5 Updates in Asthma for Primary Care

If it’s not really asthma but not really COPD-what is it called?

ACOS is the acronym for “asthma and COPD overlap syndrome.”

Asthma and COPD can be difficult to distinguish but separation may not be appropriate when features of both coexist-the entity now referred to as ACOS. ACOS is a combined clinical and spirometry diagnosis:

It exhibits symptoms like asthma that may be variable day to day and week to week usually beginning in childhood or adolescence.

Plus spirometry results consistent with COPD (FEV₁/FVC <.70 and FEV₁ <80% of predicted that does not reverse completely to normal range with short-acting bronchodilators).

ACOS usually is seen in a person with long-standing asthma who is also a smoker. Unlike the typical asthma history, the level of lung function in ACOS progressively gets worse similar to the disease progression seen in COPD.

People with ACOS have worse treatment outcomes, more frequent exacerbations, poorer quality of life, more rapid decline in lung function, and a disproportionately high use of health care resources.

Treatment for ACOS is still really empirical and based on combining first-line asthma treatment
(inhaled corticosteroids [ICS]) with first-line COPD treatment (long-acting bronchodilator therapy-either ß₂-agonists; LABA or antimuscarinic; LAMA medications) or the combinations of both.

Therefore, individuals with ACOS are treated with combination therapy of ICS+LABA or ICS+LAMA or ICS+LABA+LAMA.¹  

But stay tuned, just as for the treatment of COPD, the value of ICS for reduction of exacerbations in ACOS is being questioned. For now, most physicians will continue to prescribed combination ICS and long-acting bronchodilators, but that could change in the near future.²

1. Papaiwannou A, Zarogoulidis P, Porpodis K, et al. Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS): current literature review. J Thorac Dis. 2014;6(suppl 1):S146-S151.

2. Lim HS, Choi SM, Lee J, et al. Responsiveness to inhaled corticosteroid treatment in patients with asthma-chronic obstructive pulmonary disease overlap syndrome. Ann Allergy Asthma Immunol. 2014;113:652-657.

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Successful asthma treatment takes more than getting the Rx right; inhaler technique education and revieware essential

Prescribing proper medications for asthma based on severity and control assessment is important.³ But the patient still needs to get the medication to the target to ensure that outcomes will improve.

Significant attention has been given to problems with adherence but even if an inhaler is used regularly, it must also be used properly. Recent studies suggest that once is not enough to teach inhaler technique. Several studies have demonstrated that patients develop errors in inhaler technique as the time since teaching lengthens.

But a new study (granted from Turkey and of modest size-but still valuable) suggests that repeated education can help maintain good inhaler technique.⁴

3. Rank M, Bertram S, Wollan P, et al. Comparing the Asthma APGAR system and the Asthma Control Test in a multicenter primary care sample. Mayo Clin Proc. 2014;89:917-925.

4. Yildiz F. Importance of inhaler device use status in the control of asthma in adults: the asthma inhaler treatment study.Respir Care. 2014;59:223-230.

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Reducing antibiotic prescriptions by diagnosing all those missed asthma cases

We have all seen children aged 2 to 16 years who just keep getting prolonged respiratory infections or “bronchitis”-whatever that may be. These are not the toddlers and preschoolers with the runny nose that is passed around at daycare; these are the youngsters that have cough and “colds” that last weeks instead of days.

For the first time, a group has demonstrated that assessing, and when present, diagnosing asthma in those children can reduce the need for antibiotics in the following year.

A group of children (N=332) with repeated episodes (≥3 in a year) of respiratory infections for whom antibiotics had been prescribed were studied. When asthma was diagnosed and the children were treated for asthma, there was a reduction from an average of 7 antibiotic prescriptions per year down to only 2 per year.⁵

The message: correct diagnosis and treatment of asthma with daily anti-inflammatory medication can reduce the number of episodes of “bronchitis”-actually probably asthma exacerbations-treated with antibiotics.⁵    

Within your patient population, be suspicious of recurrent diagnoses of  “bronchitis,” “chest colds,” or bad colds in children.

Think possible asthma and proceed with asthma evaluation.
 

5. Gedik AH, Cakir E, Ozkaya E, et al. Can appropriate diagnosis and treatment of childhood asthma reduce excessive antibiotic usage?.Med Princ Pract. 2014;23:443-447.

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Vitamin D supplementation does not improve asthma outcomes

For several years there has been speculation that vitamin D was potentially important in asthma control and outcomes, particularly for children and adults with low serum vitamin D3 levels.

A large US clinical trial enrolled adult patients with symptomatic asthma and a serum 25-hydroxyvitamin D level of <30 ng/mL. The group that was randomized to 28 weeks of oral vitamin D3 supplementation (100,000 IU once, then 4000 IU/d for 28 weeks) did not have any improvement in time to first asthma exacerbation compared with those receiving a placebo.

None of the secondary outcomes showed any improvement either. The message-these data from the largest clinical trial to date do not support use of vitamin D3 in improving asthma outcomes among adults with vitamin D insufficiency.

You may choose to treat the vitamin insufficiency for other reasons, but it does not appear that it will improve asthma control or decrease asthma exacerbations.⁶

6. Castro M, King TS, Kunselman SJ, et al. Effect of vitamin D3 on asthma treatment failures in adults with symptomatic asthma and lower vitamin D levels: the VIDA randomized clinical trial.JAMA. 2014;311:2083-2091.

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Is montelukast as effective as ICS in asthma management?

Montelukast is an oral leukotriene antagonist that has been used for many years to replace ICS in children and adults with mild to moderate asthma. Recent systematic reviews suggest that montelukast is clearly better than placebo but not as effective as ICS or ICS+LABA in reducing exacerbations or improving control in either children or adults.^7,8

This supports the recommendation in the 2007 national asthma guidelines of ICS as the first-choice anti-inflammatory medication for persistent asthma. So, is there a place for oral montelukast? Yes.

It can be used as alternative therapy for patients or physicians who are concerned about the long-term side effects of ICS-preferably in patients with mild to moderate asthma.

These results are supported by a pragmatic trial of primary care patients that reported that ICS and montelukast were equivalent at 2 months but not 2 years in affecting asthma control and asthma-related quality of life.

The role for adjunct montelukast (added to ICS or ICS+LABA) in moderate to more severe asthma is still in question.⁹

7. Massingham K, Fox S, Smaldone A. Asthma therapy in pediatric patients: a systematic review of treatment with montelukast versus inhaled corticosteroids.J Pediatr Health Care. 2014;28:51-62.

8. Zhang HP, Jia CE, Lv Y, et al. Montelukast for prevention and treatment of asthma exacerbations in adults: Systematic review and meta-analysis. Allergy Asthma Proc. 2014;35:278-287.

9. Price D, Musgrave SD, Shepstone L, et al. Leukotriene antagonists as first-line or add-on asthma-controller therapy.N Engl J Med. 2011;364:1695-1707.