Help patients control their asthma

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Applied Evidence

Help patients control their asthma

J Fam Pract. 2013 April;62(4):184-190

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References

1. American Academy of Allergy, Asthma, and Immunology. Asthma statistics. Available at: http://www.aaaai.org/about-the-aaaai/newsroom/asthma-statistics.aspx. Accessed March 7, 2012.

2. National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for diagnosis and management of asthma. J Allergy Clin Immunol. 2007;120(5 suppl):S94-S138.

3. Centers for Disease Control and Prevention. National surveillance for asthma—United States, 1980-2004. MMWR Surveill Summ. 2007;56(8):1-54.

4. Stout JW, Visness CM, Enright P, et al. Classification of asthma severity in children. Arch Pediatr Adolesc Med. 2006;160:844-850.

5. Bacharier LB, Strunk RC, Mauger D, et al. Classifying asthma severity in children. Am J Respir Crit Care Med. 2004;170:426-432.

6. Juniper EF, Guyatt GH, Cox FM, et al. Development and validation of the Mini Asthma Quality of Life Questionnaire. Eur Respir J. 1999;14:32-38.

7. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999;159:179-187.

8. Miller MR, Hankinson J, Brusasco V, et al. ATS/ERS Task Force. Standardisation of spirometry. Eur Respir J. 2005;26:319-338.

9. Bateman ED, Hurd SS, Barnes PJ, et al. Global Strategy for Asthma Management and Prevention. Eur Respir J. 2008;31:143-178.

10. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD. February 2013. Available at: http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed March 7, 2013.

11. AsthmaMD. Available at: http://www.asthmamd.org/#resources/iphone_chart.jpg. Accessed March 7, 2013.

12. Indiegogo. Huff & Puff. Available at: http://www.indiegogo.com/projects/the-best-asthma-education-app-in-the-world-period. Accessed March 7, 2013.

13. Vimukti Technologies Pvt Ltd. Peak flow calculator. Available at: http://appworld.blackberry.com/webstore/content/7615. Accessed March 7, 2013,

14. Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med. 2004;35:1068-1080.

15. Phipatanakul W, Matsui E, Portnoy J, et al. Environmental assessment and exposure reduction of rodents: a practice parameter. Ann Allergy Asthma Immunol. 2012;109:375-387.

16. Nelson HS, Weiss ST, Bleeker ER, et al. The Salmeterol Multicenter Asthma Research Trial. Chest. 2006;129:15-26.

17. Ducharme FM, Ni Chroinin M, Greenstone I, et al. Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma. Cochrane Database Syst Rev. 2010;(4):CD005533.-

18. Papi A, Corradi M, Pigeon-Francisco C, et al. Beclometasone-formoterol as maintenance and reliever treatment in patients with asthma. Lancet Respir Med. 2013;1:23-31.

19. Patel M, Pilcher J, Pritchard A, et al. Efficacy and safety of maintenance and reliever combination budesonide-formoterol inhaler in patients with asthma at risk of severe exacerba-tions. Lancet Respir Med. 2013;1:32-42.

20. Chauhan BF, Ducharme FM. Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children. Cochrane Database Syst Rev. 2012;(5):CD002314.-

21. Ducharme FM. Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma. Cochrane Database Syst Rev. 2004;(1):CD003133.-

22. Ducharme FM, Lasserson TJ, Cates CJ. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev. 2011;(5):CD003137.-

23. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363:1715-1726.

24. Vandenplas O, Dramaix M, Joos G, et al. The impact of concomitant rhinitis on asthma-related quality of life and asthma control. Allergy. 2010;65:1290-1297.

25. Gibson PG, Henry RL, Coughlan JL. Gastroesophageal reflux treatment for asthma in adults and children. Cochrane Database Syst Rev. 2003;(2):CD001496.-

26. The American Lung Association Asthma Clinical Research Centers. Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med. 2009;360:1487-1499.

27. Eneli IU, Skybo T, Camargo CA, Jr. Weight loss and asthma. Thorax. 2008;63:671-676.

28. Stenius-Aarniala B, Poussa T, Kvarnstrom J, et al. Immediate and long term effects of weight reduction in obese people with asthma. BMJ. 2000;320:827-832.

29. Sariman N, Levent E, Cubuk R, et al. Bronchial hyperreactivity and airway wall thickening in obstructive sleep apnea patients. Sleep Breath. 2011;15:341-50.

