of patients regarded the Bufomix Easyhaler® as 'very good' and > 90.0% of physicians described the Bufomix Easyhaler® as easy to teach; 73.8% and 98.9% of patients learned the technique within 5 and 10 min of teaching, respectively. CONCLUSION Twelve weeks' treatment with the Bufomix Easyhaler® resulted in significant improvements in disease control and quality of life. The Bufomix Easyhaler® was considered easy to use, and most patients were satisfied with the inhaler. Results confirm the real-world effectiveness of the Bufomix Easyhaler® in the treatment of adult outpatients with obstructive airway disease. FUNDING Orion Corp., Orion Pharma.
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Huffaker MF, Carchia M, Harris BU, Kethman WC, Murphy TE, Sakarovitch CCD, Qin F, Cornfield DN. Passive Nocturnal Physiologic Monitoring Enables Early Detection of Exacerbations in Children with Asthma. A Proof-of-Concept Study. Am J Respir Crit Care Med 2018; 198:320-328. [PMID: 29688023 PMCID: PMC6835062 DOI: 10.1164/rccm.201712-2606oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/23/2018] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Asthma management depends on prompt identification of symptoms, which challenges both patients and providers. In asthma, a misapprehension of health between exacerbations can compromise compliance. Thus, there is a need for a tool that permits objective longitudinal monitoring without increasing the burden of patient compliance. OBJECTIVES We sought to determine whether changes in nocturnal physiology are associated with asthma symptoms in pediatric patients. METHODS Using a contactless bed sensor, nocturnal heart rate (HR), respiratory rate, relative stroke volume, and movement in children with asthma 5-18 years of age (n = 16) were recorded. Asthma symptoms and asthma control test (ACT) score were reported every 2 weeks. Random forest model was used to identify physiologic parameters associated with asthma symptoms. Elastic net regression was used to identify variables associated with ACT score. MEASUREMENTS AND MAIN RESULTS The model on the full cohort performed with sensitivity of 47.2%, specificity of 96.3%, and accuracy of 87.4%; HR and respiratory parameters were the most important variables in this model. The model predicted asthma symptoms 35% of the time on the day before perception of symptoms, and 100% of the time for a select subject for which the model performed with greater sensitivity. Multivariable and bivariable analyses demonstrated significant association between HR and respiratory rate parameters and ACT score. CONCLUSIONS Nocturnal physiologic changes correlate with asthma symptoms, supporting the notion that nocturnal physiologic monitoring represents an objective diagnostic tool capable of longitudinally assessing disease control and predicting asthma exacerbations in children with asthma at home.
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Affiliation(s)
| | | | - Bronwyn U. Harris
- Department of Pediatrics–Cardiology
- Tueo Health, Inc., San Francisco, California
| | | | | | | | | | - David N. Cornfield
- Center for Excellence in Pulmonary Biology, Division of Pulmonary, Asthma, and Sleep Medicine, Department of Pediatrics, Stanford University Medical School, Stanford, California; and
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Ferrari CR, Cooley J, Mujahid N, Costa LR, Wills RW, Johnson ME, Swiderski CE. Horses With Pasture Asthma Have Airway Remodeling That Is Characteristic of Human Asthma. Vet Pathol 2018; 55:144-158. [PMID: 29254472 DOI: 10.1177/0300985817741729] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Severe equine asthma, formerly recurrent airway obstruction (RAO), is the horse counterpart of human asthma, affecting horses maintained indoors in continental climates. Equine pasture asthma, formerly summer pasture RAO, is clinically similar but affects grazing horses during hot, humid conditions in the southeastern United States and United Kingdom. To advance translational relevance of equine pasture asthma to human asthma, histologic features of airway remodeling in human asthma were scored in lung lobes from 15 pasture asthma-affected and 9 control horses of mixed breeds. All noncartilaginous airways were scored using a standardized grading rubric (0-3) in hematoxylin and eosin (HE) and Movat's pentachrome-stained sections; 15 airways were chosen randomly from each lobe for analysis. Logistic regression identified disease, age, and lobe effects on probability of histologic outcomes. Airway smooth muscle (odds ratio [OR] = 2.5, P < .001), goblet cell hyperplasia/metaplasia (OR = 37.6, P < .0001), peribronchiolar elastic system fibers (OR = 4.2, P < .001), peribronchiolar fibrosis (OR = 3.8, P = .01), airway occlusion by mucus/inflammation (OR = 4.2, P = .04), and airway adventitial inflammation (OR = 3.0, P = .01) were significantly greater in diseased airways. A novel complex tissue disorganization, designated terminal bronchiolar remodeling, was overrepresented in diseased airways (OR = 3.7, P < .0001). Distribution of terminal bronchiolar remodeling corresponded to putative sites of air trapping in human asthma, at secondary pulmonary lobules. Age (>15 years) was an independent risk factor for increased peribronchiolar fibrosis, elastic system fibers, and terminal bronchiolar remodeling. Remodeling differed significantly between lung lobes, congruent with nonhomogeneous remodeling in human asthma. Equine pasture asthma recapitulates airway remodeling in human asthma in a manner not achieved in induced animal asthma models, endorsing its translational relevance for human asthma investigation.
