[ocgirl]

TEACHING TOPIC

1. Mild Persistent Asthma: What is the Best Treatment?
ORIGINAL ARTICLE, Randomized Comparison of Strategies for Reducing Treatment in Mild Persistent Asthma, The American Lung Association Asthma Clinical Research Centers, Abstract | Full Text | PDF | PPT Slide Set

CLINICAL DECISIONS, Treatment of Mild Persistent Asthma, M. Kraft, E. Israel, and G.T. O'Connor, Extract | Full Text | PDF

This Clinical Decisions article, a new interactive Journal feature, presents the case of a 30-year-old woman with mild persistent asthma treated with inhaled beclomethasone twice daily plus the use of an albuterol inhaler two to three times per week. Her disease is well controlled, but she would like to receive less medication. Three possible treatment options are presented, together with expert opinion on each. Which treatment would you recommend? Vote for one at www.nejm.org and then submit a comment about your clinical decision. Voting results and a broad selection of comments will be posted on the Journal's Web site.

Figure 3. Kaplan–Meier Estimates of Cumulative Percentages of Patients with Treatment Failure.

top

Clinical Pearls

Reducing Treatment
In this randomized trial, patients with mild persistent asthma that was well controlled with the use of twice-daily inhaled fluticasone (corticosteroid) were given the same treatment or were switched either to once-daily fluticasone plus salmeterol (long-acting beta-agonist) or to montelukast (leukotriene modifier). There was no difference in asthma control in the two groups of patients receiving corticosteroid, indicating that it is possible to use a lower dose of inhaled corticosteroid. A switch to montelukast resulted in an increased rate of treatment failure (30.3% versus 20% of patients) and decreased asthma control. However, despite the increased rate of treatment failure associated with montelukast, the rates of clinically significant asthma exacerbation did not differ significantly among the three groups.

Definition of Asthma
Asthma is a reversible inflammatory condition causing a nonspecific hyperresponsiveness of the airways with multifactorial etiology. In this study of treatment of patients with mild persistent asthma, entry criteria specified that subjects had to be 6 years or older, have a forced expiratory volume in 1 second (FEV1) of 60% or more of the predicted value before administration of a bronchodilator; with a documented reversibility of airway obstruction by 12% or more with use of a beta-agonist or a provocative concentration of methacholine producing 20% in FEV1 of 8 mg per milliliter or less within the previous 2 years.

“Whether the better outcomes found in our fluticasone–salmeterol group offset the convenience of a once-daily oral formulation (montelukast) depends on the preferences of patients and physicians as well as on cost.” The American Lung Association Asthma Clinical Research Centers, Original Article, “Randomized Comparison of Strategies for Reducing Treatment in Mild Persistent Asthma”

top

Morning Report Question

Q:What is the potential long-term risk to bone health, if any, in a 30-year-old woman using an inhaled steroid twice a day?

A:If a 30-year-old woman initiates inhaled beclomethasone, two puffs (80 µg per puff) twice a day, and continues that regimen for 25 years, her risk of bone fracture may be doubled.

top

TEACHING TOPIC

2. Case: Woman with Asthma and Cardiopulmonary Arrest
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL, Case 15-2007: A 20-Year-Old Woman with Asthma and Cardiopulmonary Arrest, M.E. Wechsler, J.O. Shepard, and E.J. Mark, Extract | Full Text | PDF | PPT Slide Set

A 20-year-old woman with a history of severe asthma was found at home in an unresponsive state and was taken to the emergency room. Her multiple medications included nebulized albuterol and ipratropium, salmeterol, aerosolized fluticasone propionate, prednisone, and inhaled albuterol. She was a smoker and had a history of obesity, gastroesophageal reflux, and exposure to various allergens and secondhand smoke since birth. The patient also had a history of multiple emergency room visits and hospitalizations for asthma exacerbations and had a recent pulmonary infection for which antibiotics were administered.

Figure 1. Radiographic Images.

top

Clinical Pearls

Treatment of Asthma
All patients with asthma should avoid or control factors that trigger attacks (including allergens, cold or hot air, humid air, and infections); patients with persistent asthma should also use medication daily to control airway inflammation (e.g., inhaled corticosteroids) and, as the severity increases, should escalate therapy appropriately. Asthma guidelines focus on maintenance therapy for control of the disease. Inhaled corticosteroids are a cornerstone of therapy. Unfortunately 70% of patients with severe asthma do not refill their inhaled prescriptions for various reasons — lack of a perceived immediate benefit, preference for pills rather than inhalers, suboptimal results due to suboptimal inhalation technique, cost, inconvenience, or lack of education by health care providers.

Fatal Asthma
Four thousand people die from asthma each year in the United States. There are many possible causes of death in a patient with asthma if respiratory failure develops. Patients with corticosteroid-induced chronic immunosuppression are predisposed to life-threatening infections, anaphylaxis, and acute hypersensitivity reactions. Cigarette smoking, aspirin sensitivity, the Churg–Strauss syndrome can also increase the risk of death from asthma, as can older age, long duration or poor control of asthma, prior hospitalization or mechanical ventilation, and psychosocial factors.

Table 3. Risk Factors for Life-Threatening Asthma and Death from Asthma.

Factors that Exacerbate or Mimic Asthma
Coexistent diseases that can exacerbate or mimic asthma symptoms include gastroesophageal reflux, sinusitis, postnasal drip, and repeated episodes of pneumonia. Additionally, diseases such as cystic fibrosis, allergic bronchopulmonary aspergillosis, bronchocentric granulomatosis, or the Churg–Strauss syndrome (necrotizing, small-vessel vasculitis with eosinophilic infiltration) may cause fleeting pulmonary infiltrates or airway obstruction mimicking asthma.

top

Morning Report Questions

Q:What are the side effects of inhaled corticosteroids?

A:Inhaled corticosteroids can cause dysphonia, oral thrush, osteoporosis, cataracts, glaucoma, and adrenal suppression.

Q:How does omalizumab work in asthma?

A:Omalizumab, a monoclonal antibody against IgE, prevents IgE from binding to mast cells and other inflammatory cells, thereby preventing the release of inflammatory mediators. Omalizumab use may permit lower dose of corticosteroids and may reduce the frequency of asthma exacerbations, which, in turn, might reduce the number of outpatient and emergency room visits and hospitalizations among patients with moderate-to-severe asthma.

[Jomar]

this came on my medpage email newsletter-

[WINSTON-SALEM, N.C., May 16 -- For patients with mild persistent asthma, treatment options appear to have widened, according to two randomized trials reported today.]

more here- http://www.medpagetoday.com/Pulmonary/Asthma/dh/5664