282 Demographic characteristics of patients experiencing near-fatal and fatal asthma: Results of a regional survey of 400 asthma specialists

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Abstracts

279

Budesonide Aqueous Nasal Spray Improved Quality of Life in Patients with Perennial Allergic Rhinitis Assessed by a Disease Specific Quality of Life Questionnaire E SrBhlJ, M Bendez. K Svensson’, T Carrilld, I VUna4. M da Graca Castelo-Branch. L Arhedenl 1AstraZeneca Lund, Sweden *Central Hospital, Skovde, Sweden 3Hospitai Nuestra Senora del Pino, Las PaimasGran Canaria, Spain 4PtYTE. Budapest, Hungary sHospita1 de Sao Joao, Pot-to, Portugal The aim was to compare the change in Quality of Life (QoL) in patients with perennial allergic rhinitis (PAR). 337 patients, aged between 16 and 74 years, (mean age=31 years) from four countries were randomized to budesonide aqueous nasal spray (BANS), either 256 or 128 pg. or placebo for a 4-week period. QoL was assessed at baseline and after study completion. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) consisting of 28 items in 6 domains was used (scale: 0-6,O=not troubled, 6=extremeiy troubled). At baseline, the three groups had similar values of RQLQ overall score: I .99, 2.25 and 2.25 after BANS 256 pg, BANS 128 pg. and placebo, respectively. Adjusted mean changes from baseline were as follows: BANS 256 BANS 128

OVERALL SLEEP PROBLEMS NONE HAY FEVER PROBLEMS PRACTICAL. PROBLEMS NASAL SYMPTOMS EYE SYFTMOMS EMOTIONAL FUNCllON

J ALLERGY CLIN IMMUNOL JANUARY 2000

PLACEBO

Kl

w

-0.92 -0.98

-0.98 -1.00

-0.46

-0.72

-0.77

-0.35

-0.57

-1.50

-1.56

-0.78

-1.35

-1.46

-0.56

-0.60

-0.69

-0.19

-0.74

-0.82

-0.48

Overall RQLQ as well as ail domains were significantly improved for both doses of BANS compared with placebo (p <0.005 for all domains and overall score). No significant differences were seen between the two doses of BANS. CONCLUSION: Budesonide aqueous nasal spray improved health-related quality of life in patients with perennial allergic rhinitis assessed by the Rhinoconjunctivitis Quality of Life Questionnaire.

280 An Inner

City Hospital Approach to Asthma Disease Management D Schull. V Tidwell, S Basmadjian, D Kennerly Parkland Health & Hospital System, Dallas, TX Parkland Health and Hospital System, a publicly supported hospital, provides outpatient, emergency and specialty medical care to Dallas County residents. The Asthma Clinic with referrals from the Emergency Department and Primary Clinics manages 1100 moderately severe to severe high risk patients, a sub population of the 15,000-20.000 patients with asthma who are served by the hospital system. The projects within this program include a hospital based and community education, a 24 hour call center, a provider education program, dust encasement program, cockroach abatement program, and nebuiizer program. Hospital-based Asthma Clinic: A multidisciplinary program with specialty based care provided pharmacy and nursing directed education classes, social work assessment, skin testing and pulmonary function tests. Community Oriented Primary Care Clinic: A multidisciplinary program with primary care provided asthma risk assessments and asthma patient education. Asthma Education Booklet and Care Plan: Multicultural educational materials in English and Spanish for adults with asthma. Deveiaped with extensive input from patient focus groups. Asthma Call Center: A general call center addressing patient ques-

