Medco study finds doctors overprescribe inhalers for acute asthma attack sufferers

EDITOR'S NOTE: In Monday's original headline, Drug Store News indicated that pharmacists were overprescribing inhalers, when it should have said that doctors or physicians were overprescribing such medication. Pharmacists cannot prescribe medication, only dispense it.

Pharmacists pushing physicians not to write prescriptions for excessive quantities of inhalers used to treat acute asthma attacks can help reduce overprescription of the inhalers without compromising patient safety while saving money, according to a study.

Pharmacy benefit manager Medco Health Solutions presented a study at the annual meeting of the American College of Allergy, Asthma and Immunology last week showing that when physicians receive educational materials and follow-up communications outreach, and have to give a response before the pharmacist can dispense a prescription, the number of new prescriptions for excessive quantities of rescue inhalers – defined as more than one inhaler per month – decreased by 60%.

Rescue inhalers, also known as short-acting beta2 agonists, are meant for patients experiencing acute asthma attacks, though many physicians will prescribe them for daily, long-term use. While wasting medicine, this also can have dangerous implications for patient health by masking exacerbations of the disease and causing more serious problems down the road.

The Medco study, conducted between July 2007 and June 2008 on 250,000 patients, found that as a result of the intervention, 200,000 fewer inhalers were used, saving $4.2 million.

“Excessive use of rescue inhalers wastes medicine, but even more importantly, it can be masking an asthma exacerbation,” study researcher Luis Salmun stated. “Rather than over-relying on rescue inhalers, patients should speak to their physicians to make sure that they’re using their daily asthma medications properly or to determine if an adjustment in those medications is needed.”

The researchers also looked at pharmacy and medical claims for a 1,835-patient subset of the study population. During the 12 months following the intervention, 67% of the patients no longer were prescribed excessive quantities of rescue inhalers, while the number of hospitalizations and emergency room visits stayed the same.

P.S. reduce your asthma sufferings by eating lots of Vitamin C and Vitamin D rich Foods and Fruits.

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Child asthma, mother's depression linked

Maternal depression may aggravate a child's asthma but how often a child had symptoms did not seem to affect the mother's symptoms, U.S. researchers said.

Researchers at Johns Hopkins Children's Center in Baltimore analyzed data from interviews with 262 mothers of African-American children with asthma -- a population disproportionately affected by the inflammatory airway disorder.

The study, in the Journal of Pediatric Psychology, found children whose mothers had more depressive symptoms had more frequent asthma symptoms during the six-month study. Conversely, children whose mothers reported fewer depressive symptoms had less frequent asthma symptoms.

Senior investigator Kristin Riekert, a pediatric psychologist and co-director of the Johns Hopkins Adherence Research Center, and colleagues tracked ups and downs in maternal depression as related to the frequency of symptoms among children.

"Even though our research was not set up to measure just how much a mom's depression increased the frequency of her child's symptoms, a clear pattern emerged in which the latter followed the earlier," Riekert said in a statement.

"Intuitively, it may seem that we're dealing with a chicken-egg situation, but our study suggests otherwise. The fact that mom's depression was not affected by how often her child had symptoms really caught us off guard, but it also suggested which factor comes first."



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How to Use Your Albuterol in Asthma Treatment

Albuterol, also commonly called salbutamol, is one of the most common medications that you would be given if you have asthma. Albuterol is a bronchodilator, and as such its main purpose is to relax the muscles in your airways to allow more air to pass through. It is one of the most effective weapons against asthma attacks and is important to have with you at all times. Call your doctor or get one from the nearest pharmacy if you think that you are running out. Having two inhalers just in case one gets lost is also a good idea. If you feel that you medication is not working as is used to, or if you are reacting negatively to the medication, inform your doctor right away.

