Impact of Payor-Initiated Switching of Inhaled Corticosteroids on Lung Function.

OBJECTIVES: To evaluate the impact of a payor-initiated formulary change in inhaled corticosteroid coverage on lung function in patients with asthma and on provider prescribing practices. This formulary change, undertaken in August 2016 by a Medicaid payor in Kentucky, eliminated coverage of beclomethasone dipropionate, a metered dose inhaler (MDI), in favor of mometasone furoate, available as MDI and dry powder inhaler (DPI). STUDY DESIGN: A retrospective chart review was conducted on children with asthma ages 6-18 years covered by the relevant payor from a university-based pediatric practice who were seen before the formulary change (February to July 2016) and after (February to July 2017). Spirometry data from each visit was compared using the paired Student t test. RESULTS: Fifty-eight patients were identified who were initially on beclomethasone dipropionate and had spirometry available at both visits. Those who switched from an MDI to a DPI (n = 24) saw a decline in median predicted forced expiratory volume in 1 second from 98.5% to 91% (P = .013). A decline was also seen in forced expiratory flow at 25%-75%, from 89.5% predicted to 76% predicted (P = .041). No significant changes were observed in children remaining on an MDI. Seven patients discontinued inhaled corticosteroid therapy. CONCLUSIONS: This study suggests insurance formulary changes leading to use of a different inhaler device may have a detrimental impact on pediatric lung function, which may be a surrogate measure for overall asthma control. This could be due to a lack of adequate timely educational intervention as well as the inability of some children to use DPIs.

Effect of a mobile health, sensor-driven asthma management platform on asthma control.

BACKGROUND: Asthma inflicts a significant health and economic burden in the United States. Self-management approaches to monitoring and treatment can be burdensome for patients. OBJECTIVE: To assess the effect of a digital health management program on asthma outcomes. METHODS: Residents of Louisville, Kentucky, with asthma were enrolled in a single-arm pilot study. Participants received electronic inhaler sensors that tracked the time, frequency, and location of short-acting ß-agonist (SABA) use. After a 30-day baseline period during which reference medication use was recorded by the sensors, participants received access to a digital health intervention designed to enhance self-management. Changes in outcomes, including mean daily SABA use, symptom-free days, and asthma control status, were compared among the initial 30-day baseline period and all subsequent months of the intervention using mixed-model logistic regressions and χ2 tests. RESULTS: The mean number of SABA events per participant per day was 0.44 during the control period and 0.27 after the first month of the intervention, a 39% reduction. The percentage of symptom-free days was 77% during the baseline period and 86% after the first month, a 12% improvement. Improvement was observed throughout the study; each intervention month demonstrated significantly lower SABA use and higher symptom-free days than the baseline month (P < .001). Sixty-nine percent had well-controlled asthma during the baseline period, 67% during the first month of the intervention. Each intervention month demonstrated significantly higher percentages than the baseline month (P < .001), except for month 1 (P = .80). CONCLUSION: A digital health asthma management intervention demonstrated significant reductions in SABA use, increased number of symptom-free days, and improvements in asthma control. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02162576.

Anti-inflammatory dosing of theophylline in the treatment of status asthmaticus in children.

BACKGROUND: Low-dose theophylline has been recognized for its ability to restore histone deacetylase-2 activity which leads to improved steroid responsiveness and thus improved clinical outcome. We retrospectively evaluated the effect of low-dose theophylline therapy in pediatric patients hospitalized for an acute asthma exacerbation as a proof of concept study. METHODS: We compared patients who received low-dose theophylline (5-7 mg/kg/day) in addition to current standard of care to patients who were treated with current standard of care alone. The primary outcome of the study was hospital length of stay (LOS). Generalized linear mixed-effects modeling (GLMM) was used to test whether receiving theophylline independently predicted outcomes. A Cox (proportional hazards) regression model was also developed to examine whether theophylline impacted LOS. RESULTS: After adjustment for illness severity measures, theophylline significantly reduces LOS (ß=-21.17, P<0.001), time to discontinue oxygen (ß=-15.88, P=0.044), time to spirometric improvement (ß=-16.60, P=0.014), and time to space albuterol (ß=-23.2, P<0.001) as well as reduced costs (ß=-US$2,746, P<0.001). Furthermore, theophylline significantly increased the hazards of being discharged from the hospital (hazards ratio =1.75, 95% confidence interval 1.20-2.54, P=0.004). There was no difference in side effects between patients who receive low-dose theophylline and those who did not. CONCLUSION: The results of this retrospective study suggest low-dose theophylline may have a positive effect in acute status asthmaticus. This study suggests that further research with a prospective, randomized, double-blinded, placebo controlled trial may be warranted to confirm and extend our findings.

