Highly Prevalent But Terribly Underappreciated

Folsom, CA. War has been declared on Severe Asthma-COPD Overlap Syndrome (ACOS).
It’s tied in with recognition of World Asthma Day May 7, 2013.

The World Asthma Foundation (WAF) is leading the charge to raise awareness and to elevate the discussion about this highly prevalent but terribly underappreciated ACOS syndrome.

ACOS, which was formerly called “asthmatic bronchitis,” is a commonly experienced, yet loosely defined clinical entity. It accounts for approximately 15 to 25 percent of the general population with obstructive airway diseases who experience more severe outcomes compared to asthma or COPD alone.

The prevalence of frequent exacerbations in ACOS is nearly two-and-a-half times higher than COPD and risk of severe exacerbations in ACOS is twice as high as COPD. However, standard treatment options are not as aggressive as needed to treat the asthma-COPD syndrome.

“ACOS is concerning because it’s much worse in terms of exacerbations, or acute attacks of breathlessness, as compared to COPD.” said Amir Zeki, MD, assistant professor of medicine pulmonary, critical, and sleep medicine at the Center for Comparative Respiratory Biology and Medicine at the University of California Davis School Of Medicine and World Asthma Foundation Board Member.

“We are entering a new era of public awareness of people living with chronic lung disease such as asthma and COPD,” said Sam Louie, MD and professor of medicine, director of the UC Davis Asthma Network (UCAN), director of the UC Davis Reversible Obstructive Airway Disease (ROAD) Center, which serves adults and adolescents in Northern California who have difficult to control asthma, bronchiectasis and COPD.

“Our mission at UC Davis is to transform health care by integrating and provide quality patient care services these conditions, which promote patient education and safety, social networking, and to align our goals with national efforts to transform people’s lives,” Louie said. “But we can achieve success without recognizing the clear and present danger from not being aware of the Asthma-COPD Overlap syndrome.”

“It really all begins with empathy.” Louie said. “Empathy of healthcare providers for how asthma, COPD and ACOS patients suffer when they are given prescription drugs without education on an individual level. We have to ignite that empathy by increasing awareness and providing education.”
The two physicians are board members of the World Asthma Foundation, which provides educational resources that inform patients, medical professionals and the general public about the latest clinical advances, management and treatment options for asthma disorders, including ACOS.

“People with asthma, COPD and ACOS deserve better,” Louie said. “It requires that we all take responsibility, patients too, but physicians must take their empathy one step further and realize how reversible asthma, COPD and ACOS can be.”

William Cullifer, executive director of the World Asthma Foundation, said, “This is a fascinating new development in the understanding of asthma and COPD and it’s fantastic to be on the forefront of educating the public and the healthcare community about this issue.”

Louie added, “When you get done taking care of the disease, you’re taking care of people. We must fight indifference and the only way to do that is to get the word out that we all have much more to achieve together to empower patients with reversible obstructive airway diseases.”

For more information visit: http://asthmacopdoverlapsyndrome.org

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The research was done in mice, but it supports the “hygiene hypothesis”: the idea that bacteria are needed to shape a healthy immune system, and that our bacteria-fearing lifestyles are increasing levels of asthma, allergy and other autoimmune diseases.

In the study, which was published in the journal Science, the researchers compared normal mice with mice that were raised in special germ-free environments. They found high levels of special white blood cells called invariant natural killer T cells (iNKT) in the lungs and intestines of the germ-free mice.

These iNKT cells release proteins that cause inflammation and attract more inflammatory white blood cells. Inflammation plays an important role in many autoimmune diseases, and iNKT cells are known to be an active ingredient in asthma, which is in the lungs, and ulcerative colitis, an inflammatory disease of the bowel.

Even when exposed to normal bacteria later in life, the germ-free mice still had abnormally high levels of iNKT cells and diseased lungs and intestines. This indicated that an “immune priming event” happens very early in life and is essential for the proper formation of the immune system, the researchers said.