Knowing the proper procedures when taking your inhaler can prove crucial and even life-saving. Here’s the list of the things that you need to take note of when using your Albuterol inhaler:

Make sure the inhaler canister is properly inserted. If you encounter difficulties inserting the canister refer to the manufacturer leaflets or diagrams that can be found either on the packaging or inside the box of medicine.

Shake the inhaler for about ten seconds and actuate the device at least once to test. Shaking ensures effectiveness of the medication while test spraying can help get rid of any foreign object that may be in the nozzle.

When having an asthma attack, lying down makes you feel worse. So to avoid rendering your inhaler useless, use it while sitting in an upright position. Using the inhaler while sitting or standing increases the rate at which the medicine can reach your lungs.

Place in inhaler about an inch away from your mouth, if you are having difficulty estimating you can also use a spacer to help you out. Remember to forcefully inhale every time you puff. Inhaling forcefully will ensure that the medicine goes directly into your lungs and not end up at the back of your throat or just circulate inside your mouth.

After inhaling the medication, hold your breath for five to ten seconds. This allows the medication to travel further into the air passages. If you need additional puffs, wait about thirty seconds before doing so again.

Replace the cap after use. Rinse your mouth with water to clear any residue of the medicine.

Depending on your asthma severity and advice taken from your doctor, you may be required to take more puffs. It is important that you adhere strictly to the instructions given to you. Bronchodilators can have side effects. Not using them to be as efficient as they should leads you to use them for a longer term. Your albuterol treatment effectivity is directly proportional to how well you use it.

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An Exercise in Better Breathing

Life was active and healthy in early 2005 for Terri Lange, then 54. A successful massage therapist in Atlanta, she was practicing yoga, calisthenics and strength training to keep off the 60 pounds that had crept on her body in her 40s during the beginning stages of menopause.

Lange's health deteriorated in the summer of that year, however. A sinus infection quickly evolved into bronchitis, then into pneumonia and a diagnosis of residual asthma. The lung inflammation lingered, and a year later, she was diagnosed with exercise-induced asthma—coughing or shortness of breath that gets worse with activity.

Day-to-day tasks became a challenge as she labored to breathe. She couldn't walk up or down stairs without stopping to catch her breath and avoided putting the top down on her convertible for fear that the air pollution would make her wheeze.

Lange's exercise routine dropped off, too. "I worked as an allergy nurse for many years so I was very familiar with asthma," says Lange, who is also a registered nurse. "The asthma left me wheezing, short of breath and fatigued. It became more of a struggle to work out."

Luckily, as Lange learned, a diagnosis of exercise-induced asthma doesn't require cutting out exercise altogether—if you take precautions.

"I recommend that patients use an inhaler about 15 minutes prior to exercising," says Dr. Anthony Petracca, of Glens Falls, N.Y. It's also a good idea to warm up and cool down for about 15 minutes before and after your workout. And opt for low-intensity activities such as walking, yoga and swimming. (The warm, humid conditions in most pools are lung-friendly.)

Lange can attest to the benefits of such precautions. A few years after decreasing the intensity of her workouts, her lungs are stronger and she has stopped taking medication for her exercise-induced asthma.

"It was a challenge to find the right amount of exercise that would strengthen me but not wear me out. Yoga, plus the deep belly-breathing I do each day, have been critical in helping me build my lung capacity," says Lange, who also does 20-minute workouts on the elliptical machine and lifts free weights three days a week.

Lange keeps a positive outlook about her residual asthma, although she still takes medication to manage it. "Asthma can be a challenge, but I don't see it as a disease," she says.

Instead, she tries to control her environment as much as possible—shunning scented candles or harsh household chemicals, avoiding cats, using an air purifier in her bedroom, and eliminating dairy and gluten from her diet.

"When I don't eat inflammatory foods, my body feels stronger," she explains. "Nutrition is a powerful aid to controlling my asthma. I eat several servings a day of fruits and vegetables and make my own veggie juice drink for an afternoon snack. I keep well hydrated with water.

"I want people with asthma to know there are many tools for a better life, from nutrition and exercise to getting quality sleep. There are so many ways to help yourself."