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Affiliation(s)
- Claudenir R Ferrari
- 1 Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, MS, USA.,2 Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Starkville, MS, USA
| | - Jim Cooley
- 2 Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Starkville, MS, USA
| | - Nisma Mujahid
- 1 Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, MS, USA
| | - Lais R Costa
- 1 Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, MS, USA
| | - Robert W Wills
- 2 Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Starkville, MS, USA
| | - Melanie E Johnson
- 1 Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, MS, USA.,2 Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Starkville, MS, USA
| | - Cyprianna E Swiderski
- 1 Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, MS, USA
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Sullivan PW, Ghushchyan V, Kavati A, Navaratnam P, Friedman HS, Ortiz B. Health Disparities Among Children with Asthma in the United States by Place of Residence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:148-155. [PMID: 29782937 DOI: 10.1016/j.jaip.2018.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/08/2018] [Accepted: 05/03/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Children residing in poor-urban areas may have greater asthma morbidity. It is unclear whether this is due to individual characteristics such as race and ethnicity or place of residence. OBJECTIVE Assess indicators of control and treatment by residence. METHODS This was a cross-sectional analysis of children (aged 1-17 years) in the 2000-2014 Medical Expenditure Panel Survey (MEPS). Indicators of poor control included use of more than 3 canisters of short-acting beta agonist (SABA) in 3 months, asthma attack, and emergency department (ED) or inpatient (IP) visit during the year. Treatment measures included use of controller medications and a ratio of controller-to-total prescriptions of 0.7 or more. RESULTS There were 15,052 children with asthma in the MEPS 2000-2014 data, reflecting 8.4 million children in 2014. After controlling for covariates, children with asthma residing in poor-urban areas had lower odds of using controller medications (odds ratio [OR] = 0.77), having a controller-to-total ratio of 0.7 or more (OR = 0.75), and reporting an asthma attack (OR = 0.75) and higher odds of having an ED/IP visit (OR = 1.3) compared with those living elsewhere. Black race and Hispanic ethnicity were associated with greater odds of excessive SABA use (OR = 2.11) and ED/IP visits (OR = 2.03) and lower odds of controller-to-total ratio of 0.07 or more (OR = 0.50). CONCLUSIONS Poor-urban residence may be independently associated with asthma control and treatment even after controlling for individual characteristics such as race and ethnicity. Future research is needed to understand the sources of these geographic health disparities to more successfully target public health interventions.
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Affiliation(s)
| | - Vahram Ghushchyan
- University of Colorado, Denver, Colo; American University of Armenia, Yerevan, Armenia
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49
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Abstract
PURPOSE OF REVIEW Asthma is the most prevalent chronic respiratory disease and represents a relevant socioeconomic burden. e-Health has the potential to improve disease control and adherence to treatment in asthmatic patients. Available data are, however, scarce and inconsistent limiting the use of e-health in clinical practice. This article aims to provide a systematic review of the literature published in the last year regarding the real place and impact of e-health in the management of asthma. RECENT FINDINGS Despite few conflicting results, collected findings support a beneficial effect of e-health on asthma management and control, as well as positive patients' acceptance and satisfaction. Included studies mainly assessed m-health, telemedicine, electronic health record and digital app interventions, in both adults and children. Existing evidence appears however to be only of moderate quality and high heterogeneity was found in the study endpoints and designs. SUMMARY There is the need to establish widely adopted standards for conducting trials and reporting results in e-health. These should include minimal clinical difference assessment and prevent potential pitfalls such as patient privacy protection, data fishing and lack of compliance of interventions with evidence-based medicine, guideline recommendations and regulatory board statements.
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Severe Asthma Phenotypes - How Should They Guide Evaluation and Treatment? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:901-908. [PMID: 28689840 DOI: 10.1016/j.jaip.2017.05.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 11/22/2022]
Abstract
Although patients with "severe" asthma tend to be characterized by ongoing symptoms and airway inflammation despite treatment with high doses of inhaled and systemic corticosteroids, there is increasing recognition of marked phenotypic heterogeneity within affected patients. Although "precision medicine" approaches for patients with severe asthma are needed, there are many hurdles that must be overcome in daily practice. The National Heart, Lung and Blood Institute's Severe Asthma Research Program (SARP) has been at the forefront of phenotype discovery in severe asthma for the past decade. SARP, along with other international groups, has described clinical severe asthma phenotypes in both adults and children that can be evaluated in the clinical setting. Although these clinical phenotypes provide a good "starting point" for addressing disease heterogeneity in severe asthma in everyday practice, more efforts are needed to understand how these phenotypes relate to underlying disease mechanisms and pharmacological treatment responses. This review highlights the clinical asthma phenotypes identified to date, their associations with underlying endotypes and potential biomarkers, and remaining knowledge gaps that must be addressed before precision medicine can become a reality for patients with severe asthma.
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