The Back to School asthma study: the effect of montelukast on asthma burden when initiated prophylactically at the start of the school year.

BACKGROUND: Pediatric asthma hospitalizations peak in early autumn. OBJECTIVE: To determine the effectiveness of montelukast therapy in reducing the asthma burden in children when initiated prophylactically on school return. METHODS: This was a randomized, multicenter, double-blind, placebo-controlled study of children with asthma aged 6 to 14 years. No minimum asthma symptoms were required, and patients could continue inhaled corticosteroid (ICS) use. Montelukast, 5 mg, chewable tablet (n = 580) or matching placebo (n = 582) was taken the night before the first day of school and nightly thereafter for 8 weeks. The primary end point was the percentage of days with worsening asthma, defined by one of the following: (1) increased beta-agonist use, (2) increased daytime symptoms, (3) awake "all night," (4) oral corticosteroid rescue or increased ICS use for worsening asthma, or (5) unanticipated health care utilization. RESULTS: The reduction in the percentage of days with worsening asthma with montelukast use versus placebo use was not significant (24.3% vs 27.2%, P = .07). Prespecified subgroup analyses demonstrated nonsignificant trends favoring montelukast therapy in boys and older children but no effect by baseline ICS use or history of cold symptoms. Post hoc analysis showed a nonsignificant trend favoring montelukast therapy in reducing worsening asthma days for children commencing school after August 15 compared with earlier commencement. CONCLUSIONS: Montelukast use was not significantly more effective than was placebo use in reducing the percentage of days with worsening asthma when initiated at the start of the school year. The effect of montelukast treatment on the fall peak in asthma burden may depend on sex, age, and the date of school return.

Natural history of asthma: persistence versus progression-does the beginning predict the end?

Environmental exposures during the early years and airway obstruction that develops during this time, in conjunction with genetic susceptibility, are important factors in the development of persistent asthma in childhood. Established risk factors for childhood asthma include frequent wheezing during the first 3 years, a parental history of asthma, a history of eczema, allergic rhinitis, wheezing apart from colds, and peripheral blood eosinophilia, as well as allergic sensitization to aeroallergens and certain foods. Risk factors for the development of asthma in adulthood remain ill defined. Moreover, reasons for variability in the clinical course of asthma--persistence in some individuals and progression in others--remain an enigma. The distinction between disease persistence and disease progression suggests that these are different entities or phenotypes. There is currently no consensus on whether disease progression requires either airway inflammation or airway remodeling or the combination of the two. For patients with irreversible airway obstruction, inflammation might, in part, be necessary but perhaps not entirely sufficient to induce the irreversible component, some of which could be attributed to alterations in the structure of the bronchial wall. Intervening with intermittent or daily inhaled corticosteroids in high-risk infants and children does not prevent disease progression or impaired lung growth. These findings, however, might not apply to adults, and further study in adults is needed to determine the effect of inhaled corticosteroid therapy on disease progression.

Efficacy of montelukast during the allergy season in patients with chronic asthma and seasonal aeroallergen sensitivity.

BACKGROUND: Montelukast has proven efficacy in the treatment of chronic asthma and seasonal allergic rhinitis, but it has not been evaluated in the subpopulation of asthmatic patients with seasonal asthma symptoms. OBJECTIVE: To determine the effectiveness of montelukast treatment in improving the control of asthma symptoms during the allergy season in patients with active asthma and seasonal aeroallergen sensitivity. METHODS: Adults with a history of chronic asthma who are also symptomatic during the allergy season and with skin test sensitivity to seasonal aeroallergens were enrolled in a randomized, parallel-group, multicenter study with a 1-week, single-blind, placebo run-in period followed by 3 weeks of double-blind treatment during the spring of 2004. After the run-in period, eligible patients were randomly assigned to receive either oral montelukast (10 mg) or placebo. Daytime and nighttime asthma symptom scores, beta-agonist use, and morning and evening peak expiratory flow rates were recorded daily using an electronic diary. The primary end point was mean change from baseline to week 3 in the daytime asthma symptom score. RESULTS: Of 455 randomized patients, 433 completed the study. Compared with placebo, treatment with montelukast resulted in a significant improvement from baseline in the daytime asthma symptom score (-0.54 vs -0.34; P = .002) and in beta-agonist use, nighttime symptoms, and peak expiratory flow rates. Few patients in the montelukast and placebo groups discontinued study participation because of asthma (1.3% and 3.0%, respectively). CONCLUSION: In patients with chronic asthma and seasonal aeroallergen sensitivity, montelukast treatment provided significant asthma control during the allergy season compared with placebo.

Asthma morbidity and treatment in the Chicago metropolitan area: one decade after national guidelines.

