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Compliance with the canadian asthma guidelines in different medical practices
$ 2 3 8 Abstracts
J ALLERGYCLIN IMMUNOL JANUARY 2002
22
Case Report: Cushing's Syndrome From Moderate Dose Fluticasone Metered Dose Inhaler (MGI) in a Child AE Ward, JA Bardelas Allergy and Asthma Center, High Point, NC As allergists, occasionally we are faced with what to do with children that have Cushing's syndrome, growth suppression and low serum cortisol from inhaled steroids. In particular, Cushing's syndrome has been reported in asthmatic children at what are considered low to moderate dosages of fluticasone. This case illustrates an approach that may result in quicker resolution of Cushing's syndrome and low serum cortisol in these patients. The patient is 9-year-old Caucasian male with a diagnosis of asthma. He was initially placed on Flovent MD144 mcg, two puffs twice a day with an InspirEase device. Because of continued cough, a month later, Flovent was increased to 110 mcg, two puffs twice a day with an InspirEase device. Three weeks later Flovent 110 mcg was increased to three puffs twice day with an InspirEase device, because of continued cough. Two months later, his mother called with a chief complaint of facial swelling since Flovent was increased to the 110 mcg MDI from the 44 mcg MDI. She also had noted a flush. He had never received oral steroids. His physical exam was remarkable for moon facies and a flushed appearance to his face. He had not grown in the five months that he had been on inhaled steroids. The remainder of his exam was normal as were his vital signs. He had a serum cortisol of 0.2 mcg/dl at 8:00 A.M. He was placed on Pulmicort Turbuhaler 200 mcg, twice a day and one week later he had an 8:00 A.M. serum cortisol of 12.5 mcg/dl. This case illustrates a very rapid normalization of 8:00 A.M. serum cortisol within a week after fluticasone was stopped, and after Pulmicort was started. The case reports of growth suppression and Cushing's syndrome in children on fluticasone have occurred with doses as low as 250 mcg/day by MDI, and, within one month of switching fluticasone to bodesonide, the cortisol levels have become normal and the Cushingoid features have disappeared. In the one case of Cushing's syndrome where the fluticasone MDI dosage was tapered from 550 mcg per day with spacer to fluticasone MD188 mcg once a day with spacer, it took seven months for the 8:00 A.M. cortisol levels to return to normal. When faced with patients with adverse side effects from fhiticasone, the switch to a less lipophilic steroid (fluticasone 200-300 times more lipophilic than budesonide or beclomethasone) and to a steroid with a shorter half-life (2-3 hours budesonide after inhalation vs. 8-14 hours fluticasone after inhalation) may result in quicker resolution of the adverse side effects.
723'°' c°'"'°Asthma
Education
Dan A Dalan*, Sue Kahler§ *Allergy & Asthma Care Center, Fargo, ND §American Lung Association of North Dakota, Bismarck, ND Asthma education is an NIHBL recommendation, (1) & we requested funding for Open Airways (OAS) (2) & asthma camp (AC) (3) from Dakota Medical Foundation & were asked to monitor outcomes. Physician diagnosed asthmatic children ages 8-14 were solicited from local clinics, & community through letters & advertisements. They were asked to participate in OAS or AC. Those who attend neither were asked to serve as control. Three measures were performed at baseline, FEVI, the Child Health Questionnaire-Parent Report, CHQ (5) & Paediatric Asthma Quality of Life Questionnaire (PAQLQ) (2), then repeated 4 & 8 weeks. Health care utilization will be asked. Attached table shows all groups characteristics at baseline. CHQ scoring is pending. These kids on average are NIHBL classified mild according to FEV1. No differences were found when compared at baseline FEV 1 and PAQLQ using analysis of variance. Paired t-tests performed separately for each group to determine changes from baseline on pulmonary function and PAQLQ showed only OAS significant improvements from
baseline on all PAQLQ scores. The children in this study were mild asthmatics & lack of improvement in FEVI is not unexpected. Moderate to severe asthmatics spirometry have been shown to improve in other studies (2). PAQLQ was able to detect significant change, FEV1 could not. The goal to provide asthma education in our community has been met. We have so far shown that kids attending OAS show significant improvement in an asthma specific questionnaire. Annett, (6) stresses the use of multiple outcome measures for assessing asthma characteristics, including psychosocial to impact compliance. This study so far emphasizes this importance. Literature Cited: 1. National Asthma Education and Prevention Program. National Institutes of Health, National Heart, Lung, and Blood Institute; July 1997. NIH Publication No. 98-051.2. A school health education program for children with asthma. Evans D et al Health Education Quarterly. 1987. 14:267-279.3. Outcomes Analysis of Summer Asthma Camp. Kelly, CS et al Journal of Asthma, 35(2), 165-171, 1998.4. Measuring quality of life in children with asthma. Juniper, EF et al. Qual Life Res 1996. Feb; 5(1): 35-46.5. Landgraf JM Abetz L Ware JE The CHQ User's Manual. First Edition. Boston, MA: The Health Institute, New England Medical Center, 1996. 6. Annett, RD Assessmentof health status & quality of life outcome for children with asthma. JACI. Supplement Vo1107. No 5 May 2001.