Prescription Fill Adherence in Pediatric Asthma: Are Privately Insured Children at Increased Risk?

Adherence in asthma is a complex issue, which remains a major barrier to achieving control of symptoms and preventing morbidity. In children, there is a paucity of literature regarding risk factors for nonadherence to obtaining prescriptions. The aim of this study was to measure the first-fill rate of newly prescribed asthma medications for new patients presenting to a pediatric subspecialty asthma clinic, determine potential risk factors for not filling medication, and evaluate change in lung function at follow-up. We collected data on prescription refill rates, lung function, and clinic return rates in patients presenting for the first time to our clinic. We collected data on 77 children with persistent asthma encompassing 140 new prescriptions. A 2-sided Fischer's exact test was used with categorical variables to analyze variables, which may influence filling prescriptions and follow-up. A one-sided paired Student's t-test was used to analyze improvement in lung function between visits. The overall prescription fill rate was 83.5% (117/140). We found that patients with public insurance were statistically more likely to fill inhaled asthma medications than those with private insurance (P = 0.0133). Despite higher rates of filling medications, those with public insurance had a trend toward being significantly less likely to return for their follow-up appointment (P = 0.058). Those who filled their inhaled controller medications [inhaled corticosteroids (ICSs) or ICS/long-acting beta-agonist (LABA)] and followed up had a statistically significant improvement in forced expiratory volume in 1 s (P = 0.04), while those who did not fill their inhaled controller medications had no significant change (P = 0.31). Our data suggest that children with private insurance are at risk for nonadherence related to filling inhaled asthma medication prescriptions. In addition, patients who fill their inhaled controller medications had improved lung function, irrespective of other traditional assessments of adherence.

The impact of asthma exacerbations and preventive strategies.

OBJECTIVE: To review the pathophysiologic mechanisms underlying asthma exacerbations, the impact of exacerbations, and both current and future treatment strategies to establish asthma control and reduce the risk of future exacerbations. RESEARCH DESIGN AND METHODS: Relevant adult data were identified via PubMed, with additional references obtained by reviewing bibliographies from selected articles. RESULTS: Asthma exacerbations or 'attacks' are acute episodes of progressive worsening of symptoms which occur in patients with all degrees of asthma severity and are an important cause of morbidity and mortality. For patients, these asthma attacks constitute a considerable part of the disease burden in terms of both personal suffering and economic impact. Exacerbations are characterized in part by decreases in expiratory flow or lung function. The pathophysiologic mechanism underlying these changes is likely to be different depending on the specific asthma phenotype. Asthma exacerbations are commonly initiated by upper respiratory tract infections and/or environmental allergens, although there are other known factors which increase the risk of a patient developing exacerbations, such as cigarette smoking. Establishing asthma control and reducing the risk of future exacerbations is the main goal of asthma treatment. Inhaled corticosteroids alone or in combination with long-acting ß2-agonists, in addition to other step-up strategies such as leukotriene receptor antagonists and theophylline, are recommended. The anti-immunoglobulin E monoclonal antibody omalizumab should also be considered in difficult-to-treat allergic asthma. CONCLUSIONS: Despite the currently available treatments, many patients with asthma remain symptomatic and experience exacerbations regardless of disease severity. New therapies, including long-acting anticholinergics, anti-cytokines, and chemoattractant receptor-homologous molecules, are under investigation with some promising results. In addition to increased education and use of self-management plans, these novel therapies are essential to help improve asthma control and reduce exacerbation risk.

Impulse oscillometry: interpretation and practical applications.

Simple spirometry and body plethysmography have been routinely used in children aged > 5 years. New techniques based on physiologic concepts that were first described almost 50 years ago are emerging in research and in clinical practice for measuring pulmonary function in children. These techniques have led to an increased understanding of the pediatric lung and respiratory mechanics. Impulse oscillometry (IOS), a simple, noninvasive method using the forced oscillation technique, requires minimal patient cooperation and is suitable for use in both children and adults. This method can be used to assess obstruction in the large and small peripheral airways and has been used to measure bronchodilator response and bronchoprovocation testing. New data suggest that IOS may be useful in predicting loss of asthma control in the pediatric population. This article reviews the clinical applications of IOS, with an emphasis on the pediatric setting, and discusses appropriate coding practices for the clinician.