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Researchers at Henry Ford Hospital have found that one-quarter of severe asthma attacks could be prevented if only patients consistently took their medication as prescribed.

Moreover, an asthma attack was only significantly reduced when patients used at least 75 percent of their prescribed dose, according to the study.

Patients often poorly take their medication based on the onset and degree of symptoms.

Henry Ford researchers say this is the first time that asthma medication use has been tracked closely over time and related to the likelihood of severe asthma attacks. The findings are published online in the December issue of The Journal of Allergy and Clinical Immunology http://www.jacionline.org/article/S0091-6749%2811%2901481-3/abstract

“Our findings demonstrated a relationship between medication adherence and asthma events in a manner that accounts for the changing patterns of inhaler use over time,” says lead author Keoki Williams, M.D., MPH, an Internal Medicine physician and associate director of Henry Ford’s Center for Health Policy and Health Service Research.

Inhaled corticosteroid (ICS) medication is the most effective treatment for controlling symptoms and preventing attacks, which can lead to a visit to the emergency department or hospitalization or death if left untreated.

Working from their theory that ICS use changes with the episodic nature of asthma, Dr. Williams and his team of researchers set out to measure changes in medication use over time and to estimate the effect of ICS use on asthma attacks among 298 patients. Patients were followed on average for two years and had 435 asthma attacks during that time.

“We found that every 25 percent increase in ICS adherence was associated with an 11 percent decrease in asthma attacks,” Dr. Williams says. “But most importantly, we found that causal use of these medications is not enough, especially among patients whose asthma is not controlled. Patients must use their asthma controller medication as prescribed if they want to have the best chance of preventing serious asthma attacks.”

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Armed with the right information, physicians can play a stronger role in ensuring asthma patients don’t waver in taking drugs proven to prevent asthma attacks, according to researchers at Henry Ford Hospital in Detroit.

The study finds patients are more likely to routinely take inhaled corticosteroids (ICS) for asthma control when physicians kept close watch over their medication use and reviewed detailed electronic prescription information, including how often patients fill their prescriptions and the estimated number of days each prescription would last.

“Better inhaled corticosteroid adherence means better overall asthma control, and less hospitalization,” says lead study author L. Keoki Williams, M.D., MPH, Center for Health Services Research and Department of Internal Medicine at Henry Ford Hospital.

“Unfortunately, overall patient adherence to ICS medication is poor, accounting for an estimated 60 percent of asthma hospitalizations. So it’s important, as we move forward with health care reform, to look for more effective ways to make sure patients stay with their prescription regimens.”

The study – the first large-scale, controlled study to test the effectiveness of routinely providing patient medication adherence information to physicians – appears online in the Journal of Allergy and Clinical Immunology (www.jacionline.org).

ICS, taken using an inhaler, help prevent and reduce airway swelling, and are considered the cornerstone therapy for controlling persistent asthma in patients, says Dr. Williams.

The Henry Ford scientific team set out to design an intervention that would provide physicians information on the most recent national asthma guidelines and methods for discussing medication non-adherence with their patients.

The intervention also offered physicians electronic access to patients’ medication prescription fill/refill information via Henry Ford’s ePrescribing application, part of its electronic medical record system that allows physicians to prescribe and review patient medications electronically.

The study enrolled 193 Henry Ford primary care physicians (family medicine, internal medicine, pediatrics). Eighty-eight were randomly assigned to the intervention group, while 105 were assigned to the control group (no intervention).

Physicians in the intervention group used ePrescribing to track medication fills and refills. The application also offered physicians the option to take it one step further: To review detailed adherence data, including estimates of the proportion of time that the patients took their medication.

Medication adherence for both groups was measured by using both electronic prescriptions and pharmacy claims for medication fills and refills.

Researchers found ICS adherence to be very similar among patients in the intervention group and those in the control group (21.3 percent vs. 23.3 percent).

But adherence was significantly higher in the intervention group (35 percent) when the patient’s physician elected to view detailed adherence information via the ePrescribing application.