30. Di Marco F, Verga M, Santus P, et al. Close correlation between anxiety, depression, and asthma control. Respir Med. 2010;104:22-28.

The safety of LABAs continues to be a concern, however, as serious adverse events were more common in the LABA group. The number needed to harm (NNH) with LABA therapy vs LTRA over 48 weeks was 78; 95% CI, 33 to infinity.²² (The width of the CI indicates that while harm is possible in as few as 33 patients, it is also possible that an infinite number of patients would need to be treated for one individual to incur harm.) Overall, the evidence suggests that LABAs are superior add-on therapy to ICS for the treatment of uncontrolled asthma compared with LTRAs, but their use nonetheless requires caution and close monitoring in African American and pediatric patients.¹⁷

Is there a role for a long-acting anticholinergic inhaler?

Long-acting anticholinergic medication (LAAM)—tiotropium is the only drug in this class on the market, but there are others in clinical trials—is the mainstay of therapy for chronic obstructive pulmonary disease. This drug class was not widely available or studied as an asthma treatment when the NHLBI guidelines were drafted.

A 2010 study of tiotropium challenged the notion that there is no place for LAAMs in asthma therapy. Using a 3-way crossover design, the study compared the addition of tiotropium to ICS with a double dose of ICS or a LABA/ICS combination.²³

The results suggest that LAAMs could be useful in treating uncontrolled asthma. Compared with the double dose of ICS, the tiotropium/ICS combination increased PEF by a mean difference of 25.8 L/min (P<.001) and resulted in a statistically significant improvement in the proportion of asthma control days, FEV₁, and daily symptom scores.²³ As an adjunctive treatment to ICS, tiotropium was not inferior to a LABA.

CASE After a detailed history, physical exam, and diagnostic testing, Ms. D was given a diagnosis of moderate persistent asthma. We recognized the need to step up her treatment. Prior to making any changes in her medication regimen, however, our team, which included a clinical pharmacist, observed her use of inhaled medications and verified that she was using the inhaler properly. We then initiated combination therapy, pairing a LABA and ICS.

Comorbidities complicate asthma management

Asthma management is often complicated by other uncontrolled coexisting medical problems. Common comorbidities that can affect asthma severity include allergic rhinitis, chronic sinusitis, gastroesophageal reflux disease (GERD), obesity, obstructive sleep apnea (OSA), mental health disorders, tobacco use, and hormonal disturbances.²

Allergic rhinitis. Allergic rhinitis has been associated with worse asthma control and a negative impact on quality of life, and the upper airway inflammation associated with it should be treated.²⁴

Antihistamines and nasal steroids are the most effective medical management. Some patients with allergic rhinitis benefit from blood or skin allergy testing for confirmation or to aid in avoidance. Referral to an allergist may be necessary if symptoms are recalcitrant, a food allergy is in question, or the diagnosis is unclear.

GERD. Compared with the general population, patients with asthma have a much higher risk of GERD, although it is not always symptomatic. While results are inconsistent and difficult to predict, treating symptomatic GERD with acid-blocking medications can result in better asthma control for some patients. However, proton pump inhibitors should not be used to treat asthma symptoms in patients with asymptomatic GERD.^25,26

Obesity and OSA. Weight loss can significantly improve asthma control, decrease medication use, and improve quality of life.^27,28 Obese patients are less likely to respond to treatment with ICS.² Weight loss also benefits those who suffer from OSA, which may contribute to airway hyperresponsiveness.²⁹

Mental health disorders. Compared with the general population, patients with asthma are more likely to have depression, anxiety, and panic disorders.³⁰ Diagnosis and treatment of these comorbid conditions can lead to better asthma management, increased medication adherence, decreased health care utilization—including fewer ED visits and hospitalizations—and a better quality of life.³⁰

CASE We also addressed our patient’s comorbidities—weight gain, allergic rhinitis, and anxiety. The allergic rhinitis was already well-controlled with a nasal steroid, but we suspected a relationship between Ms. D’s weight gain and increasing anxiety associated with some recent life events. We suggested she see a counselor, and she agreed.

When the patient returned in 12 weeks, she reported that she hardly needed her rescue inhaler anymore and that she was managing her anxiety more effectively. She also told us that she had begun a low-fat dietary regimen, and we confirmed that she had already lost 5 pounds.

CORRESPONDENCE
Stephen A. Wilson, MD, MPH, FAAFP, UPMC St. Margaret, 815 Freeport Road, Pittsburgh, PA 15215; wilsons2@upmc.edu