New treatments for exercise-induced asthma

Exercise-induced bronchospasm: coding and billing for physician services

Physician reporting of the service to insurance companies for reimbursement is multifaceted and perplexing to those who do not understand the factors to consider. Test selection should be individualized based on the patient's history and/or needs. Federal regulations concerning physician supervision of diagnostic tests mandate different levels of physician supervision based on the type and complexity of the test. Many factors play a key role in physician claim submission. These include testing location, component services, coding edits, and additional visits. Medical necessity of the service(s) must also be demonstrated for payer consideration and reimbursement. The following article reviews various tests for exercise-induced bronchospasm and focuses on issues to assist the physician in reporting the services accurately and appropriately.

Antileukotrienes in clinical development for asthma

Asthma is a serious world health problem characterised by a chronic inflammatory disorder of the airways. Asthma attacks, or exacerbations, are episodic but airway inflammation is chronically present. Thus, this disorder requires long-term management. The goals of asthma management include prevention steps for long-term control, action steps to stop attacks, recognising deteriorating asthma, how to treat deteriorating asthma, how and when to seek medical attention and education. In order to achieve the best therapeutic choice, a stepwise approach should be adopted. In recent years, much progress regarding the characterisation of leukotrienes (LTs) has been achieved. These substances are important products of action of the 5-lipoxygenase (5-LO) enzyme on arachidonic acid (AA) and it has been established that the leukotrienes are key mediators of both allergy and inflammation. Consequently, the important role of the cysteinyl-leukotrienes (Cys-LTs) in the pathophysiology of bronchial asthma has been suggested. Pharmacological support for the role of Cys-LTs in asthma has been observed using inhibitors of 5-LO and specific LT receptor antagonists. In the clinical setting, the LT receptor, which plays the most important role, is the Cys-LT1 receptor. The antagonists of this receptor have proven an effective therapy in chronic asthmatics, agonist antigens and exercise-induced bronchoconstriction and in aspirin-intolerant asthmatics. These drugs provide a new approach in asthmatic therapy and therefore may facilitate the compliance of daily therapy.

Asthma

Asthma is an important and increasingly prevalent respiratory disease. Its proper diagnosis and treatment lie at the heart of improving asthma outcome. Unfortunately, asthma has many faces and is affected by many variables, many of them difficult to control. Like many chronic illnesses, asthma tends to affect the poor and less advantaged individuals in society. Heightened awareness among patients and physicians of the serious nature of the disease is needed to reduce the morbidity and mortality of asthma. Treatment clearly requires a multifaceted approach, including behavioral, environmental, social, and medical interventions, in which the National Asthma Education and Prevention Program guidelines provide a logical, step-wise, and effective approach.

Expedient liquid chromatographic method with fluorescence detection for montelukast sodium in micro-samples of plasma

This study describes an expedient assay for the analysis of the asthma medication, montelukast sodium (Singulair, MK-0476), in human plasma samples. After a simple extraction of the plasma, the drug and internal standard, quinine bisulfate, were measured by HPLC. The chromatographic system consisted of a single pump, a refrigerated autosampler, a C8 4-microm particle size radial compression cartridge at 40 degrees C and a fluorescence detector with the excitation and emission wavelengths set at 350 and 400 nm, respectively. The mobile phase which was delivered at 1.0 ml/min, was prepared by adding 200 ml of 0.025 M sodium acetate, pH adjusted to 4.0 with acetic acid, to 800 ml of acetonitrile, with 50 microl triethylamine. With a run time of only 10 min per sample, this assay had an overall recovery of >97% with a detection limit of 1 ng/ml. The inter- and intra-run relative standard deviations at 0.05, 0.2 and 1.0 microg/ml were all <9.2%, while the analytical recovery at the same concentrations were within 7.7% of the amount added.

Leukotriene receptor antagonist therapy

Leukotriene receptor antagonists (LTRA) are a new class of drugs for asthma treatment, available in tablet form. Their unique mechanism of action results in a combination of both bronchodilator and anti-inflammatory effects. While their optimal place in asthma management is still under review, LTRA represent an important advance in asthma pharmacotherapy.

Advances in medical management of asthma, headaches, and fatigue

The 1990s in medicine have been characterized by the development of various clinical guidelines to assist in the diagnosis, classification, and management of common disorders. Among the most frequent presenting complaints of adolescent patients are asthma, headaches, and fatique. In an era of managed care and brief clinical encounters, application of standardized guidelines, modified appropriately for adolescents, is likely to improve clinical outcomes, including patient and parent satisfaction. In each of these disorders, engaging the adolescent patient as a partner in planning and implementing management is crucial to success.