P.S. Boost your health by eating lots of Vitamin C and Vitamin D rich foods and fruits.




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Sufferer finds relief with steroid puffer

Until a new job in a new climate brought Stacey Fell to Dubai in 2005, the Briton thought little about her asthma.

There was the occasional bout of breathlessness during the summer in the UK, when her hay fever flared up. But in the UAE, her respiratory ailment was worse than ever.

Ms Fell, 29, saw several doctors after a persistent cough developed. She had chest X-rays as well as tests for allergies.

Eventually, she learnt that her asthma was aggravated by the local humidity, smoke, dust and air-conditioning.

“I noticed it was progressively getting worse,” said Ms Fell, who works in a bank. “There was a tightness in the chest and a feeling of compression.”

Diagnosed when she was 13, Ms Fell is among roughly 900,000 asthmatics living in the UAE.

About 15 per cent of the population here is believed to have the condition one of the highest rates in the world.

The World Health Organisation has warned that the prevalence of the lung disease is increasing worldwide by 50 per cent every decade, mainly affecting children.

It now afflicts 300 million people and may worsen due to pollution and climate change.

Asthmatics in the UAE may suffer more than in other countries, according to specialists, who say the humid climate and construction dust aggravate symptoms.

“I have a lot of my patients who are absolutely fine when they’re outside the UAE,” said Dr Bassam Mahboub, a pulmonologist and member of the Emirates Respiratory Society. “Once they come here, they start coughing and get the symptoms.”

Another respiratory specialist in the capital, Dr Zouhair Harb, said asthmatics now dominate his practice, accounting for “65 to 75 per cent” of his patients. For general practitioners in the US, the figure is about 20 per cent.

Ms Fell’s condition deteriorated so much that she sought out a chest specialist last week.

Previously, Ms Fell relied only on a Ventolin “rescue” inhaler during an asthma attack. Her doctor later prescribed a Symbicort inhaler that includes a dose of steroids to reduce inflammation in her airways, preventing symptoms.

“Now the routine I’m on at the moment, in the morning I’ll take two puffs of Symbicort, at lunchtime I’ll take two puffs of the Ventolin, and in the evening I take two puffs again of Symbicort.”

The inhaled steroids have made a difference for Ms Fell, but a recent study showed that only 5.5 per cent of asthmatics in the UAE used preventive therapies.

Dr Mahboub, who helped author the study, advised asthmatics to follow Ms Fell’s lead. “We need all asthmatics to be on controlled medications,” he said.



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Asthmatics shun prevention

Asthmatics are endangering their lives and draining the health system of millions of dirhams annually by over-relying on “rescue” medications instead of preventive treatments, according to the region’s largest study of the disease.

The Asthma Insights and Reality in the Gulf and the Near East study found that only 5.5 per cent of the 200 asthmatics surveyed across the Emirates used preventive treatments such as inhaled steroids.

That figure is “shockingly low”, according to Dr Zouhair Harb, a lung specialist working in Abu Dhabi.

The report, released last month, interviewed 1,000 asthmatics in the UAE, Jordan, Kuwait, Lebanon and Oman between January 2007 and March 2008.

The study showed that more than 31 per cent of asthma sufferers surveyed had been hospitalised or sent to emergency rooms during the period, although most of the admissions had been preventable. Another 48 per cent fell back on emergency bronchodilators to bail themselves out of asthma attacks.

It concluded: “[Regional] asthma morbidity is high, with an unacceptably high reliance on the use of emergency or rescue care.”

Ignorance about the respiratory disorder, which constricts the airways, “places a great burden on the healthcare system and society as a whole, with substantial loss of time from work and school”, it added.

Patient denial is also to blame, the researchers said.

Dr Bassam Mahboub, who led the UAE surveys at the University of Sharjah, said most asthma-related fatalities occurred because patients “don’t perceive themselves as having a disease, so they stop medication”.