n
Total Score
Symptom
Activity
Emotion
FEV1
Control
25
6
6
5,6
6.2
91
AC OAS
37 32
6 5.8
6 6
5.7 5.2
6.2 5.8
85 88
24
Compliance With the Canadian Asthma Guidelines in Different Medical Practices
Jorge Mazza*, Bill Moote*, Keith Payton*, Flavia Mazza§ *University of Western Ontario, London, ON, Canada §McMaster University, Hamilton, ON, Canada The purpose of this study was to review and determine if the Canadian Asthma Guidelines that were published in 1996 and then revised in 1999 have influenced physicians in the daily management of patients with asthma. We reviewed records from 6 different practices of academic allergists and respirologists in southwestern Ontario. Changes were defined as 1) a decrease in the dosage of inhaled steroids, 2) an introduction of antileukotrienes and/or 3) the use of long acting beta 2 agonist. These changes were noted when reviewing the files after the publishing of the 1996 Guidelines and then once again after the revised Guidelines in 1999. Other parameters in the study include recommendations of environmental control, patient education as well as objective measurements of asthma. Of the 60 patients enrolled in the study, 46 of the patients had a change in their treatment in accordance with the Canadian Asthma Guidelines. Thirteen patients were initiated on antileukotrienes (21%), in 25 patients the dosage of inhaled steroids was reduced (41%) and 32 patients were using long acting beta 2 agonist (63%). All of the patients in the study were on inhaled steroids. We conclude that a referral of patients with asthma to a tertiary care medical center is likely to be associated with immediate changes that optimize the treatment and outcome of patients with asthma. The asthma control was not jeopardized by the changes in the treatment, for example reducing the total dosage of inhaled steroids. Rather, the patients' asthma improved and the cost of medications reduced. There weren't any statistically significant differences in the compliance with the guidelines between the 6 different practices, three of them being allergists and three being respirologists.
J ALLERGYCLIN IMMUNOL JANUARY 2002
22
Case Report: Cushing's Syndrome From Moderate Dose Fluticasone Metered Dose Inhaler (MGI) in a Child AE Ward, JA Bardelas Allergy and Asthma Center, High Point, NC As allergists, occasionally we are faced with what to do with children that have Cushing's syndrome, growth suppression and low serum cortisol from inhaled steroids. In particular, Cushing's syndrome has been reported in asthmatic children at what are considered low to moderate dosages of fluticasone. This case illustrates an approach that may result in quicker resolution of Cushing's syndrome and low serum cortisol in these patients. The patient is 9-year-old Caucasian male with a diagnosis of asthma. He was initially placed on Flovent MD144 mcg, two puffs twice a day with an InspirEase device. Because of continued cough, a month later, Flovent was increased to 110 mcg, two puffs twice a day with an InspirEase device. Three weeks later Flovent 110 mcg was increased to three puffs twice day with an InspirEase device, because of continued cough. Two months later, his mother called with a chief complaint of facial swelling since Flovent was increased to the 110 mcg MDI from the 44 mcg MDI. She also had noted a flush. He had never received oral steroids. His physical exam was remarkable for moon facies and a flushed appearance to his face. He had not grown in the five months that he had been on inhaled steroids. The remainder of his exam was normal as were his vital signs. He had a serum cortisol of 0.2 mcg/dl at 8:00 A.M. He was placed on Pulmicort Turbuhaler 200 mcg, twice a day and one week later he had an 8:00 A.M. serum cortisol of 12.5 mcg/dl. This case illustrates a very rapid normalization of 8:00 A.M. serum cortisol within a week after fluticasone was stopped, and after Pulmicort was started. The case reports of growth suppression and Cushing's syndrome in children on fluticasone have occurred with doses as low as 250 mcg/day by MDI, and, within one month of switching fluticasone to bodesonide, the cortisol levels have become normal and the Cushingoid features have disappeared. In the one case of Cushing's syndrome where the fluticasone MDI dosage was tapered from 550 mcg per day with spacer to fluticasone MD188 mcg once a day with spacer, it took seven months for the 8:00 A.M. cortisol levels to return to normal. When faced with patients with adverse side effects from fhiticasone, the switch to a less lipophilic steroid (fluticasone 200-300 times more lipophilic than budesonide or beclomethasone) and to a steroid with a shorter half-life (2-3 hours budesonide after inhalation vs. 8-14 hours fluticasone after inhalation) may result in quicker resolution of the adverse side effects.