tions, assessing patient needs and triage. Issues involve general asthma education, medication usage and refills, revising clinic appointments to meet subacute needs, referral for social service support, and medication changes during acute exacerbations. More than 3 100 calls recieved during the first year of operation. Dust Encasement Program: Provided free dust encasements to inner city patients with positive allergies to dust mites. Nebuiizer Program: Provided free nebulizers to inner city patients with moderate to severe asthma and frequent emergency department admissions. Cockroach Abatement Program: Provided free roach entrapments in the community to prevent asthma exacerbations triggered by cockroach sensitivity. Outcomes were monitored through the use of a pharmacy and clinical database. The outcome of these programs included a 39% decrease in emergency department utilization, linkage of urgentbased care with primary and specialty care. improved patterns of care by providers, and improved patient self-management of asthma. The Impact of Inhaled Corticosteroid Therapy on the Natural Course of Childhood Asthma. Does it Improve the Prognosis? Neritl N. Bahceciler; IfI B. Bar/an. Mujdat M. Basaran Marmara University Hospital. Pediatric Allergy & Immunology Division, Istanbul, Turkey Although a number of risk factors have been shown to influence the persistence of respiratory symptoms in childhood asthma, the majority of patients included in those studies were either receiving inadequate treatment or no treatment at ail. In this study, we aimed to assess the effect of the currently recommended therapeutic approach on the course of childhood asthma. For this purpose a retrospective review was performed on the records of 279 children with asthma and an end of study interview, results of spirometry and prick tests completed the data. The study was approved by the ethical committee of the hospital. The mean age at referral and at final survey was 6.2 yr and 8.9 yr. respectively: and the children were followed up for a mean of 3 years. Treatments included beta-2 agonists pm (mild intermittent) and inhaled budesonide (mild persistent, moderate. severe). Eighty-five of the 279 patients (30%) experienced no respiratory symptoms in the previous 12 months. There was no significant difference between those with and without current respiratory symptoms with respect to age, gender, age at onset of symptoms, follow-up period, age at referral, therapy, severity of asthma and duration of symptoms at referral. For subjects with current respiratory symptoms the initial serum total IgE level, and the percentage of prick test positivity was significantly higher than those without current respiratory symptoms (p=O.O027, p=O.Ol 1. respectively). Although the initial FBF2s.,s, FBV,, and FBV,@VC was significantly lower in those with current respiratory symptoms (p=O.O03, p=O.O05, p=O.O4. respectively), there was no difference between lung functions of the two groups at the end of follow-up. In logistic regression analysis. the persistence of respiratory symptoms was found to be significantly predicted by initial FBFz,.,, and sensitivity to allergens (p=O.O3, p=O.O4, respectively). We concluded that treatment with inhaled steroids may alter the long-term outcome of asthmatic children by leading to sustained control of symptoms and thus favouring optimal lung growth throughout childhood.

282 Demographic

Characteristics of Patients Experiencing NearFatal and Fatal Asthma: Results of a Regional Survey of 400 Asthma Specialists PJ Hannnway Salem, MA BACKGROUND: Case-control studies now describe a growing number of younger patients with varying levels of asthma severity who experience near-fatal or fatal asthma unexpectedly at home, en route to the hospital or in public places.

Abstracts

J ALLERGY CLIN IMMUNOL VOLUME 105. NUMBER 1, PART 2

OBJECTIVE: To collect case reports and analyze the demographic characteristics and patient profiles which may help identify predisposing factors which trigger near-fatal and fatal asthma episodes. METHODS: In order to gather case reports and analyze the demographics and clinical characteristics of patients experiencing near fatal and fatal asthma, a questionnaire on near-fatal and fatal asthma was distributed to 400 regional asthma specialists. RESULTS: Forty physicians reported 25 cases of near-fatal asthma and 20 cases of fatal asthma. Twenty-five patients. (13 males, 12 females) with a mean age of 29.4 years experienced near-fatal asthma. The time of onset of the near-fatal event was sudden (less than 3 hours) in 60% of cases and 76% of the episodes occurred at home or en route to the hospital. All 25 patients were using short acting inhaled beta agonists and 88% were reportedly using inhaled corticosteroids on a daily basis. Good to excellent compliance was noted in 60% of patients. Six patients were using a peak flow meter prior to their near-fatal attack. Predisposing psychosocial factors for life threatening asthma were noted in 44% of patients. Twenty patients (4 males, 16 females) with a mean age of 21.7 years experienced fatal asthma. The time of onset of the fatal event was sudden (less than 3 hours) in 80% of cases and all but one patient died at home, en route to the hospital or in a public place. All 20 patients were using short acting inhaled beta agonists. 80% were reportedly on daily inhaled corticosteroids and six patients were on oral corticosteroids. Good to excellent compliance was noted in 60% of patients. Only two patients were using a peak flow meter immediately prior to their fatal attack. Predisposing psychosocial factors for life threatening asthma were noted in 45% of decedent patients. Risk factors for fatal asthma included running in colder weather, overrelying on home nebulizers and a delaying in seeking care on longer holiday weekends. CONCLUSIONS: While approximately 50% of the patients in this survey had moderate to severe asthma tainted by adverse psychosocial factors. nearly half of near-fatal and fatal attacks occurred suddenly and unexpectedly, outside the hospital in stable, younger. atopic, reportedly compliant patients utilizing inhaled corticosteroids on a daily basis. This regional survey supports the need for additional studies and the establishment of a national case registry to collect case reports and analyze the demographics and clinical characteristics of patients experiencing near-fatal and fatal asthma in order to further define the risk factors and develop preventative protocols for patients at risk for near-fatal or fatal asthma.