He is now studying the economic impact that poorly managed asthma has on the health sector, which he estimates to be in the “hundreds of millions” of dirhams.

“We actually need a majority of our asthmatic patients to be on the controlled medications,” said Dr Mahboub, a member of the Emirates Respiratory Society. “So 5.5 per cent is way too low.”

The findings are particularly grim given that the UAE has one of the highest rates of asthma in the world; doctors estimate that 15 per cent of the population suffers from the condition.

The European average is about seven per cent, based on 2004 figures from the Global Initiative for Asthma.

And in 2005, the prevalence of asthma in the US was just under eight per cent, according to the American Academy of Allergy, Asthma and Immunology.

“But it’s especially hard [in the UAE], where you have a lot of dust and dependence on airconditioning,” said Dr Harb, of the Advanced Cure Diagnostic Centre in Al Bateen. “That’s a lot of wear and tear on the airways.”

The Lebanese-American lung specialist was dismayed by the study’s finding that fewer asthmatics in the UAE than in any of the countries surveyed were proactively treating their illness.

“In a perfect world, I would be expecting 100 per cent of asthmatics [to use preventive inhalers],” he said. “Really 5.5 per cent in the UAE is quite low. Shockingly low.”

Dr Harb estimated that 30 to 50 per cent of asthmatics in the most developed countries use the recommended steroid therapies.

According to the report, nearly 30 per cent of Lebanese patients use preventive inhalers. Roughly 19 per cent of Kuwaitis are also on controlled treatments.

Quick-relief medications such as bronchodilator puffers reopen clogged airways during bouts of breathlessness. But daily steroid therapy prevents the attacks from happening in the first place.

“[The patients] have a choice between two medicines,” Dr Harb said. “A rescue medication will work within five minutes and the maintenance one will work maybe over a week. They’re going for the quick gratification, the immediate remedy, which isn’t the right remedy.”

Overusing the emergency devices can stress the lungs and cause long-term problems.

Fixed doses of preventive steroids control inflammation in the lungs, said Dr Asif Sattar, a pulmonologist at City Hospital in Dubai.

“It seems people in Dubai tend to use emergency departments more and tend not to follow up with their physicians regularly,” he said. “Well-controlled asthmatics shouldn’t need to use their reliever at all.”

Dr Sattar said patients might dismiss preventive treatments because they might not realise they have a chronic disease.

There may also be negative connotations associated with the idea of taking steroids, although the inhaled steroids are safe, he said.

Dr Ashraf al Zaabi, the head of the respiratory division at Zayed Military Hospital, hoped the study would better inform physicians and patients about the importance of preventive therapies.

“This low compliance with the controlled medication is not surprising,” he said. “But there are explanations.”

For one, he said “especially younger patients tend to get fed up with taking medicines” over a long period of time.

Dr al Zaabi also noted that half of the UAE respondents in the study were Emiratis, while the remainder were mostly other Arabs and South Asians.

“A lot of those guys can’t afford the Dh200 or Dh300 medications, so that might explain the low percentage, with those non-nationals perhaps not having health insurance.”

Unlike in the UK, many asthma medications in the UAE can be purchased over the counter. In some cases, patients who self-medicate might buy only rescue puffers.

“We know that asthmatics tend to have poor perception of the control over their condition, so patients sometimes delay seeking medical advice until they are really bad,” he said.



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CHEST: Lower Doses Benefit Pediatric Asthma Patients

In children who are hospitalized with asthma, a reduced-dose steroid regimen has no effect on hospital stays, and low-dose albuterol treatment is associated with a lower risk of metabolic acidosis than high-dose treatment, according to research presented at the 75th annual international scientific assembly of the American College of Chest Physicians, held from Oct. 31 to Nov. 5 in San Diego.

