In this Issue July 2002

Paediatric Asthma in the Asthma Management Handbook

'Something in the Air' Conference Reminder

International Primary Care Respiratory Group World Conference, 2002 and 2004

Review of Asthma Medication and Back-titration of Inhaled Corticosteroids

Paediatric Asthma in the Asthma Management Handbook.

Managing a child with asthma is a continuing challenge. There is evidence of increasing asthma prevalence and severity in children and asthma is the most common medical cause for hospital admission in children.

The encouraging news is that for the majority of children, asthma will either resolve or at least improve with age. There is, however, a large variation in the pattern and severity of asthma in childhood. Achieving a balance between the intensity of the treatment and the severity of the asthma will assist a child to achieve normal quality of life, normal levels of cardiopulmonary fitness and normal growth.

The diagnosis of asthma for the majority of children is entirely clinical, and is based on a history of recurrent or persistent wheeze in the absence of any other apparent cause.

It is important to understand the patterns of asthma in children - infrequent episodic, frequent episodic, and persistent. The pattern of asthma determines the need for preventive therapy.

A feature of the latest edition of the Asthma Management Handbook (AMH) is the section devoted specifically to paediatric asthma. It is essential to recognise that the management of asthma in children cannot be directly extrapolated from adult care. There are differences in the pattern of asthma, the natural history, the potential for side effects, mechanisms for drug delivery and anatomical factors.

For more information see the Asthma Management Handbook 2002:

Diagnosis, Assessment, Treatment and Long-Term Management of Paediatric Asthma

Childhood Asthma Consensus Statement.

The Third Pediatric Asthma Consensus Group met in Sao Paulo, Brazil in March 1995 and published the consensus statement. It covers almost all relevant aspects of paediatric asthma management including a discussion on the definition, comments on monitoring inflammation markers, role of allergy, allergens, avoidance of allergens and immunotherapy.

All participants expressed concern about the inappropriate extrapolation of observations from adults with asthma to wheezing in young children, and also from older asthmatic children to wheezing infants. This was particularly relevant to the discussions on definition and pharmacotherapy.

Go to the consensus document (PDF format Adobe Acrobat Reader required):

Third International Pediatric Consensus Statement on the Management of Childhood Asthma

Children and exercise-induced asthma.

Gaining plenty of exercise as a child today is often quite a challenge and even more so for a child with asthma. Most people with asthma will have asthma symptoms if they exercise in dry or cold air. This is called exercise-induced asthma (EIA). Even someone with well-managed asthma, who uses preventers, may still have EIA.

So for children with asthma enjoying some physical activity may need a little preparation in order to avoid EIA. Parents should advise the class teacher and physical education teacher that if their child exhibits signs of asthma during exercise the child should:

be allowed to rest;
use their reliever medication; and
not be forced to continue physical activity.

For more information see:

Asthma Management Handbook 2002 - Exercise-induced Asthma

Information Sheet Exercise-induced Asthma

Spacers versus Nebulisers

During the 3+ Visit Plan Workshops held at GPCE in Sydney late May, a common question was how nebulisers compared with spacers in delivering salbutamol for children.

An evidenced-based response is provided by the Cochrane Collaboration, which is an international organisation that started up in 1993 in response to Archie Cochrane's call for systematic, up-to-date reviews in healthcare. Cochrane was an epidemiologist who observed that:

Healthcare practice is not always based on good evidence
There is too much information for any individual to access and use
Resources are always limited, so it is all the more important to know which interventions work

The latest Cochrane review of spacers (holding chambers) versus nebulisers for treatment of acute asthma covers both children and adults was completed in February 2002.

The objective of spacer versus nebuliser review of 880 children and 444 adults included in 21 trials was to assess the effects of the delivery systems for beta2-agonists for acute asthma.

