Markers Of Asthma Control Research Articles

Correlations of Exhaled Nitric Oxide and Spirometry with Markers of Asthma Control and Severity

Correlations of Exhaled Nitric Oxide and Spirometry with Markers of Asthma Control and Severity

Cost‐effectiveness of budesonide/formoterol for maintenance and reliever asthma therapy

Budesonide/formoterol (Symbicort) Maintenance and Reliever Therapy (SMART) is an effective asthma-management approach that treats symptoms with rapid increases in budesonide/formoterol. The cost-effectiveness of SMART vs higher fixed-dose budesonide/formoterol or salmeterol/fluticasone is unknown. This 6-month, double-blind study randomized patients with asthma uncontrolled by inhaled corticosteroids alone (n = 3335; age > or =12 years) to budesonide/formoterol 160/4.5 microg b.i.d. plus additional doses as needed (SMART), budesonide/formoterol 320/9 microg b.i.d. plus as-needed terbutaline, or salmeterol/fluticasone 50/250 microg b.i.d. plus as-needed terbutaline. Economic analysis, assuming health care and societal perspectives, applied 2004 UK and Australian unit costs to pooled resource-use data. The effectiveness variable was the rate of severe exacerbations/patient/6 months. Patients treated using the SMART approach experienced fewer severe exacerbations than fixed-dose budesonide/formoterol and salmeterol/fluticasone patients (0.12 vs 0.16 and 0.19 events/patient/6 months, respectively; P < or = 0.0048). Budesonide/formoterol (Symbicort) Maintenance and Reliever Therapy provided similar improvements in other markers of asthma control at a lower overall daily inhaled corticosteroid dose compared with fixed-dose treatment. Study drug costs accounted for a majority of both direct costs (DC; 78-87%) and total costs (TC; 50-63%) for all treatments, and were significantly lower in the SMART group compared with the fixed-dose groups (P < or = 0.0014). Direct and TC per patient/6 months were lower for SMART vs salmeterol/fluticasone (DC:-AUS$154, P < 0.0001; TC:-AUS$163, P = 0.0036;-87 pound sterling, P = 0.0026) and vs budesonide/formoterol using UK costs (DC:-73 pounds sterling, P < 0.0001; TC:- 91 pounds sterling, P = 0.0014). Costs tended to be lower for SMART vs budesonide/formoterol using Australian costs (DC:-AUS$35, P = 0.16; TC:-AUS$70, P = 0.20). Results were stable under sensitivity testing. Indirect resource use and cost were not significantly different between groups. Compared with higher fixed-dose budesonide/formoterol and salmeterol/fluticasone, SMART reduces the incidence of severe exacerbations at a lower or similar overall cost and can be considered a cost-effective treatment regimen.

Asthma Control and Exhaled Nitric Oxide in Real Life

RATIONALE: Exhaled nitric oxide (eNO), a marker of airway inflammation, has been shown to reflect asthma status in controlled studies. We examined this eNO ability in a real life context. METHODS: Asthma control questionnaire (ACQ) , eNO and FEV1 were evaluated on several occasions in 100 non-smoking patients suffering from asthma and treated according to the international guidelines. The ability of eNO and FEV1 to detect an improvement in asthma control as assessed by the ACQ score was evaluated using the Roc curve technique. RESULTS: We evaluated 199 pairs of consecutive visits. When considering patients treated with low doses of ICS (= 500 μg BDP equivalent), a 10 ppb decrease in eNO level displayed higher sensitivity and specificity to detect any change in ACQ score compared with a 6% increase in FEV1 (e.g. 75% and 79,3% as compared to 30.6% and 84,4% respectively for an ACQ score decreasing by 0.50 which is considered as a cut-off value for a significant change). In the high ICS dose group, eNO and FEV1 showed similar characteristics (sensitivity: 64.9% and 67.6%; specificity: 69,1% and 79.5% for a decrease of 0.5 in the ACQ score). At visit 1, FEV1 averaged 92.5 %pred in the low dose group versus 70.4%pred only in the high dose group. CONCLUSIONS: It is concluded that eNO is a useful marker of asthma control in the real life context, especially in patients treated by low doses of ICS, in whom asthma control is poorly reflected by a close to normal FEV1.

Beyond Our Pages

Beyond Our Pages

Short-acting β2-agonist and oral corticosteroid use in asthma patients prescribed either concurrent beclomethasone and long-acting β2-agonist or salmeterol/fluticasone propionate combination

Prescriptions for short-acting beta(2)-agonists (SABAs) and oral corticosteroids recorded in a primary care database were used as markers of asthma control. Drug use in the 6 months before and after step-up in treatment from inhaled corticosteroids [ICs; total daily dosage of < or =1000 microg beclomethasone dipropionate (BDP) or equivalent] to either salmeterol/fluticasone propionate combination (SFC) or concurrent BDP and long-acting beta(2)-agonists (LABAs) given in separate inhalers was compared. After step-up, the calculated median number of doses of SABAs prescribed fell by 100 in the SFC group (n = 211) but was unchanged with BDP + LABA (n = 377, p < 0.0001), and fewer patients in the SFC group were prescribed oral corticosteroids (13.7 vs. 20.7%, p = 0.036). Other measures of SABA use after step-up indicated lower use in the SFC group. In clinical practice, adding LABA to IC therapy by using a combination inhaler produces significantly better asthma control than administering the drugs in separate inhalers.

