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Education Program Improves Asthma Outcomes in Children

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Assess clinically focused product information on Medscape. Click Here for Product Infosites Information from Industry. By Karla Gale NEW YORK (Reuters Health) Nov 10 - A one-to-one asthma education program for pediatric patients and their families can prevent severe exacerbations, reduce medical costs and improve school and work attendance, investigators reported at the annual scientific meeting of the American College of Allergy, Asthma and Immunology underway in Miami Beach, Florida. "Our asthma education and self-management training program provides what patients and families want and when they want it while making sure that we give messages that are compatible with what providers hope to accomplish in the office," Dr. Laura Blaisdell told Reuters Health The education/self-management training sessions last 1 to 2 hours for 1 or 2 sessions. The goals are to help patients understand "that asthma is a chronic disease and why the medications are used and how to use them, how to avoid triggers and what to do in case of a flare," the researcher explained. In addition, she said, "We often need to dispel the myths that exist around asthma; written asthma plans need to be reviewed; patients need to be checked on their ability to actually use the medications prescribed (e.g., nebulizers vs. dry powder inhaler vs. metered dose inhaler with spacer). Sometimes we actually have to help patients find resources to help with the cost of medications." Dr. Blaisdell and associates from the Maine Medical Center in Portland evaluated their AH! Asthma Health Program in an observational study that spanned the period from 1999 to 2008 and involved 1096 children. The program achieved consistent reductions in a variety of endpoints. Over the 9 years of the study, for example, emergency department visits averaged 25 percentage points lower after participation, falling to less than 10%. The percentage of children who required hospitalization declined on average from 30% prior to the program to 1% afterward. The average proportions of patients who missed school or work were 58% during the 6 months prior to participation compared to only 12% afterward. Dr. Blaisdell's advice to clinicians: "Partner with certified asthma educators to support the prescribing and diagnosing that goes on in the office. Identify someone in the office who can become expert in device training and trouble shooting. And refer to a specialist who can help the patient figure out their triggers and help to decide on best management strategies."
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First, let's look at the EPR-3 guideline information on assessing asthma severity at the initial visit, shown in Figure 1 (children, ages 0-4), Figure 2 (children, ages 5-11), and Figure 3 (youths, age 12 and adults).

Figure 1. Classifying asthma severity in children 0-4 years of age. Reprinted with Permission from US Department of Health and Human Services, NIH, NHLBI.
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Figure 2. Classifying asthma severity in children 5-11 years of age. Reprinted with Permission from US Department of Health and Human Services, NIH, NHLBI.
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Figure 3. Classifying asthma severity in youths 12 years of age and adults. Reprinted with Permission from US Department of Health and Human Services, NIH, NHLBI.
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Next, let's look at the EPR-3 guidelines regarding assessing asthma control in follow-up visits in Figure 4 (children, ages 0-4); Figure 5 (children, ages 5-11), and Figure 6 (youths, age 12 and adults).
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Figure 5. Assessing asthma control in children 6-11 years of age. Reprinted with permission from US Department of Health and Human Services, NIH, NHLBI.
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For example, research has shown that a general question posed to a patient with asthma such as "How are you doing with your asthma?" is not very helpful at determining how well controlled a patient's asthma is at that particular time. More specific questions, such as asking them how many times they're needing their albuterol inhaler in a week, or whether shortness of breath is limiting exercise or waking them up from sleep at night, is much more helpful at assessing asthma control. In addition, measured pulmonary function provides an objective assessment that can be followed over time. Using these particular questions and measurements can be much more accurate than asking general questions regarding a patient's perception of their disease control. Unfortunately, patients will accommodate to their level of airway obstruction and it will become "normal" to them. This underscores the need for objective data in following their disease, much as we use serial blood pressure measurements for patients with hypertension or hemoglobin A1C for diabetics. I think that one of the barriers to more widespread use of the NIH Guidelines in general practice is a perception that it will add more work and "hassle factor" to caring for these patients. In fact, I think it is just the opposite. Use of the NIH

asthma treatment guidelines is very straightforward and, in my view, actually speeds your treatment decisions regarding management of patients with asthma. Let's examine the stepwise approach for managing each age group according to the EPR-3 guidelines: Figure 7 for children ages 0 to 4; Figure 8 for children ages 5 to 11; and, Figure 9 for youths 12 years old and older and adults.
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There are also simple helpful hints in the guidelines. For example, once you obtain adequate asthma control, your patient should not be using their albuterol more than twice per week to control spontaneous asthma symptoms In other words, if somebody spontaneously needs albuterol for shortness of breath (not counting pre-treatment for exercise) more than twice a week, then your level of asthma control is probably not adequate. Medscape: The guidelines place a strong emphasis on spirometry. Should clinicians be monitoring spirometry regularly in an office setting, and, if so, how do you obtain this without adversely affecting the flow of patient care?