The relative risk of hospital admission for children was 0.65 (95% confidence interval 0.4 to 1.06). One study in children found a significantly shorter length of stay in the emergency department when the spacer was used, with a weighted mean difference of -0.62 hours, 95% confidence interval -0.84 to -0.40 hours. For adults, the relative risk of admission for spacer versus nebuliser was 0.88 (95% confidence interval 0.56 to 1.38). Adults' length of stay in the emergency department was similar for the two delivery methods.

Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, weighted mean difference -7.8% baseline (95% confidence interval -10.2 to -5.3).

The Cochrane reviewers concluded that spacers produced results that were at least equivalent to nebuliser delivery and for children there may be some advantage.

Finally, a key point to bear in mind is that in comparison with spacers, in the community setting, nebulisers are more expensive, require a power source and need regular maintenance.

Holding chambers versus nebulisers for beta-agonist treatment of acute asthma (Cochrane Review)

Asthma Management Handbook 2002 - Spacers

Asthma Management Handbook 2002 - Nebulisers

How to Look After your Nebuliser

'Something in the Air' Conference Reminder

The Australian Asthma Conference, 'Something in the Air', 20-23 August in Hobart, will provide doctors, pharmacists, nurses, asthma educators and other health professionals with an interest in asthma:

up-to-date information on the management of asthma, with a panel of international and national speakers;
access to research on all aspects of the management of asthma;
the opportunity for delegates to network with their peers and leading asthma researchers and practitioners: and,
the opportunity for delegates to access details of products and information from manufacturers, suppliers and companies with an interest in the asthma market.

For registration and full venue details please go to the official conference web site.

"Something in the Air" - Australian Asthma Conference

International Primary Care Respiratory Group First World Conference, 2002 and Second World Conference 2004

This new primary care group encompasses 15 national groups of primary care physicians worldwide and provides health professionals with access to information on respiratory medicine, including asthma, chronic obstructive pulmonary disease, lung cancer and infectious diseases.

The IPCRG held its first world conference in Amsterdam in June 2002. The NAC is a member of IPCRG through its General Practitioners' Asthma Group (GPAG), and Dr H. John Fardy, chair of GPAG, has been elected co-president of IPCRG for the next 2 years, with Prof. Jim Reid of New Zealand.

The NAC sent an Australian contingent of nine people (including Dr Ron Tomlins, NAC chairman, and Dr H. John Fardy) to Amsterdam. They presented an integrated session on the 3+ Visit Plan (Government GP Asthma Initiative), which sparked much interest in Australian asthma management, especially in the implementation of proactive care.

The conference attracted worldwide attendance, creating the ideal setting for leading discussion of asthma and COPD. The second world conference, in Melbourne in February 2004, will also aim to attract global representation. It will provide a wonderful opportunity for health professionals in the Asia Pacific region to discuss the management of respiratory disease.

Information on the 2004 IPCRG world conference in Melbourne can be found at

IPCRG-Melbourne

The latest media release from about IPCRG from the NAC:

Review of Asthma Medication and Back-titration of Inhaled Corticosteroids

Dr H. John Fardy, Chairman, General Practitioners' Asthma Group, National Asthma Council

How often in a consultation are GPs asked "…and while I am here doctor, can I have a script for…."?

It is worth taking a look at what prescribing medication is all about. What the patient sees is the GP writing out the script or, more commonly now, the even less complicated 'point and click'. The patient sees this and may think that that is all there is to prescribing without ever thinking that the GP should consider, at least, the following areas:

What is this medication being used for?
Is it the best available medication for this problem?
Is it having the desired medical benefits?
Does the medication suit the patient?
Are there side effects that the patient is aware of or concerned by?
Are there interactions with other medications (both prescribed and OTC) that the patient is taking?
Does this patient need to continue on this medication and on this dose?
When should this patient be reviewed for this particular medication or group of medications?

The whole philosophy of the 3+ Visit Plan is that it gives the doctor the opportunity of 'turning their mind to' the matter of the patient's asthma and the medications associated with that. In fact, the 3+ Visit Plan includes review of asthma related medications as one of the essential elements.