In one study, Courtney Edwards, of Kosair Children's Hospital in Louisville, Ky., and colleagues compared outcomes in children who were hospitalized with status asthmaticus, 152 of whom received a maximum steroid dose of 240 mg/day and 141 of whom received a maximum dose of 60 mg/day. No difference was found in the median length of stay between the high-dose and low-dose groups (2.01 versus 1.98 days).

In a second study, Muhammad A. Rishi, M.D., of the Yale School of Medicine in Bridgeport, Conn., and colleagues studied 201 children admitted to the pediatric intensive care unit with a diagnosis of severe acute asthma. Compared to low-dose albuterol treatment, they found that high-dose treatment was associated with increased heart and respiratory rates and a significantly higher rate of metabolic acidosis (43.3 versus 8.3 percent).

"We conclude that lower dose inhaled corticosteroids may be helpful in most children admitted with status asthmaticus," Edwards and colleagues conclude. "Further prospective studies are needed to confirm our findings."

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Asthma remains a chronic ailment affecting children

The impact of childhood asthma on the health care system is considerable. As one of the most chronic ailments among children, asthma is a frequent cause of emergency room visits and hospitals admissions.

Chronic asthma is one of the most common long-term children’s diseases. Statistics indicate that approximately one to two percent of all children will develop chronic asthma during their childhood, while 15 to 20 percent of all children will show signs of wheezing, despite not having chronic asthma.

Saudi Gazette spoke to Dr. Mohammed Barzanji, a pediatrician and allergy specialist at Dr. Soliman Fakeeh hospital who said: “There are many factors why children become asthmatic, including exposure to cigarette or pipe smoke, pollution, dust and exercise or exertion.” He pointed out that exercise should still be encouraged, with asthmatic symptoms being treated by medication.

The real problem lies with the fact that many parents have a lack of knowledge of asthma symptoms. Dr. Wid Kattan from the King Abdulaziz University described asthma as “bronchial asthma that is related to airway hypersensitivity, which causes reversible obstruction of the airways.” This means that an individual with bronchial asthma is oversensitive to things in the environment like dust; this causes an immune reaction, leading the airways in the lungs to narrow, constricting air flow.

“The most characteristic symptom is wheezing in which whistling and coughing sounds are heard as the child breathes, particularly while exhaling,” explained Dr. Kattan.

The most important thing in the management of asthma is a prevention of the factors that can cause attacks - such as inhalation of dust and pollen and severe exercise - though these vary from child to child.

A mother of two asthmatic children in Jeddah, Basma Hassan Mohammed, shared her experience with Saudi Gazette. “My eldest son developed asthma when he was a year old and I wasn’t aware of the symptoms until a doctor told me that he will get these attacks frequently,” she said. “Each time he used to get this attack, he was hospitalized for at least three days until I learned to use the inhaler correctly and at the necessary time.”

Dr, Kattan added that the correct use of medication will prevent children from getting more of such attacks. The most common medication is, of course, the steroid inhaler, but he pointed out that most parents are fearful of administering it to their children on a regular basis. “I must point out that every child is different though, so some children who experience very mild symptoms only require occasional medication,” he remarked. It is therefore, necessary to consult with the doctor on a regular basis.



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CAFFEINE CAN REDUCE ASTHMA SYMPTOMS

A study presented at a conference at the American College of Sports Medicine found that those who ingested caffeine within an hour of exercise reduced their symptoms of exercise-induced asthma (EIA), which is characterised as a shortness of breath during sustained aerobic activity.

The randomised, double-blind, double-dummy crossover study was led by University of Utah researcher Timothy A. VanHaitsma and fellow researchers at Indiana University and involved ten asthmatic people who had also had EIA. Each took either three, six, or nine milligrams of caffeine per kilogram of body weight or a placebo, an hour before exercising on a treadmill. Tests of pulmonary function were taken 15 minutes before exercise commenced, then again 1, 5, 10, 15 and 30 minutes after the exercise stopped.