Montelukast: a review of its therapeutic potential in persistent asthma

Montelukast is a cysteinyl leukotriene receptor antagonist used to treat persistent asthma in patients aged > or = 6 years. The drug has a rapid onset of action. Improvements in lung function and reductions in as-needed beta2-agonist usage are apparent within 1 day of initiating montelukast treatment in adults and adolescents (aged > or = 15 years treated with 10 mg/day) or children (aged 6 to 14 years treated with 5 mg/day) with persistent asthma as shown in clinical trials. In two 12-week, multicentre, randomised, double-blind studies in adults and adolescents aged > or = 15 years with persistent asthma [forced expiratory volume in 1 second (FEV1) = 50 to 85% predicted] there was significantly (p < 0.05) greater improvement in FEV1, symptom scores, peak expiratory flow (PEF), as-needed beta2-agonist use, peripheral eosinophil counts and health-related quality of life (QOL) in patients treated with montelukast 10 mg/day than in recipients of placebo. Improvements were significantly greater in patients treated with inhaled beclomethasone 400 microg/day than in recipients of montelukast 10 mg/day in 1 of these studies. Nonetheless, 42% of montelukast recipients experienced > or = 11% improvement in FEV1, the median improvement in this parameter in beclomethasone-treated patients. In an 8-week multicentre, randomised, double-blind, study in children aged 6 to 14 years with persistent asthma (FEV1 50 to 85% predicted), montelukast 5 mg/day produced significantly greater improvements in FEV1, clinic PEF, as-needed beta2-agonist use, peripheral eosinophil counts, asthma exacerbations and QOL scores than placebo. The combination of montelukast 10 mg/day plus inhaled beclomethasone 200 microg twice daily provided significantly better asthma control than inhaled beclomethasone 200 microg twice daily in adults with poorly controlled asthma (mean FEV1 = 72% predicted) despite 4 weeks treatment with inhaled beclomethasone. Patients receiving the combination experienced significant improvements in FEV1 and morning PEF, significant reductions in daytime symptom scores, as-needed beta2 agonist usage and night-time awakenings with asthma, and had significantly lower peripheral blood eosinophil counts after 16 weeks in this multicentre, randomised, double-blind, placebo-controlled study. Among adults (FEV1 > or = 70%) treated with montelukast 10 mg/day for 12 weeks, inhaled corticosteroid dosages were titrated downward by 47% (vs 30% in placebo recipients), 40% of patients were tapered off of inhaled corticosteroids (vs 29%), and significantly fewer patients (16 vs 30%) experienced failed corticosteroid rescues in a multicentre, randomised, double-blind study. During clinical studies, the frequency of adverse events in montelukast-treated adults, adolescents and children was similar to that in placebo recipients. In conclusion, montelukast is well tolerated and effective in adults and children aged > or = 6 years with persistent asthma including those with exercise-induced bronchoconstriction and/or aspirin sensitivity. Furthermore, montelukast has glucocorticoid sparing properties. Hence, montelukast, as monotherapy in patients with mild persistent asthma, or as an adjunct to inhaled corticosteroids is useful across a broad spectrum of patients with persistent asthma.

Montelukast: data from clinical trials in the management of asthma

OBJECTIVE

To review the pharmacology, pharmacokinetics, clinical efficacy, and adverse effects of montelukast, a leukotriene receptor antagonist used to treat asthma, and to discuss the therapeutic role of montelukast as long-term medication and difficulties associated with the management of asthma.

DATA SOURCES

A MEDLINE search (up to May 1999) was conducted to identify relevant English-language publications, including preclinical studies, clinical trials, and recent reviews.

STUDY SELECTION

All available published reports of controlled, clinical trials of montelukast in adults and children with asthma were summarized, including pharmacokinetic and pharmacologic effects of montelukast.

DATA EXTRACTION

Information on the safety and efficacy of montelukast was evaluated on the basis of patient selection, study design, methodology, and statistical significance as compared with placebo or inhaled corticosteroid treatment.

DATA SYNTHESIS

Montelukast is approved for the prophylaxis and chronic treatment of asthma at a dose of 10 mg once daily for adolescents (> or =15 y) and adults and 5 mg once daily for children (6-14 y). In placebo-controlled clinical trials, montelukast significantly improved pulmonary lung function (as measured by forced expiratory volume in 1 sec), significantly reduced beta2-agonist use, and significantly improved patient-reported end points in adults and children (> or =6 y) with chronic asthma. In adults, a similar magnitude of improvement in lung function is seen with or without inhaled corticosteroid use; the effects of montelukast may be additive to those of inhaled corticosteroids and permit the reduction of the required dose of inhaled corticosteroids. In cases of exercise-induced asthma (adults and children), montelukast treatment attenuates the fall in pulmonary function following exercise. It attenuates both the early- and late-phase responses of asthma after allergen inhalation. Improvements in asthma control are similar in asthmatic patients who are aspirin-sensitive or not aspirin-sensitive and can be seen within one day of treatment. Tolerance does not develop, and the adverse events do not differ from those of placebo.

CONCLUSIONS

Montelukast is indicated for the prophylaxis of chronic asthma in adults and children (> or =6 y). It may be considered for use as first-line therapy in patients with mild persistent asthma or for additional control in patients who are still symptomatic while receiving treatment with inhaled corticosteroids. It may also be used for additional control in aspirin-sensitive asthmatic patients. Consideration may be given for using montelukast to allow tapering of the dose of inhaled corticosteroids while maintaining clinical stability. Chronic treatment with montelukast can provide additional control of symptoms during exercise, but inhaled beta2-agonists remain first-line therapy for prophylaxis and treatment.

Exercise-induced asthma

Exercise-induced asthma (EIA) is a common condition that can impede physical activity, particularly for children, adolescents, and young adults. A detailed patient history can help the physician identify subtle EIA clues such as fatigue or poorer performance than training would predict. A careful physical exam can help rule out conditions that mimic EIA such as respiratory infections or cardiac conditions. Pulmonary function testing is often useful for assessing severity and establishing a baseline for assessing treatment efficacy. Treatment options include nonpharmacologic measures that address the exercise environment and warm-up routines. Several medication options and combinations can help patients avoid symptoms and participate fully in fitness and sports activities.