Originally Published: ican Physician News and Views Spring 2007 Newsletter. ican Website Physician Newsletter Article Archive Page 1

Transcription

1 ALVESCO: NEW ICS CICLESONIDE by Dr. Sheldon Spier Until recently there have been 3 excellent inhaled corticosteroids (ICS) in primary use for asthma in Canada budesonide (Pulmicort), beclomethasone (Qvar) and fluticasone (Flovent). The newest addition to the market is ciclesonide (Alvesco) which is presently available in a metered dose inhaler (MDI or puffer ). Some of the drug s most important properties are: it has extremely high protein binding in the serum so it is delivered to the liver to be metabolized almost entirely which means almost no other tissues of the body are exposed to the medication it only becomes activated in the lungs so it causes minimal thrush or voice hoarseness in well controlled asthma it can be used as a once daily medication As with many medications, the product is presently approved by Health Canada for patients 18 years of age and older, but there are many clinical studies of children down to the age of 12 and some clinical studies in younger children. I personally would have little or no hesitancy prescribing this medication to children of any age once I have informed parents/patients. Sheldon Spier is a pediatric respirologist and past Medical Director of the Asthma Clinic, Alberta Children s Hospital. Dr. Spier was also Co-Leader (with Dr. Wendy Tink) of the Child Asthma Network Project , was funded by Alberta Health Innovation Fund. This project eventually led to the creation of the current Community Pediatric Asthma Service, sponsor of the ican website. Originally Published: ican Physician News and Views Spring 2007 Newsletter ican Website Physician Newsletter Article Archive Page 1

2 ASMANEX TWISTHALER: NEW ASTHMA MEDICATION & DEVICE Merck has just added a new once daily inhaled corticosteroid (ICS) Asmanex (mometasone) for use in children 12+ years. Mometasone is a well known and effective nasal corticosteroid (Nasonex). Their combination product, Zenhale (mometasone and formoterol), was introduced to Canada in Asmanex is most comparable to Alvesco, QVAR, Flovent and Pulmicort. This once-a-day ICS is available in 200 mcg (pink) and 400 mcg (purple). The new device is actuated by twisting the cap, has a counter and will not open when it is empty. The lock when empty feature is a valuable and unique first in Canada. If your patients report any difficulty accessing Asmanex at their pharmacy, contact your Merck rep or have them call Merck Customer Service at Originally Published: ican Physician News and Views Spring 2011 Newsletter ican Website Physician Newsletter Article Archive Page 2

3 ASSESSMENT AND TREATMENT OF WHEEZING DISORDERS (Excerpts from Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach P.L.P. Brand et al, European Respiratory Journal 2008; 32: Sheldon Spier, MDCM, FRCPC, Director Pediatric Respiratory Medicine and Asthma Clinic, Alberta Children s Hospital) Episodic (viral) wheeze is defined as wheeze in discrete episodes, with the child being well between episodes. This phenotype is common in preschool children. It is usually associated with clinical evidence of a viral respiratory tract infection. The most common causative agents include rhinovirus, respiratory syncytial virus (RSV), coronavirus, human metapneumonvirus, parainfluenza virus and adenovirus. Repeated episodes tend to occur seasonally. Multiple-trigger wheeze. Although a viral respiratory tract infection is the most common trigger factor for wheeze in preschool children, some young children also wheeze in response to other triggers. Others have used the term persistent wheeze for this syndrome. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting ß2-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitization has been established. Maintenance treatment with inhaled corticosteroids (ICS) is recommended for multiple-trigger wheeze. Intermittent montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop and continued for the duration of the cold. Intermittent use of ICS is not recommended. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, maintenance use of inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Originally Published: ican Physician News and Views Winter 2008 Newsletter ican Website Physician Newsletter Article Archive Page 3