723'°' c°'"'°Asthma
Education
Dan A Dalan*, Sue Kahler§ *Allergy & Asthma Care Center, Fargo, ND §American Lung Association of North Dakota, Bismarck, ND Asthma education is an NIHBL recommendation, (1) & we requested funding for Open Airways (OAS) (2) & asthma camp (AC) (3) from Dakota Medical Foundation & were asked to monitor outcomes. Physician diagnosed asthmatic children ages 8-14 were solicited from local clinics, & community through letters & advertisements. They were asked to participate in OAS or AC. Those who attend neither were asked to serve as control. Three measures were performed at baseline, FEVI, the Child Health Questionnaire-Parent Report, CHQ (5) & Paediatric Asthma Quality of Life Questionnaire (PAQLQ) (2), then repeated 4 & 8 weeks. Health care utilization will be asked. Attached table shows all groups characteristics at baseline. CHQ scoring is pending. These kids on average are NIHBL classified mild according to FEV1. No differences were found when compared at baseline FEV 1 and PAQLQ using analysis of variance. Paired t-tests performed separately for each group to determine changes from baseline on pulmonary function and PAQLQ showed only OAS significant improvements from
baseline on all PAQLQ scores. The children in this study were mild asthmatics & lack of improvement in FEVI is not unexpected. Moderate to severe asthmatics spirometry have been shown to improve in other studies (2). PAQLQ was able to detect significant change, FEV1 could not. The goal to provide asthma education in our community has been met. We have so far shown that kids attending OAS show significant improvement in an asthma specific questionnaire. Annett, (6) stresses the use of multiple outcome measures for assessing asthma characteristics, including psychosocial to impact compliance. This study so far emphasizes this importance. Literature Cited: 1. National Asthma Education and Prevention Program. National Institutes of Health, National Heart, Lung, and Blood Institute; July 1997. NIH Publication No. 98-051.2. A school health education program for children with asthma. Evans D et al Health Education Quarterly. 1987. 14:267-279.3. Outcomes Analysis of Summer Asthma Camp. Kelly, CS et al Journal of Asthma, 35(2), 165-171, 1998.4. Measuring quality of life in children with asthma. Juniper, EF et al. Qual Life Res 1996. Feb; 5(1): 35-46.5. Landgraf JM Abetz L Ware JE The CHQ User's Manual. First Edition. Boston, MA: The Health Institute, New England Medical Center, 1996. 6. Annett, RD Assessmentof health status & quality of life outcome for children with asthma. JACI. Supplement Vo1107. No 5 May 2001.
n
Total Score
Symptom
Activity
Emotion
FEV1
Control
25
6
6
5,6
6.2
91
AC OAS
37 32
6 5.8
6 6
5.7 5.2
6.2 5.8
85 88
24
Compliance With the Canadian Asthma Guidelines in Different Medical Practices
Jorge Mazza*, Bill Moote*, Keith Payton*, Flavia Mazza§ *University of Western Ontario, London, ON, Canada §McMaster University, Hamilton, ON, Canada The purpose of this study was to review and determine if the Canadian Asthma Guidelines that were published in 1996 and then revised in 1999 have influenced physicians in the daily management of patients with asthma. We reviewed records from 6 different practices of academic allergists and respirologists in southwestern Ontario. Changes were defined as 1) a decrease in the dosage of inhaled steroids, 2) an introduction of antileukotrienes and/or 3) the use of long acting beta 2 agonist. These changes were noted when reviewing the files after the publishing of the 1996 Guidelines and then once again after the revised Guidelines in 1999. Other parameters in the study include recommendations of environmental control, patient education as well as objective measurements of asthma. Of the 60 patients enrolled in the study, 46 of the patients had a change in their treatment in accordance with the Canadian Asthma Guidelines. Thirteen patients were initiated on antileukotrienes (21%), in 25 patients the dosage of inhaled steroids was reduced (41%) and 32 patients were using long acting beta 2 agonist (63%). All of the patients in the study were on inhaled steroids. We conclude that a referral of patients with asthma to a tertiary care medical center is likely to be associated with immediate changes that optimize the treatment and outcome of patients with asthma. The asthma control was not jeopardized by the changes in the treatment, for example reducing the total dosage of inhaled steroids. Rather, the patients' asthma improved and the cost of medications reduced. There weren't any statistically significant differences in the compliance with the guidelines between the 6 different practices, three of them being allergists and three being respirologists.