Stepping-down treatment in stable asthma should be individualized, ACAAI

The American College of Allergy, Asthma, and Immunology (ACAAI) has published a new guideline “Asthma Controller Step Down Yardstick” to help physicians decide when and how to step down asthma controller therapy according to guideline-defined control levels after the asthma symptoms improve and asthma is stable. The guideline outlines both reasons for, and reasons not to consider stepping down treatment, which should be “individualized according to the patient's current treatment, risk factors, values, and preferences”.

As per the guideline, stepping down treatment should be considered to:

·         Re-assess a current diagnosis of asthma.

·         Decrease the potential adverse effects of asthma medications.

·         Address patient and family preferences about taking medications.

·         Reduce the burden of treatment (e.g., time to take medications, remembering to take medications, having to take medications at work or school).

·         Reduce treatment costs.

·         Simplify therapy and enhance adherence with treatment.

Consider not stepping down treatment when:

·         Reducing asthma medication may increase risk of asthma exacerbation or loss of control.

·         It is unclear whether the patient is using asthma medications as indicated.

·         A seasonal maintenance of therapy is needed (e.g., during the allergy season or viral season).

Stepping down from Step 2 treatment (ICS)

·         Patients who are likely to adhere to daily ICS treatment: Once-daily low-dose ICS monotherapy or once-daily low-dose ICS/long-acting beta-antagonist (LABA)

·         Patients who prefer an alternative to daily treatment or who may not adhere to daily treatment: Anti-inflammatory/reliever therapy with a combination ICS + fast-acting short-acting beta antagonist (SABA) or the LABA formoterol

·         Patients who prefer an oral medication or who have difficulty using an inhaler: Leukotriene modifier daily + SABA reliever (as-needed)

Stepping Down From Step 3 Treatment

For patients using an ICS/LABA combination

·         Decreasing the ICS dose by changing the number of puffs or frequency of dosing

·         Switching to a combination product with a lower ICS dose

·         Discontinuing the LABA while maintaining (and potentially tapering over time) the ICS dose

For patients using only an ICS

·         Decreasing the dose of ICS

·         Stepping down to a low-dose ICS/LABA

·         Using low-dose budesonide/formoterol  as maintenance and reliever medication (not FDA approved)

·         Patients with allergic asthma: Immunotherapy to further reduce ICS dose

Stepping Down From Step 4 Treatment

·         Consider step down only after a careful review of the patient's history confirms a minimum of 6 months of asthma control and no exacerbations during the previous year.

·         For patients on ICS/LABA, reduce the dose of ICS while maintaining LABA.

·         Patients on tiotropium with ICS: Lower the dose of ICS while maintaining and possibly eventually discontinuing tiotropium if control is maintained.

·         Patients using tiotropium + ICS/LABA: Stop tiotropium while maintaining the ICS/LABA; wait at least 3 months between titration steps to ensure control is established.

Stepping Down From Step 5 Treatment

·         Objectively evaluating oral corticosteroids (OCS) and controller therapy use to determine adherence

·         Objectively evaluating responsiveness to a minimum 3-month trial of high-dose ICS/LABA under direct supervision

·         Initiating trial treatment with an appropriate biologic agent for a minimum of 4 to 6 months; assess asthma control and attempt to taper OCS over 2 to 4 months

The guideline is published online Dec. 12, 2018 in the Annals of Allergy, Asthma and Immunology

(Source: Medscape, EurekAlert)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Always enquire about chronic rhinitis in asthma and COPD patients

Patients hospitalized for either asthma or chronic obstructive pulmonary disease (COPD) have a higher risk of being readmitted for a hospital stay within 30 days of release if they also suffer from chronic rhinitis, says a new research from the University of Cincinnati.

The study, published in the Journal of Allergy and Clinical Immunology: In Practice, examined 4,754 asthmatic patients and 2,176 patients with COPD for a five-year period between 2012 and 2017. The 30-day asthma- and COPD-related readmissions of patients with allergic and non-allergic rhinitis with those patients without that diagnosis were compared using multivariate hazard models adjusted for relevant patient comorbidities.