283 Adverse

Pregnancy Outcomes In Asthmatic Women: A Research Synthesis From Published Data JE Fischer*. M Schat:f. E ran Mutius# *Zurich, Switzerland tSan Diego, CA SMunich, Germany Previous studies regarding the risks of adverse outcomes of pregnancy in asthmatic women have been conflicting. We performed a meta-analysis of the prior controlled studies in order to determine 1) the average relative risk of important adverse perinatal outcomes in asthmatic women, and 2) the sources of heterogeneity in the prior studies. Multiple data bases were searched applying keywords “pregnancy” and “asthma”. Studies which assessed the incidences of perinatal mortality, preeclampsia, preterm birth (< 37 weeks), low birthweight (< 2500 gm), or congenital malformations in the pregnancies of asthmatic women compared to a concurrently followed control group were included. For each outcome, meta-analsyes of relative risks (RR) using both fixed and random effects models were performed. The potential roles of various study and asthma severity factors in explaining heterogeneity were evaluated by meta-regression techniques. Out of 176 potentially relevant articles. 14 met the study criteria. The number of studies reporting each outcome and the ranges of RR in these studies for each outcome were as follows: Perinatal mortality: 7 studies, 0.24 - 3.00 Preeclampsia: I I studies, 0.93 - 3. I I

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Low birthweight: 9 studies, 0.63 - 9.00 Preterm birth I 1 studies, 0.80 - 7.70 Congenital malformations: 8 studies, 0.57 - 4.00 The meta-analyses revealed increased RR (95 % confidence intervals) in pregnant asthmatic women (random effects model) for the following outcomes: perinatal mortality: RR 1.67 (I. 17-2.39) preeclampsia: RR I .62 (I .30-2.03) low birthweight infants: RR 1.49 (1.15-1.92) Although the overall analysis suggested only a borderline increase for preterm births [RR I .28 (0.99- 1.64)). me&analysis of the 5 studies which controlled for confounders found a significant increased risk [RR 1.35 (I. l9- I .54)]. No significant increased risk of congenital malformations was identified in either total studies [RR I. IO (0.87I .39)] or those that controlled for confounders [RR I .06 (0.69-1.63)J. The major source of heterogeneity appeared to be asthma severity, best assessed by the requirement for oral corticosteroids. The proportion of patients in each study who required oral corticosteroids ranged from 1.1% to 38.3% and explained 83% of the heterogeneity for preeclampsia, 94% for low birthweight, and 47% for preterm birth. The average pregnant women with asthma suffers more than a 60% increased risk of perinatal mortality and preeclampsia, a nearly 50% increased risk of delivering a low birthweight infant, and probably a 30-35% increased risk of a preterm birth. The infants of asthmatic women do not appear to be at increased risk for congenital malformations. Although more severe asthma appears to confer the greatest risk, the exact mechanism of this effect cannot be determined from these data.

284 Effect of Partial

Adherence With Controller Therapy on Asthma Outcomes AT Luskin. DA Bukstein Dean Medical Center, Madison, WI Non-adherence in patients with chronic diseases including asthma is common. It has been associated with mortality, increased hospitalizations and ED visits, increased attack rates and need for steroid bursts, increased costs and decreased lung function. However, adherence is typically variable and partial; patients may take “drug holidays” spaced between periods of relatively good compliance or may be consistently only partially adherent. Little data exists as to the level of adherence necessary to evidence improved outcomes. Pharmacy refill data is an accepted but inexact method of assessing compliance. It is far more sensitive to nonadherence than patient reporting or clinician estimates but fails to give usable information about variable compliance, which can best be assessed by electronic monitoring. One advantage of refill data is that it is a widely available objective measure. We used pharmacy refill data to categorize asthmatics into groups based on 6-month aggregate adherence levels >90%, 50-90%. lo50%. and 90%) compliers and “average” (50-90%) compliers and the “low” (IO50%) and “non” (