Real-Life Environmental Tobacco Exposure Does Not Affect Exhaled Nitric Oxide Levels in Asthmatic Children

Serial measurement of exhaled nitric oxide (eNO) has been shown to be a good noninvasive marker of asthma control. Active smoking decreases eNO levels. The effect of real-life environmental exposure to tobacco smoke (ETS) on eNO levels is not known. Our objective was to study the impact of environmental tobacco exposure on eNO levels in asthmatic and non-asthmatic children. Single breath off-line collection of eNO was performed in asthmatic and non-asthmatic children with and without ETS. Urine was collected for cotinine/nicotine analysis. Fifty-seven children were enrolled, of which 25 were asthmatic and 32 had smoke exposure. One active smoker was excluded from the data analysis. The mean eNO was 11.1 ppb (n = 31; SD = 18.5) in those passively exposed vs. 11.1 ppb (n = 25; SD = 19.9) among the unexposed (not statistically significant). The mean eNO was 6.1 (n = 32; SD = 4.4) among the non-asthmatics and 17.8 (n = 24; SD = 27.4) among the asthmatics (p = 0.02; CI: 1.9–21.6). Real-life environmental tobacco exposure does not appear to decrease eNO levels in asthmatic children. Off-line collection of exhaled nitric oxide with a Mylar collection device helps differentiate asthmatics from non-asthmatics.

The impact of a nationally coordinated pharmacy-based asthma education intervention.

To assess the impact of a nationally coordinated pharmacy-based educational intervention on self-management behaviour and markers of asthma control in self-referred patients with asthma. An asthma clinic day was set up by a national chain of community pharmacies whereby pharmacists used a structured questionnaire to assess asthma control and self-care among self-referred patients with doctor-diagnosed asthma. In a one-on-one counselling session, each patient's educational needs were identified and the appropriate education offered. A telephone follow-up 30 days later assessed the impact of teaching. Community pharmacies across Canada. The follow-up questionnaire quantified the number of wheezing episodes or other symptoms per week, the number of night-time awakenings per week, and the frequency of use of reliever and preventive medications. Of 4080 patients assessed, 22.2% used an inadequate inhaler technique, 16.4% used a short acting beta2-agonist excessively and 21.0% were not using an inhaled corticosteroid daily despite a frequency of symptoms that would suggest that it was needed. Common educational interventions included a review of inhaler technique (41.9%), a recommendation for regular inhaled corticosteroids (31.5%) and a referral to the primary care physician (21.0%). Thirty days after the educational intervention, patients reported significant decreases in the frequency of daytime asthma symptoms, the frequency of nocturnal symptoms and the frequency with which short acting beta2-agonists were used, while reporting significant increases in their use of preventive medication. A brief assessment and an educational intervention in the community pharmacy can produce significant short term improvements in patient-reported symptom control and appropriate self-management behaviour.

Exhaled nitric oxide levels correlate with measures of disease control in asthma

Background: Asthma guidelines emphasize maintaining disease control. However, objective measures of asthma disease control are lacking. Objective: We sought to examine the relationship between exhaled nitric oxide (NO) levels and measures of asthma disease control versus asthma disease severity. Methods: We performed a cross-sectional study of 100 patients (age range, 7-80 years) with asthma. We administered a questionnaire to identify characteristics of asthma, performed spirometric testing before and after administration of a bronchodilator, and measured exhaled NO levels in all participants. Results: Exhaled NO was significantly correlated with the following markers of asthma disease control: asthma symptoms within the past 2 weeks (P = .02), dyspnea score (P = .02), daily use of rescue medications (P = .01), and reversibility of airflow obstruction (P = .02). Exhaled NO levels were not correlated with the following markers of asthma disease severity: history of respiratory failure (P = .20), health care use (P = .08), fixed airflow obstruction (P = .91), or a validated asthma severity score (P = .19). Markers with relevance to both disease control and severity showed either a weak correlation (FEV1 and FEV1 percent predicted) or no correlation (controller drug use) with exhaled NO. Conclusion: We conclude that exhaled NO levels are correlated predominantly with markers of asthma control rather than asthma severity. Monitoring of exhaled NO may be useful in outpatient asthma management. (J Allergy Clin Immunol 2000;106:645-50.)

Asthma from the perspective of the patient

Background: The published literature is lacking in data on the frequency and severity of medication side effects in the general asthma population. Methods: Questionnaires regarding asthma severity, treatment, and medication side effects were answered by 1230 and 604 pediatric and adult asthmatics, respectively, 70% to 75% of whom were consulting a specialist. Results: Most respondents (58%-79%) reported unwanted side effects from their bronchodilators, most of which had been racemic albuterol prescribed in either generic or name brand form. Side effects were most common in nebulizer users of all ages and in pediatric patients using oral medications. The most common troublesome side effects were jitteriness (58%), restlessness (57%), tachycardia (56%) and cough (56%) in the pediatric patients and tachycardia (64%), jitteriness (60%), shaky hands (43%), and restlessness (42%) in the adult respondents. Most patients had spoken to their physicians about their side effects, and the most common response was to change brands within the same class of medication, adjust the dose, or advise the patients to tolerate the side effects because the medications were necessary and side effects were to be expected. Fewer than 4% of all respondents viewed their physicians as “caring/sympathetic/willing to listen/discuss their bronchodilator side effects.” Twenty-five to thirty percent of patients had reduced their bronchodilator dose on their own, and 14% to 24% had skipped doses to avoid unwanted side effects. Hospitalizations were infrequent and were most commonly seen in the nebulizer users, who were also rated by their physicians as more likely to have severe asthma. Other markers of asthma control (such as emergency room visits, unscheduled doctor visits, and being sent home from school/work for asthma symptoms) were not only common in the nebulizer user group but also in children who used oral medications. This group was more likely to have been classified by their physicians as having mild asthma, suggesting perhaps a need for more intensive asthma education in this group. Conclusion: Medication side effects are common in individuals with asthma and are most often ascribed by the patients to their bronchodilators. There is a need for new, rapid-acting bronchodilators with fewer side effects. (J Allergy Clin Immunol 1999;104:S47-52.)