4 CONTROL OF ASTHMA The most important outcome measure for asthma is the assessment of how the disease is controlled, as it is for any chronic disease. Assessing asthma control can be compared to recording blood pressure for patients with hypertension. The control criteria for asthma have been adopted around the world. Asthma control is defined as: No daytime symptoms No night time symptoms No limits to normal physical activity No missed school or work No need for reliever medication, except for exercise A recent study from the Asthma Society of Canada showed that, even today, approximately 60% of children in Canada are not in good control of their asthma. Assessing and recording the level of asthma control at every visit will help you adjust their medications and other therapies appropriately and providing your patients with an Asthma Action Plan will teach them how to adjust their medications. Originally Published: ican Physician News and Views Winter 2009 Newsletter ican Website Physician Newsletter Article Archive Page 4

5 DIFFERENTIAL DIAGNOSIS: ASTHMA VS. COPD DIFFERENTIAL DIAGNOSIS: ASTHMA VS. COPD Asthma COPD Age of onset Usually <40 years Usually >40 years Smoking history Not causal Usually >10 pack years Sputum production Infrequent Often Allergies Often Infrequent Disease Course Stable (with exacerbations) Progressive worsening (with exacerbations) Spirometry Often normalizes May improve; Never normalizes Clinical Symptoms Intermittent & variable Persistent Reference: O Donnell DE, et a. Can Respir J, Vl 14 Suppl B September 2007: (108) Originally Published: ican Physician News and Views Winter 2009 Newsletter ican Website Physician Newsletter Article Archive Page 5

6 DON T FORGET THE NOSE! The nose is part of our single airway therapy for asthma, but is commonly forgotten in the diagnosis and treatment of asthma. If the nose is involved, successful asthma treatment and management will include nasal therapy. When the environment triggers seasonal/allergic rhinitis, daily oral antihistamines and nasal steroids are recommended. Dramatic changes in barometric pressure like those we experience in Calgary during a Chinook cause inflammatory changes in the nose and lungs and may mean some of your patients will be on nasal therapy all year! See our nasal steroid instruction sheet insert or view/print it from our website at in our Video section, under Nasal Steroid Spray. Originally Published: ican Physician News and Views Spring 2011 Newsletter ican Website Physician Newsletter Article Archive Page 6

7 KEYS TO ASTHMA SELF-MANAGEMENT With limited time to spend with patients, wouldn t you like to know you were being most effective with your time? The keys for asthma management are: 1. Assess control of asthma 2. Obtain spirometry 3. Review device technique 4. Evaluate medication (efficacy & concordance) 5. Write an asthma action plan Originally Published: ican Physician News and Views Spring 2009 Newsletter ican Website Physician Newsletter Article Archive Page 7

8 NEW Canadian Asthma Consensus Guidelines U P D A T E Mary Noseworthy, MDCM, FRCPC, Director, Asthma Specialty Clinic, Alberta Children s Hospital and Medical Co-Leader, Community Pediatric Asthma Service (Calgary Zone), Alberta Health Services The Canadian Thoracic Society 2012 guideline update critically evaluated 4 main topics: ICS/LABA Inhaled Corticosteroid/Long- Acting Beta Agonist aka Combination Therapy Advair (fluticasone/salmeterol) Symbicort (budesonide/formoterol) Zenhale (mometasone/formoterol) 1. Asthma control the role of non-invasive measures of airway inflammation 2. Adjunct controller therapy 3. ICS/LABA combination therapy in a single inhaler 4. Asthma Action Plans which medication to add, at what ICS dose used as a reliever, or as both a reliever and a controller how to adjust controller therapy in the yellow zone Abbreviated terms (from the Slim Jim ) with examples include: ICS SABA FABA LABA LTRA Inhaled Corticosteroids Alvesco Asmanex Flovent Pulmicort Qvar Short-Acting Beta Agonist Airomir Bricanyl Ventolin Generic salbutamol Fast-Acting Beta Agonist Note: All SABA s are fast-acting, therefore, they are also FABA s All SABA s listed above Formoterol sold as Oxeze and Foradil Formoterol sold in two combinations with an ICS - Symbicort and Zenhale. Long-Acting Beta Agonist Note: Not all LABA s are fast-acting Foradil Oxeze Serevent. Note: Not fast-acting, therefore, NOT for use as a rescue medication Leukotriene Receptor Antagonist Generic montelukast Singulair Accolate s Our thoughts on the most important messages that might impact your practice follow. 1. Asthma Control Inhaled corticosteroids (ICS) remain the first-line controller therapy for all ages Controller therapy should take into account both current control and future risk for severe exacerbations Spirometry is the gold standard in testing for children and adults. In adults, specialists are also now measuring exhaled nitric oxide as a measure of airway inflammation to guide adjustments to therapy. 2. Adjunct Controller Therapy It is not recommended to use single inhaler therapy (Symbicort) as a reliever and a controller as a selfmanagement strategy in lieu of ensuring adherence to lowdose ICS with a fast-acting reliever in children 12+ years In children <12 years, there is not sufficient evidence to recommend the use of combination therapy (ie. Advair, Symbicort or Zenhale) over moderate dose ICS or ICS and montelukast (Singulair) as maintenance therapy 3. ICS/LABA Combination Therapy in a Single Inhaler In individuals with mild intermittent asthma on no maintenance controller therapy or mild asthma on ICS monotherapy, use of a short-acting beta agonist is recommended instead of either a LABA (Oxeze) or an ICS/LABA combination inhaler (Advair, Symbicort or Zenhale) as a reliever As per Health Canada:»» Advair (fluticasone/salmeterol) is not indicated for PRN use»» Zenhale (mometasone/formoterol) is not indicated for PRN use»» Symbicort is the only combination therapy indicated for PRN use in conjunction with BID maintenance dosing For patients 12+ years, Symbicort (budesonide/formoterol) may be used:»» As a reliever - in patients with uncontrolled asthma despite adherence to a medium dose of combination therapy (Symbicort)... s