Few physicians, however, in the intervention group accessed the detailed adherence information. “Going forward, one of the obstacles will be finding time for physicians to review and discuss this information with patients in their typically busy practices,” says Dr. Williams.

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According to published reports bu the U.S. National Institute of Health, Johns Hopkins University scientists supported by NIEHS report that high levels of nitrogen dioxide gas from cooking and heating stoves in indoor environments aggravate asthma symptoms in inner-city children, especially pre-school aged children. Nitrogen dioxide gas is most prevalent in industrial settings, but it also found at high levels in many poor, inner-city homes that have unvented gas stoves. In a recent report published in Environmental Health Perspectives the Hopkins researchers report that asthma exacerbations were directly related to high concentrations of nitrogen dioxide in the inner-city homes they studied.

The research team compared the nitrogen dioxide levels in the homes of 150 inner-city Baltimore children aged 2-6 to the frequency and intensity of coughing, wheezing, shortness of breath, and chest tightness. Each 20-point increase in nitrogen dioxide levels led to 10 percent more days of coughing and 15 percent more days of limited speech due to wheezing. Eighty-three percent of the homes had gas cooking stoves and 72 percent were heated with natural gas. Forty-two percent of the households had annual incomes less than $25,000.

Asthma is the most common pediatric chronic disease affecting 6.2 million children in the United States alone. It is widely known that severe asthma is most prevalent in the inner-city environment. This is due in part to poor access to health care and environmental conditions such as the disproportionate exposure to indoor allergens, dust, cigarette smoke, and automobile exhaust. The authors conclude that physicians caring for children with asthma should ask about their home’s heating and cooking appliances and recommend using alternatives if possible or at least encourage the parents to have the stoves properly vented.

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Growing every year

Introduction

Asthma is a lifelong disease that causes wheezing, breathlessness, chest tightness, and coughing. It can limit a person’s quality of life. While we don’t know why asthma rates are rising, we do know that most people with asthma can control their symptoms and prevent asthma attacks by avoiding asthma triggers and correctly using prescribed medicines, such as inhaled corticosteroids.

The number of people diagnosed with asthma grew by 4.3 million from 2001 to 2009. From 2001 through 2009 asthma rates rose the most among black children, almost a 50% increase. Asthma was linked to 3,447 deaths (about 9 per day) in 2007. Asthma costs in the US grew from about $53 billion in 2002 to about $56 billion in 2007, about a 6% increase. Greater access to medical care is needed for the growing number of people with asthma.

Latest Findings

Asthma is increasing every year in the US.

Too many people have asthma.

• The number of people with asthma continues to grow. One in 12 people (about 25 million, or 8% of the population) had asthma in 2009, compared with 1 in 14 (about 20 million, or 7%) in 2001.
• More than half (53%) of people with asthma had an asthma attack in 2008. More children (57%) than adults (51%) had an attack. 185 children and 3,262 adults died from asthma in 2007.
• About 1 in 10 children (10%) had asthma and 1 in 12 adults (8%) had asthma in 2009. Women were more likely than men and boys more likely than girls to have asthma.
• About 1 in 9 (11%) non-Hispanic blacks of all ages and about 1 in 6 (17%) of non-Hispanic black children had asthma in 2009, the highest rate among racial/ethnic groups.
• The greatest rise in asthma rates was among black children (almost a 50% increase) from 2001 through 2009.

Asthma Action Plan Stages

Green Zone: Doing Well

No cough, wheeze, chest tightness, or shortness of breath; can do all usual activities. Take prescribed longterm control medicine such as inhaled corticosteroids.

Yellow Zone: Getting Worse

Cough, wheeze, chest tightness, or shortness of breath; waking at night; can do some, but not all, usual activities. Add quick-relief medicine.

Red Zone: Medical Alert!

Very short of breath; quick-relief medicines don’t help; cannot do usual activities; symptoms no better after 24 hours in Yellow Zone. Get medical help NOW.

Asthma has a high cost for individuals and the nation.