Dr. O'Hollaren: Spirometry is a very important metric that we use to see if what we're using to treat patients with asthma is actually working or not. Office spirometry is sometimes not used because clinicians feel that it will disrupt the flow of patient care. In addition, some clinicians may have forgotten some of the skills used in interpretation of office spirometry. The latter can be addressed with a brief lecture or refresher course regarding the meaning of values obtained using office spirometry. What we do in our office is check spirometry in patients prior to placing them in the examination room. It is basically a vital sign that is taken for our patients with asthma to help the clinician decide how that patient is doing at the time of the office visit. You would not think of having someone come in for a hypertension check up without having the blood pressure checked prior to seeing the patient, and the same should be true for checking spirometry in patients with asthma. We use it to help guide our decisions regarding therapy. The way not to disrupt patient care is to have it done before the patient is put in the examination room. Others will bring a small portable spirometer into the examination room and perform the test there. It is very clear that reliance on symptoms alone to follow patients with asthma is totally inadequate and cannot be the basis for clinical decision-making. If you go into a room with an asthmatic patient and ask them how they're doing, and try to make treatment decisions based on history alone, you will be more often wrong than right. It is no more accurate to guess a patient's blood pressure than it is to guess their pulmonary function and so spirometry simply needs to be checked. Medscape: You discussed the importance of a patient-clinician relationship with regard to medication compliance. How do you handle steroid phobia in patients with asthma and how about steroid phobia on the part of parents of pediatric asthma patients? Dr. O'Hollaren: This is a very common problem. I think the fundamental way to address steroid phobia in both patients and parents is to explain the physiology of asthma to the patient and the parents. I find that anatomical models that show airway swelling and inflammation speak a thousand words about why we need an antiinflammatory component to our asthma treatment programs. When we show the how smooth muscle constriction is only a small part of the physiology that produces symptoms, then we have the patients' attention and they have a conceptual framework to understand why they need to take inhaled anti-inflammatory medications. It is also important to point out that the data are very strong that the use of inhaled corticosteroids reduces the risk of dying from asthma and reduces the risk of needing emergent care or hospitalization. In contrast, the data show that increasing use of albuterol inhalers is associated with an increased risk of hospitalization and an increased risk of dying from asthma. There is a misunderstanding in the eyes of many patients that albuterol is harmless and steroids are harmful. In the case of asthma, appropriately dosed inhaled corticosteroids can be lifesaving, and excessive reliance on short-acting bronchodilators can be life-threatening. So, the relationship between inhaled steroid use and dying from asthma, which is an inverse relationship, is very helpful to bring parents on board if they think that the use of steroids will be too harmful for their child. I also discuss the results of the CAMP Study, published in The New England Journal of Medicine several years ago, in which the data showed that inhaled corticosteroids could be safely taken in children with asthma without significant effects on growth, bone density, ocular side effects, or psychological parameters. I think the data are abundantly clear and very clearly outlined in the NIH Guidelines that the cornerstone of management for persistent asthma is inhaled corticosteroids. Symptomatic use of short-acting beta-agonists should be used only on an as needed basis, and hopefully less than or equal to twice per week, so that we know we have good foundational baseline control of breathing. Frequently parents also have misconceptions about the fact that asthma is going to prevent their children from participating in sports or athletics. I find that sometimes parents will subconsciously discourage their children from relying on asthma inhalers because it means that they're weak or that they're not working hard enough to "get into shape." In fact, I point out that over 10% of the US Olympic team has asthma, and they are incredibly compliant with their medications to ensure optimal performance. In summary, I think it's important to point out that inhaled corticosteroids are lifesaving medications, that they decrease the risk for death from asthma, they decrease the risk of hospitalization and

urgent care for asthma, they improve quality of life, sleep quality, and overall will allow patients with asthma to lead a much more productive and active life. Medscape: Well thank you so much, Dr. O'Hollaren, for sharing these practical insights into the clinical management of asthma. We thank you for this 2-part series.