9 NEW Canadian Asthma Consensus Guidelines U P D A T E Examples Stepping Up a Medium Dose: Advair 250μg BID with PRN salbutamol could become Symbicort μg BID and PRN as maintenance therapy Zenhale 200μg BID with PRN salbutamol could become Symbicort μg BID and PRN as maintenance therapy Symbicort 200μg BID with PRN Bricanyl could become Symbicort μg BID and PRN as maintenance therapy»» As a reliever and a controller - in exacerbation prone patients with uncontrolled asthma despite high dose maintenance ICS or ICS/LABA therapy treatment may be increased as follows with close MD follow-up... Examples - Stepping Up a High Dose: Flovent 500μg BID with PRN salbutamol could become Symbicort 400μg BID and PRN as maintenance therapy Qvar 400μg BID with PRN salbutamol could become Symbicort 400μg BID and PRN as maintenance therapy Alvesco 800μg OD with PRN salbutamol could become Symbicort 400μg BID and PRN as maintenance therapy Advair 500μg BID with PRN salbutamol could become Symbicort 400μg BID and PRN as maintenance therapy s Rule-of-thumb MARK S Symbicort 400μg BID with PRN Bricanyl could become Symbicort 400μg BID and PRN as maintenance therapy. Note: The maximum dose of Symbicort is 1600μg/day for 7-14 days for anyone 12+ years. If your pediatric patient is on 500μg of any inhaled steroid and not controlled, reconsider diagnosis, treat allergic rhinitis and consider step-up therapies. Dr. Mark Anselmo, Division Chief, Respiratory Section, Alberta Children s Hospital 4. Asthma Action Plans Current Canadian Guidelines do not support intermittent treatment with ICS for symptoms associated with colds. Daily treatment with ICS is recommended Regular controller therapy with ICS is recommended for all ages. Add oral steroids for exacerbations when needed There is still insufficient evidence in children <12 years to support a recommendation regarding levels of step-up ICS therapy with worsening symptoms The Community Pediatric Asthma Service does not promote or endorse any asthma medication or product. All drugs named here are for example only. CONGRATULATIONS! Alberta Medical Association Honours Shirley van de Wetering The Alberta Medical Association (AMA) honoured five Albertans for their exemplary efforts in advancing the province s health care system at their September 2012 AGM and Representative Forum in Edmonton. The AMA Medal of Honor is presented to nonphysicians to recognize their contributions to the advancement of research, education, health care organization and health education, as well as their efforts to raise the standards of health care in Alberta. Shirley van de Wetering received the AMA Medal of Honor for her efforts to improve access to care for children and families living with asthma. Shirley launched this work in 2001 as the Project Manager for the Child Asthma Network (ican Project) that has evolved into the Community Pediatric Asthma Service as you know it today. The combined efforts of Shirley, the educator team and your efforts as primary care providers have contributed to a significant reduction in emergency visits and admissions for children with asthma in the Calgary Zone. Shirley is also responsible for the launch and ongoing development of the pediatric asthma ican website ( I CAN Control my Asthma Now ) which is recognized locally, nationally and internationally.