Exercise-induced bronchospasm, asthma control, and obesity.

Exercise-induced bronchospasm (EIB) commonly affects patients with asthma. However, the relationship between EIB and asthma control remains unclear. Exercise limitation due to asthma might lead to reduced physical activity, but little information is available regarding obesity and EIB in asthma. A recent survey evaluated the frequency of EIB and exercise-related respiratory symptoms in a large number of patients with asthma. The survey results were reanalyzed to address any relationship between EIB and asthma control and obesity. A nationwide random sample of children aged 4-12 years (n = 250), adolescents aged 13-17 years (n = 266), and adults aged ≥18 years (n = 1001) with asthma were interviewed by telephone. Questions in the survey addressed asthma symptoms in general, medication use, and height and weight. Asthma control was categorized using established methods in the Expert Panel Report 3. Body mass index (BMI) was calculated using standard nomograms and obesity was defined as a BMI ≥ 30 kg/m(2). Most children (77.6%), adolescents (71.1%), and adults (83.1%) had either "not well" or "very poorly" controlled asthma. Children with "not well" controlled asthma reported a history of EIB significantly more often than those with "well" controlled" asthma. Asthma patients of all ages who had "not well" and "very poorly" controlled asthma described multiple (four or more) exercise-related respiratory symptoms significantly more often than those with "well-controlled" asthma. Obesity was significantly more common in adolescents with "not well" and "very poorly" controlled asthma and adults with "very poorly" controlled asthma. Children, adolescents, and adults with asthma infrequently have well-controlled disease. A history of EIB and exercise-related respiratory symptoms occur more commonly in patients with not well and very poorly controlled asthma. Obesity was found more often in adolescents and adults, but not children, with asthma, which was not well and very poorly controlled.

From Childhood Asthma to Chronic Obstructive Pulmonary Disease: Evidence Supporting a Disease Continuum.

In this review, we analyze the available evidence showing a link between asthma and chronic obstructive pulmonary disease (COPD). Many features (epidemiologic, physiologic, and histologic) overlap between these two conditions. Both environmental cigarette smoke exposure and early lung development are risk factors for the development of asthma and COPD. However, recent studies suggest that up to 25% of COPD cases were nonsmokers. Asthma during early childhood, independent of smoking history, may be an independent risk factor for the later development of COPD. One explanation for this phenomenon suggests that early small airway dysfunction (including chronic airway inflammation and airway remodeling) can lead to permanent impairment in lung physiology. Several reasons why control of airway inflammation is difficult in some patients are explored. Finally, we examine the available evidence suggesting overlapping histologic features in both asthma and COPD.

Loss of asthma control in pediatric patients after discontinuation of long-acting Beta-agonists.

Recent asthma recommendations advocate the use of long-acting beta-agonists (LABAs) in uncontrolled asthma, but also stress the importance of stepping down this therapy once asthma control has been achieved. The objective of this study was to evaluate downtitration of LABA therapy in pediatric patients who are well-controlled on combination-inhaled corticosteroid (ICS)/LABA therapy. Clinical and physiologic outcomes were studied in children with moderate-to-severe persistent asthma after switching from combination (ICS/LABA) to monotherapy with ICS. Of the 54 patients, 34 (63%) were determined to have stable asthma after the switch, with a mean followup of 10.7 weeks. Twenty (37%) had loss of asthma control leading to addition of leukotriene receptor antagonists, increased ICS, or restarting LABA. There were 2 exacerbations requiring treatment with systemic steroids. In patients with loss of control, there was a statistically significant decline in FEV(1) (-8% versus -1.9%, P = 0.03) and asthma control test (-3.2 versus -0.5, P = 0.03). This did not approach significance for FEF(25-75%), exhaled nitric oxide, lung volumes or airway reactivity. No demographic, asthma control measures, or lung function variables predicted loss of control. Pediatric patients with moderate-to-severe persistent asthma who discontinue LABA therapy have a 37% chance of losing asthma control resulting in augmented maintenance therapies. Recent recommendations of discontinuing LABA therapy as soon as control is achieved should be evaluated in a prospective long-term study.