Guidelines Issued for Sublingual Immunotherapy


Laurie Barclay, MD Authors and Disclosures
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Assess clinically focused product information on Medscape. Click Here for Product Infosites Information from Industry. December 21, 2009 Evidence-based guidelines for use of sublingual Immunotherapy (SLIT) are issued in the World Allergy Organization Position Paper 2009, reported in the November issue of the World Allergy Organization Journal. This article is co-published as a supplement to the December 2009 issue of Allergy. "...SLIT has gained wide acceptance in many European countries and has raised the level of interest in immunotherapy among practicing allergists and primary care physicians," write World Allergy Organization (WAO) chair G. Walter Canonica, MD, from the University of Genoa in Genoa, Italy, and colleagues. "Large pivotal double-blind, placebo-controlled, randomized clinical trials have confirmed the efficacy and safety of SLIT, although some negative trials have also been published. In 2008, the...[WAO] Board Of Directors decided that it was important and timely to advise our global constituents on the current State of the Art on SLIT, to offer consensus on its use based on currently available evidence and expert opinion, and to develop practice parameters." On January 22-23, 2009, WAO convened a global consensus meeting on SLIT in Paris, France. Regional, national, and affiliate WAO member societies were represented, as were nongovernmental organizations working in the field of allergy, as well as Allergic Rhinitis and its Impact on Asthma, the European Federation of Allergy and Airway Diseases Patients Association, the International Primary Care Respiratory Group, the International Association of Asthmology, the Global Allergy and Asthma European Network, and others. The meeting and position statement were totally independent from funding or other influence of the pharmaceutical or the allergen extract/vaccine industries. Topics in the Position Statement In addition to offering guidelines for clinical practice using SLIT, the meeting aimed to identify unmet needs by analyzing recent and ongoing SLIT clinical trials and by recommending additional studies needed and appropriate methodology. Topics included in the SLIT position statement are the following:

Introduction and historical background regarding SLIT. Allergen-specific immunotherapy. Mechanisms of SLIT. Clinical efficacy of SLIT. Safety of SLIT. Effect of SLIT on the natural history of respiratory allergy.

Use of SLIT in children. Guidelines and recommendations concerning SLIT. Definition of patient selection for SLIT. The future of immunotherapy in the community care setting. Methodology of clinical trials evaluating SLIT.

In determining their recommendations for SLIT, the WAO noted that there have been several adequately powered, well-designed, randomized clinical trials. Findings from these studies suggest that high-dose, sublingual, specific immunotherapy is effective in carefully selected patients. Appropriate indications for use of SLIT include rhinitis, conjunctivitis, and/or asthma caused by pollen and/or house dust mite (HDM) allergy. Although the safety of SLIT has been confirmed in randomized clinical trials, many patients report local adverse effects. Systemic reactions have been reported only rarely. In appropriate patients, SLIT may be considered as initial treatment; failure of pharmacologic treatment is not required before starting therapy. Special SLIT indications exist in patients whose allergies are uncontrolled with optimal pharmacotherapy, patients in whom pharmacotherapy induces undesirable adverse effects, patients refusing injections, and patients who do not want to be receiving constant or long-term pharmacotherapy. Immunotherapy Recommendations To reduce risk and improve efficacy of SLIT, the WAO recommends the following considerations for starting immunotherapy:

There should be the presence of a demonstrated immunoglobulin E (IgE)mediated disease, with positive skin test results and serum-specific IgE to an allergen concordant with clinical symptoms. There should be documentation that the symptoms can be explained by specific sensitivity, based on appearance of symptoms related to exposure to the allergen(s) identified by allergy testing. Optional confirmation may include allergen challenge with the relevant allergen(s). Severity and duration of symptoms should warrant use of SLIT, with confirmation from objective parameters such as missing time from work or school. For rhinoconjunctivitis, patients should have subjective symptoms of sufficient severity and duration. For asthma, the control questionnaire should not show uncontrolled asthma, and pulmonary function testing is required to exclude patients with severe asthma. Pulmonary function should be monitored during therapy. SLIT therapy should only be started in settings where standardized or high-quality vaccines are available. Only specialists should prescribe specific immunotherapy. Subcutaneous immunotherapy should be administered only by physicians trained to manage systemic reactions if anaphylaxis occurs. Although SLIT is administered at home, patients should be educated regarding possible risks and how to control adverse effects that may develop. Patients with a single allergen sensitivity are more likely to benefit from specific immunotherapy vs patients sensitive to multiple allergens, but more data are needed in this area. Specific immunotherapy will not benefit patients with nonallergic triggers. For safety reasons, asthmatic patients must be asymptomatic when receiving SLIT injections. Asthmatic patients with severe airways obstruction are more likely to have lethal adverse reactions. To maximize the efficacy and safety of SLIT in asthmatic patients, forced expiratory volume in 1 second with pharmacologic treatment should reach at least 70% of predicted values.