Patients with asthma and allergic rhinitis were 4.4 times more likely to be rehospitalized within 30 days of discharge compared to those patients who did not have allergic rhinitis. Asthmatics with non-allergic rhinitis were 3.7 times more likely to be re-admitted within 30 days of discharge than asthmatics without non-allergic rhinitis.

Examination of COPD patients also revealed higher probability of rehospitalization when allergic rhinitis was also present.

COPD patients with allergic rhinitis may be readmitted 2.4 times the rate within 30 days of discharges compared to COPD patients without allergic rhinitis. Similarly, COPD patients with non-allergic rhinitis were 2.6 times more likely to readmitted within 30 days of discharge vs COPD patients without non-allergic rhinitis.

This study highlights the significance of a thorough history-taking, an art which many of us might have forgotten about, perhaps to meet the rush of the day.

Whenever treating a patient of asthma or COPD, one should always enquire about comorbid chronic rhinitis – allergic or non-allergic rather than treating or managing just the asthma or COPD. And, also treat it, if present.

Sir William Osler said, “Listen to your patient, he is telling you the diagnosis.”

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

#AskDrKK: A patient of CAD with bronchial asthma, how do you treat CAD without aspirin?

#DrKKAnswers: Being bronchial asthma we cannot give beta blockers. Aspirin also needs to be avoided in asthma. But we can give Clopidogrel, diltiazem, amlodipine and nitrates. 

HCFI Update: Asthma linked to smoking

Active smoking increases the risk of developing asthma, said Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India and MTNL Perfect Health Mela.

Dr. Aggarwal said that adolescents who smoke more than 300 cigarettes a year are at 4 times the risk of developing asthma compared to their non-smoking peers. Active smoking is strongly associated with high incidence of asthma between ages 17 to 33.

It is also seen that those children who develop asthma by age 7, usually go in remission but relapse by age 33 if they smoke.

Secondhand smoking is also associated with developing asthma in early life, especially, if the mother is a smoker. Many studies have shown that children of smoking mothers are two times are more likely to develop asthma than children of non-smoking mothers.

Dr KK Answers: Is asthma more in smokers?

Active smoking increases the risk of developing asthma. Adolescents who smoke more than 300 cigarettes a year are at 4 times the risk of developing asthma compared to their non-smoking peers. Active smoking is strongly associated with high incidence of asthma between ages 17 to 33.

It is also seen that those children who develop asthma by age 7, usually  go in the remission but  relapse by age 33 if they smoke.

Second had smoking is also associated with developing asthma in early life, especially, if the mother is a smoker. Many studies have shown that children of smoking mothers are two times are more likely to develop asthma than children of non-smoking mothers.

[ Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  ]

Emedinews: Dr. KK’s formula of two in Asthma

Dr. KK’s formula of two in Asthma can differentiate Intermittent Asthma from Persistent Asthma. Intermittent Asthma does not require continuous treatment.

If a patient has more than two night attacks of asthma in a month or more than two day attacks of asthma in a week or uses more than two canisters of asthma inhalers in a year, he or she is suffering from Persistent Asthma and requires continuous use of inhalers.

Dr KK Answers: Can food cause asthma?

 Sulphides are added to food. Food containing sulphides can trigger asthma in sensitive persons. Examples are potato, shrimp, dry fruit, dried fruits, beer, vinegar. 

Dr KK Answers: Can cockroaches cause asthma?

Cockroaches create allergies that can trigger asthma in sensitive individuals. Cockroaches thrive in warm environments with easily accessible food and water. Efforts should be made to get rid of cockroaches from houses where asthma patient resides. One should remove garbage and food waste from the house and wash the cooking utensils after use. Remove the cockroach debris quickly and eliminate any standing water from leaking.