10 NEW NASAL FLU-MIST VACCINE Asthma is the #1 reason for school and work related absences in North America associated with colds and flu. For this reason, we support the flu vaccine for patients and families living with asthma. Nasal spray vaccine appears to give the best protection against influenza in the 2 17 year old age group with mild to moderate asthma. Children with severe asthma should continue to receive the intramuscular injection of the vaccine. Originally Published: ican Physician News and Views Fall 2013 Newsletter ican Website Physician Newsletter Article Archive Page 10

11 SAFETY IN CHILDREN AT RISK FOR ADRENAL INSUFFICIENCY USING INHALED CORTICOSTEROIDS by Dr. Sheldon Spier There have been concerns expressed recently about the potential for side effects, including the very serious possibility of adrenal crisis, from using inhaled corticosteroids. The Canadian Pediatric Society issued a bulletin last January concerning these risks 1. There are other articles regarding this issue 2,3 and, in particular, the report from Ottawa of four children with adrenal insufficiency taking ICS with doses of fluticasone as low as 250 micrograms per day 3. At the Alberta Children s Hospital, pediatric respirologists from the Asthma Clinic have reviewed the topic and have decided to hand a pamphlet with information concerning Adrenal Insufficiency to all patients receiving the following total daily doses of ICS as their maintenance dose: Fluticasone (Flovent) 500 mics Budesonide (Pulmicort) > 1000 mics Beclomethasone (Qvar) > 800 mics Ciclesonide (Alvesco) > 1000 mics For the vast majority of our patients, the prime message is still that ICS are very safe and the risks of not using them far outweigh the risks of using them. 1. Canadian Pediatric Society surveillance program, Adverse Drug Reactions Tips of the month, Jan Todd et al, Survey of Adrenal Crisis associated with inhaled corticosteroids in the United Kingdom, Arch Dis Child 2002;87: Heller et al, J Asthma.2010; 47: Sheldon Spier is a pediatric respirologist and past Medical Director of the Asthma Clinic, Alberta Children s Hospital. Dr. Spier was also Co-Leader (with Dr. Wendy Tink) of the Child Asthma Network Project , was funded by Alberta Health Innovation Fund. This project eventually led to the creation of the current Community Pediatric Asthma Service, sponsor of the ican website. Originally Published: ican Physician News and Views Spring 2011 Newsletter ican Website Physician Newsletter Article Archive Page 11

12 SINGULAIR IN THE NEWS We support the statement released jointly by the American Academy of Allergy Asthma and Immunology and the American College of Allergy, Asthma & Immunology released March 28, 2008 MILWAUKEE - Leadership from the American Academy of Allergy Asthma & Immunology and the American College of Allergy, Asthma & Immunology today released the following statement in response to the Thursday announcement of a Food and Drug Administration investigation into Singulair: There are no data from well-designed studies to indicate a link between Singulair and suicide. The concern expressed by the FDA is based entirely on case reports and there is no indication that such effects apply to other leukotriene-modifying medications. Post-marketing case reports are incomplete. Furthermore, comparative data are lacking on the incidence of suicide in the general population versus the incidence in patients taking Singulair. Thus, it is unknown whether there is an increased incidence of suicide in patients receiving Singulair. Based on the information currently available, patients taking Singulair should continue to take the medication as prescribed provided: 1. the patient and physician feel the medication is effective; and 2. the patient does not experience any suicidal behavior or thoughts. Patients who experience suicidal thoughts or demonstrate suicidal behavior should consult their physician immediately to discuss whether to continue with this medication. Patients should not hesitate to consult their physician if they feel uncomfortable continuing on the medication. Originally Published: ican Physician News and Views Spring 2008 Newsletter ican Website Physician Newsletter Article Archive Page 12