BACKGROUND: A number of studies have demonstrated disproportionate hospitalization and mortality rates in US urban areas. Yet, no published population-based studies have examined the burden of asthma on the residents of a particular urban area known to be at high risk for poor asthma outcomes. OBJECTIVES: To examine asthma morbidity and medical care in a population-based sample of adults and children with asthma residing in the greater Chicago, IL, metropolitan area and to explore social and demographic influences on morbidity and treatment. METHODS: A telephone survey of adults living in the Chicago metropolitan area was conducted from November 1999 through December 2000. RESULTS: The final sample included 152 adults and children with active asthma. Emergency department visits and hospitalizations for asthma in the previous year were reported by 25.7% and 6.6% of respondents, respectively. Of current medication users, 32.2% reported current regular use of controller medications. After adjusting for age, sex, income, education, and reported current pharmacotherapy, compared with white individuals, African American individuals remained 6.3 times more likely to have experienced an emergency department visit and 12.3 times more likely to have been hospitalized. CONCLUSIONS: These findings suggest that poorly controlled asthma remains a prevalent problem for persons with asthma in this metropolitan area and that a large gap remains between the goals of asthma therapy and appropriate treatment as defined by the National Asthma Education and Prevention Program. The reasons for disparate treatment and health outcomes by race/ethnicity and income need further study and intervention.

Trends in emergency department asthma care in metropolitan Chicago: results from the Chicago Asthma Surveillance Initiative.

STUDY OBJECTIVE: The purpose of this study was to assess trends in emergency department (ED) asthma care in a single large community and to address how these trends meet expectations of national guidelines for asthma care. DESIGN AND SETTING: This study is based on a repeated cross-sectional, self-administered survey of ED directors (or designees) in the Chicago area. PARTICIPANTS: Fifty-one EDs that responded to both the 1996-1997 and 2000 surveys comprise the database for this study. RESULTS: Areas of significant improvement from 1996-1997 to 2000 include reduction in the use of theophylline (10.1% vs 3.1%, p < 0.0001), increased use of systemic steroid prescriptions at discharge (57.7% vs 77.2%, p < 0.0001), decreased use of arterial blood gas (ABG) analyses as part of the initial patient assessment (10.2% vs 4.5%, p = 0.02) and to document improvement after treatments (18.8% vs 8.9%, p = 0.03) and increased use of pulse oximetry as part of the initial patient assessment (95.1% vs 98.1%, p = 0.05). Areas of significant worsening of asthma care from 1996-1997 to 2000 include reduction in the use of ABG analyses in the assessment of severe cases (71.5% vs 47.5%, p < 0.0001), decreased use of instructions to inform patients what to do in the event of inability to attend their follow-up appointment (94.4% vs 38.9%, p = 0.0004), and decreased use of peak expiratory flow rate measurements to document improvement after treatments (82.7% vs 78.6%, p = 0.04). CONCLUSIONS: From 1996-1997 to 2000, ED asthma care in metropolitan Chicago has improved in some areas and worsened in others. However, most aspects of asthma care have continued to fall short of national asthma guidelines. The lack of overall improvement with the current widespread knowledge of national guidelines suggests that a dissemination strategy of medical education by itself is not sufficient to improve ED asthma care.

Parent-reported environmental exposures and environmental control measures for children with asthma.

BACKGROUND: Mounting evidence suggests that indoor allergens and irritants contribute to childhood asthma. National asthma guidelines highlight the importance of their reduction as part of comprehensive asthma treatment. OBJECTIVES: To assess the prevalence of potential environmental triggers, to identify risk factors for such exposures, and to determine whether prior parental education about trigger avoidance is associated with fewer such exposures. SETTING AND PATIENTS: Children with asthma in practices affiliated with 3 managed care organizations. INTERVENTIONS: Parents of 638 children, aged 3 to 15 years, were interviewed on enrollment in a randomized trial of asthma care improvement strategies. Parents reported recent asthma symptoms and exposures to potential environmental triggers. Multivariate models were used to identify specific demographic risk factors for environmental exposures and to determine if prior education was associated with fewer such exposures. RESULTS: Exposures to environmental triggers were frequent: 30% of households had a smoker, 18% had household pests, and 59% had furry pets. Other exposures included bedroom carpeting (78%) and forced-air heat (58%). Most children did not have mattress (65%) or pillow (84%) covers. Of the parents, 45% reported ever receiving written instructions regarding trigger avoidance and 11% reported them given in the past year. However, 42% reported discussing triggers in the home environment with a clinician in the past 6 months. In multivariate models, predictors of smoking at home included low annual family income and lower parental educational attainment. Dog ownership was associated with low educational attainment, and dog and cat ownership were less likely with black race. Reports of pests were increased for black children compared with white children. Black race was associated with lower rates of other exposures, including bedroom carpeting. After controlling for potential confounders, there was no association of reduced exposures with prior receipt of environmental control instructions. CONCLUSIONS: Exposure to potential environmental triggers is common, and recommended trigger avoidance measures are infrequently adopted. While specific exposures may vary with demographic and socioeconomic variables, all children are at risk. New methods for educating parents to reduce such exposures should be tested.