At nine milligrams of caffeine per kilogram of body weight, considered a large dose, the effects were comparable to using an albuterol inhaler, something commonly used to prevent or treat EIA. This would be the equivalent of about six cups of coffee. Smaller amounts of caffeine, such as three and 6 milligrams per kilogram of body weight, were also found to be useful, reducing coughing, wheezing and other EIA symptoms.

All participants received all doses, including the placebo, at one point or another during the experiment.

Associate professor in the Department of Kinesiology and a co-investigator of the study, Timothy Mickleborough, said that no additional benefit was found when caffeine was combined with an albuterol inhaler.

For someone who weighs 150 pounds, for example, 3 to 9 milligrams of caffeine per kilogram of body weight equals from about 205 to 610 milligrams of caffeine. This study adds to earlier work that found caffeine can reduce the symptoms of EIA and is the first to examine any synergistic effect of caffeine use along with an albuterol inhaler.

Mickleborough and his fellow researchers have also investigated the efficacy of a number of nutritional factors on EIA, with research to date showing that a diet high in fish oil and antioxidants and low in salt has the potential to reduce the severity of EIA and perhaps reduce the reliance on pharmacotherapy. With growing concern about the potential side effects of inhaled corticosteroid use, this is especially important. Also, prolonged usage of daily medications can result in their reduced effectiveness.



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Pediatric Asthma Registry Provides Research Milestone

RemedyMD’s solution addresses Institute of Medicine’s top 100 priorities and shifts focus towards research based on more comprehensive scientific evidence

RemedyMD (www.RemedyMD.com), the leading provider of disease registry software, today announced the first nationwide pediatric Asthma registry to help clinicians and researchers identify which interventions are most appropriate for specific patient populations.

Details about the registry: www.remedymd.com/cer100/asthma.html

Aligned with the Institute of Medicine’s Top 100 Priorities for Comparative Effectiveness Research (CER), RemedyMD’s asthma registry tracks the effectiveness of an integrated approach combining:

1.Counseling
2.Environmental mitigation
3.Chronic disease management
4.and legal assistance

with a non-integrated episodic care model in managing asthma in children. The registry includes all of the applications, data infrastructure, and tools that clinicians and researchers need to gather, synthesize and analyze both phenotypic and genotypic data simultaneously.

“Our experience has shown when researchers view and report across all data types at the same time, they discover patterns and associations that are indistinguishable using traditional methodologies” said Gary D. Kennedy, Founder and CEO of RemedyMD.

RemedyMD’s new pediatric asthma registry includes a comprehensive set of electronic data collection (EDC) forms that are specific to pediatric asthma research, ad hoc reporting capability, and pattern recognition tools that assist users in identifying the most effective treatment options.

In support of this initiative RemedyMD is seeking additional partners who have existing data that addresses the specific needs of pediatric asthma researchers. All institutions involved in comparative effectiveness research that are planning on submitting grant proposals for AHRQ funding are invited to visit: www.remedymd.com/cer100/asthma

RemedyMD Resources:
Resource Kit for Comparative Effectiveness Research: www.remedymd.com/cer_kit
Ways to leverage Asthma Registry: www.remedymd.com/cer100/asthma
Comparative Effectiveness Research: www.remedymd.com/cer_home
Disease Registry Software: www.remedymd.com/registries_home
Institute of Medicine’s Top 100 Priorities for CER: www.remedymd.com/cer_kit

About RemedyMD
RemedyMD® is the leading provider of specialized software applications, tools, and data necessary for comparative effectiveness research with more than 100 pre-built clinical, disease, and patient registry software applications. RemedyMD solutions are personalized to the institution, the clinical specialty, and to the individual provider’s preferences enabling researchers to identify new patterns, facilitate new discoveries, and improve medical outcomes. For more information, visit www.RemedyMD.com.

Press Contact:
Lane Peterson
RemedyMD
SALT LAKE CITY, US
801.733.3383
lpeterson@remedymd.com
http://www.RemedyMD.com



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