13 THE IMPORTANCE OF SPIROMETRY IN THE DIAGNOSIS OF ASTHMA AND COPD The most important diagnostic tool for respiratory conditions is spirometry: Objectively measures lung function and severity of lung disease Correlates the subjective and objective findings of airways obstruction Confirms diagnosis but because asthma is a variable condition, spirometry may be normal at times. This does not exclude the diagnosis but spirometry should be repeated over time to obtain an objective measure. Criteria to confirm a diagnosis of asthma: o 12% improvement in FEV1(ANDa minimum 180 ml in adults) from baseline 15 minutes after an inhaled short-acting beta2 agonist OR o 20% spontaneous variability (minimum 250 ml in adults) over time in FEV1 value Screens smokers at risk for COPD. Current CTS COPD recommendations suggest (Can Respir J Vol 14 Suppl B Sep 07): o Current or ex-smokers over the age of 40 who answer "yes" to one of the following questions should have screening spirometry: Do you cough regularly? Do you cough up phlegm regularly? Do even simple chores make you short of breath? Do you wheeze when you exert yourself or at night? Differential diagnosis of asthma/copd: o Because COPD is not typically reversible, FEV1 may improve after a bronchodilator, but will never normalize.fev1/fvc ratio will be <0.70 in COPD but can also be <0.70 with poorly controlled asthma. o Complete pulmonary lung function testing performed in a Level III or IV lab provides additional information regarding lung volumes helpful in the management of COPD DIFFERENTIAL DIAGNOSIS: ASTHMA VS. COPD Asthma COPD Age of onset Usually <40 years Usually >40 years Smoking history Not causal Usually >10 pack years Sputum production Infrequent Often Allergies Often Infrequent Disease Course Stable (with exacerbations) Progressive worsening (with exacerbations) Spirometry Often normalizes May improve; Never normalizes Clinical Symptoms Intermittent & variable Persistent Reference: O Donnell DE, et a. Can Respir J, Vl 14 Suppl B September 2007: (108) Originally Published: ican Physician News and Views Winter 2009 Newsletter ican Website Physician Newsletter Article Archive Page 13

14 TIPS DEVICE TECHNIQUE Many of the patients that come to Emergency for asthma at Alberta Children s Hospital have empty, expired and broken devices. It s no wonder their asthma is out of control! Invest a few minutes. Check the medication, devices and the technique. Make sure all your asthma prescriptions recommend the same device. Good technique is hard enough to master on one device. Device technique for all asthma devices is demonstrated on our website at in our Video section. By the time a child is about 4 years old, it s time to move to a spacer with a mouthpiece. Almost 30% of inhaled medication is lost in the nasal passages with a mask. Be specific when you write an order for a spacer with mouthpiece. If you order a pediatric spacer, your patient will often receive a spacer with a mask. EVALUATE MEDICATION Is it time to adjust the dose? Many patients remain on the same dose they were prescribed in an acute exacerbation. Optimal control of asthma is no symptoms on the lowest dose of medication ASTHMA ACTION PLAN Asthma Guidelines recommend everyone with asthma have an action plan to empower patients to adjust their medications appropriately. Management plans are readily available: on our website at in the Information section. Call our office for free copies at At the COPD & Asthma Network of Alberta (CANA) website at in the Key Resources section Originally Published: ican Physician News and Views Winter 2009 Newsletter ican Website Physician Newsletter Article Archive Page 14

15 ZENHALE: NEW ASTHMA MEDICATION Merck Frosst has just introduced Zenhale in Canada, approved by Health Canada for use in children over 12. Zenhale is a combination of mometasone (Nasonex), a well known and effective inhaled corticosteroid, and formoterol (Oxeze), a rapid onset and long-acting bronchodilator that has not previously been available in a pmdi in Canada. This new product is most comparable to Symbicort and as they both have the same LABA. It will also have similarities to Advair. Unfortunately the MDI device is blue in colour and should not be confused with short-acting bronchodilators alone. Originally Published: ican Physician News and Views Spring 2011Newsletter ican Website Physician Newsletter Article Archive Page 15