• Asthma cost the US about $3,300 per person with asthma each year from 2002 to 2007 in medical expenses, missed school and work days, and early deaths.
• Medical expenses associated with asthma increased from $48.6 billion in 2002 to $50.1 billion in 2007. About 2 in 5 (40%) uninsured people with asthma could not afford their prescription medicines and about 1 in 9 (11%) insured people with asthma could not afford
  their prescription medicines.
• More than half (59%) of children and one-third (33%) of adults who had an asthma attack missed school or work because of asthma in 2008. On average, in 2008 children missed 4 days of school and adults missed 5 days of work because of asthma.

Better asthma education is needed.

• People with asthma can prevent asthma attacks if they are taught to use inhaled corticosteroids and other prescribed daily long-term control medicines correctly and to avoid asthma triggers. Triggers can include tobacco smoke, mold, outdoor air pollution, and colds and flu.
• In 2008 less than half of people with asthma reported being taught how to avoid triggers. Almost half (48%) of adults who were taught how to avoid triggers did not follow most of this advice.
• Doctors and patients can better manage asthma by creating a personal asthma action plan that the patient follows.

Who’s At Risk?

Asthma by age and sex US, 2001-2009

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Percentages are age-adjusted

SOURCE: National Center for Health Statistics; 2010.

Asthma self-management education by age, US, 2008

SOURCE: National Health Interview Survey, 2008, asthma supplement.

U.S. State Info

Adults with asthma in the US, 2009

What Can Be Done

Federal, state, and local health officials can:

• Track asthma rates and the effectiveness of control measures so continuous improvements can be made in prevention efforts.
• Promote influenza and pneumonia vaccination for people with asthma.
• Promote improvements in indoor air quality for people with asthma through measures such as smoke-free air laws and policies, healthy schools and workplaces, and improvements in outdoor air quality.

Health care providers can:

• Determine the severity of asthma and monitor how much control the patient has over it.
• Make an asthma action plan for patients. Use this to teach them how to use inhaled corticosteroids and other prescribed medicines correctly and how to avoid asthma triggers such as tobacco smoke, mold, pet dander, and outdoor air pollution.
• Prescribe inhaled corticosteroids for all patients with persistent asthma.

People with asthma and parents of children with asthma can:

• Receive ongoing appropriate medical care.
• Be empowered through education to manage their asthma and asthma attacks.
• Avoid asthma triggers at school, work, home, and outdoors. Parents of children with asthma should not smoke, or if they do, smoke only outdoors and not in their cars.
• Use inhaled corticosteroids and other prescribed medicines correctly.

Schools and school nurses can:

• Use student asthma action plans to guide use of inhaled corticosteroids and other prescribed asthma medicines correctly and to avoid asthma triggers.
• Make students’ quick-relief inhalers readily available for them to use at school as needed.
• Take steps to fix indoor air quality problems like mold and outdoor air quality problems such as idling school buses.

Employers and insurers can:

• Promote healthy workplaces by reducing or eliminating known asthma triggers.
• Promote measures that prevent asthma attacks such as eliminating co-payments for inhaled corticosteroids and other prescribed medicines.
• Provide reimbursement for educational sessions conducted by clinicians, health educators, and other health professionals both within and outside of the clinical setting.
• Provide reimbursement for long-term control medicines, education, and services to reduce asthma triggers that are often not covered by health insurers.

ucation, and services to reduce asthma triggers that are often not covered by health insurers.

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According to the The U.S. National Library of Medicine exercise can worsen or even trigger symptoms of asthma. Tips on how to help prevent exercise-induced asthma:

* Wear a scarf across your mouth and breathe through your nose when exercising outside in cold, dry air.
* Avoid exercising when air pollution is high.
* Avoid exercising near lawns that have just been mowed.
* Always warm up at the beginning of your workout and cool down at the end.
* Try sports that may not aggravate asthma as much as others, such as swimming or baseball.
* Avoid sports that involve constant movement, such as basketball, running or soccer.

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