The above statements refer to the relatively uncomplicated matter of a repeat prescription.

Where it is a decision about the introduction of a new medication, other issues are to be taken into account. The matter of rational prescribing has its own literature but the major considerations are:

1. To define the clinical problem

2. To specify the therapeutic goal

3. To review available treatments, both drug and non-drug

4. Of the available drug groups for this particular problem, make a comparative judgement in terms of:
    (i) comparative efficacy;
    (ii) comparative safety;
    (iii) acceptability;
    (iv) cost.

5. What is the patient told about the particular medication being prescribed?

6. What arrangements are made to monitor and follow up the treatment?

So when these, and the many other individual factors relating to this patient are to be thought of, it cannot be an 'on the run' act. The decisions are complex and demand substantial professional consideration and expertise.

Apart from these general prescribing issues, there have been over the last few years, a number of changes in the types of asthma medication available to prescribers including the introduction of the long-acting beta₂ agonists (LABAs) and the leukotriene receptor antagonists.

The introduction of a LABA can often enable a reduction in the daily inhaled corticosteroid dose without any diminution in the level of asthma control for the patient.¹

These newer medications are just a part of the changes in asthma medications. The introduction of CFC-free inhalers has meant differences in the delivery devices and an increased range of dry powder devices.

One issue particular to asthma management is the back-titration of inhaled corticosteroid (ICS) doses. Over the last few years, the upper limit of acceptable inhaled corticosteroid dose has come down. Whereas 2000 microgram a day of beclomethasone (or equivalent) had been considered reasonable, this has been revised downwards and one should give a great deal of thought when having a patient on more than 1000 microgram a day of beclomethasone (or equivalent). The following guidelines are to be found in the newly published Asthma Management Handbook 2002:

For patients with mild to moderate asthma, a dose level of 500mcg fluticasone propionate (FP) or beclomethasone (BDP-HFA, or up to 800mcg/day of beclomethasone dipropionate (BDP) or budesonide (BUD) (CFC-containing).
For those who remain symptomatic, consider adding a long-acting beta₂-agonist (LABA). Some patients may find a combination treatment of a LABA and ICS more convenient.
For patients with severe asthma, or for those unable to tolerate LABAs, a higher dose of ICS may be required: up to 1000mcg/day of FP or BDP-HFA; up to 2000mcg/day of BDP or BUD (CFC-containing) and/or oral steroids.²

Patients seem to do one of two things with inhaled corticosteroids (ICS). They either stay on the originally prescribed dose of ICS, which may well have been initiated when they were having an acute exacerbation of their asthma or, if they have had no exacerbations for some time and they feel well, they stop taking their ICS. In each case there is a problem with the dose: it may be too high or too low.

The back-titration of the ICS must be monitored by history and objective measurement of lung function, preferably spirometry.

There is increasing evidence that, for many people with asthma, good control can be achieved with really quite low doses of inhaled corticosteroids, particularly if they are taken over a longer time course and if they are used in association with the long-acting beta₂ agonists.¹

This leads to the question of what is the correct dose of inhaled corticosteroids? The answer to all questions in General Practice is: "It depends!"

This issue needs to be at the forefront of the mind of the GP when prescribing asthma related medications: for this patient at this time, is this the correct dose of this inhaled corticosteroid using this device?

Think about that question and ensure that you and the patient have sufficient time to answer it to the satisfaction of both parties in the consultation.

References:

1. Pauwels R, Lofdahl C, Postma D, et al. Effect of inhaled formeterol and budesonide on exacerbations of asthma. NEJM 1997; 337:1405 - 11. (The FACET study)

2 Asthma Management Handbook 2002. National Asthma Council, Melbourne, 2002.

More detailed information about the medications and devices used for the treatment of asthma is available at:

Asthma Management Handbook 2002 - metered dose inhalers

Asthma Management Handbook 2002 - dry powder devices

Asthma Management Handbook 2002 - spacers

Asthma Management Handbook 2002 - nebulisers

Created July 14, 2002