Anticholinergic vs Long-Acting β-Agonist in Combination With Inhaled Corticosteroids in Black Adults With Asthma

Many experts question the safety of using long acting beta agonists (LABAs) in treating asthma. Particularly, many feel as though African-Americans who use LABAs are at an increased risk for exacerbating their asthma symptoms. One idea is that allelic variation in the Arg16Gly gene could be causing pharmacogenetic variability that is disproportionately affecting African-Americans.

This study tested this hypothesis by comparing the asthmatic symptoms of African-American patients using LABAs with an inhaled corticosteroid (ICS) to  African-American patients using tiotropium and an ICS. Each patient also underwent genotyping to gauge the effect of the Arg16Gly gene. The results of the study showed that use of LABAs with an ICS did not exacerbate asthmatic symptoms any more than the use of tiotropium with an ICS. The study also showed that the Arg16Gly gene did not correlate to an increase in asthmatic symptoms, thus debunking the idea of pharmacogentic variability. Overall, the study showed that there is no difference in the worsening of asthma symptoms between LABAs and tiotropium.

This study shows the importance of researching preconceived notions about discrepancies in how certain patient populations handle medications. Without this research, some patients could receive sub-optimal therapy because of an untested yet widely accepted idea.

Wechlser ME, Yawn BP, Fuhlbrigge AL, et al. Anticholinergic vs Long Acting ß-Agonist In Combination with Inhaled Corticosteroids in Black Adults with Asthma. JAMA. 2015: 314(16): 1720-1730.  

Asthma control and cold weather-related respiratory symptoms

A common condition affecting many people around the world is asthma.  This condition, if not well controlled, can decrease the quality of life of those patients.  It is possible that the amount of respiratory symptoms during cold weather are more prevalent in those with a current respiratory condition because breathing cold air can cause a change in the airways.  This study tested whether there was difference between good asthma control and poor asthma control on the occurrence of cold weather-related respiratory symptoms.

A total of 5,000 subjects were given two different questionnaires to fill out.  From the 2,033 subjects who responded, 1,995 subjects were eligible for the study.  The questionnaires contained questions such as how much times the asthma kept the subject from achieving at work, or how often the subject experienced shortness of breath.  The questions ultimately were trying to assess if the subject experienced more asthma symptoms (shortness of breath, prolonged cough, wheezing, phlegm production, and chest pain) during cold weather.

After an analysis of the results, it was determined that cold weather does increase respiratory symptoms among adults with asthma.  This study is also the first to show that a poorer control of asthma does lead to more respiratory symptoms related to cold weather.  The most common symptom was that of cold weather induced chest pain among those with poor asthma control.  A low or high BMI and smoking also affects asthma control negatively.

I feel that this is something for pharmacists to keep in mind.  There may be a higher importance on controlling asthma in patients who live in colder areas.  For pharmacists working in the community setting in a cold area, there could be emphasis placed on assessing the adherence of those with asthma medications.

Respir Med. 2016;113:1-7.

The Effects of Climate Change on Health Care

Global Warming is a growing issue in every type of community, and the cause of this increase in temperature has been proven to be from human-generated greenhouse gas emissions. These emissions come from things such as the burning of fossil fuels when driving a car. The increased temperature of the globe has lead to heat waves, a decline in air quality, increased sea levels, and more recurrent major storms, including floods and wildfires. This, in effect, is causing a decline in the quality of the air humans breath, the food they eat, the water they drink, and the places they live. This has been shown to lead to more health problems, including infections from floodwater, respiratory conditions like asthma from the dirty air, heat exhaustion, and an increase in mental illness from the stress of all of these changes and the events that come with them. In addition, there has been an increase in heart, lung, and kidney diseases, which leads to an increase in medications prescribed for these illnesses. Certain mediations, however, are not helpful to patients because they interfere with the body’s ability to regulate its temperature, which is critical during this time of global climate change. These medications include antihistamines, stimulants, and antipsychotic medications.

It has also been shown that medical providers have a great impact with making these facts known to the public, and showing them how global warming really does directly affect them. Some ways that providers can do this is by encouraging biking and walking instead of driving to not only cut down on emissions, but to get patients exercising and improving their health. In addition, they can counsel patients with asthma and other serious conditions to make sure they are being adherent to their medications and give them tips on how to keep their conditions in check during these times of stress for their body.

JAMA. 2016;315(3):239-240.

I agree with the findings of this article, because health care providers are an unlikely, yet very useful source of information and support for people in many situations, including during climate changes or times of disaster. Most people don’t listen to the advocates for a “greener” planet, or don’t take them seriously, but if health care providers join the movement, it can definitely make the population more aware of the serious effects of global warming and what it can do to their health. Do you know someone whose health is being affected because of the events associated with increasing global temperatures? Or, after reading this article, do you now realize that someone you know is at greater risk for adverse health effects due to global warming?

New Study Links Usage of Tylenol during Pregnancy and Infancy to Asthma in Children

Paracetamol, also known as acetaminophen (APAP), or as many people recognize it, Tylenol®, is the recommended analgesics for pregnant women and for infants. However, recent studies have shown that prenatal and infant exposure to APAP could include a higher risk for that child developing asthma. As the second most chronic child-hood disease, it is important to study what may be causing asthma and how we can prevent it. Using data from the Norwegian Mother and Child Cohort Study, 53,169 children were included in the analysis. The study found modest associations between asthma at 3 years old with prenatal APAP exposure and the use of APAP during infancy. However, maternal and paternal usage of APAP outside of pregnancy did not show any association with asthma development. Because APAP is the most suggested pain reliever in pregnant women and infants, it is important to uncover potential adverse effects of its wide usage. I feel that this study has made the first steps in researching the effects of a commonly used drug that is widely accepted as safe. Do you think we should continue to spend money and time researching drugs that have been determined safe and used so prevalently over the past 60+ years, or focus our time and attention on new and up-coming drugs?

Link

Magnus, Mc., Karlstad, O., Haber, SE., et al. Prenatal and infant paracetamol exposure and development of asthma: the norwegian mother and child cohort study. Int. J. Epidemiol. Published ahead of print: February 9, 2016.

Up and Coming Severe Asthma Medications

Severe asthma currently affects 5% of the total patients that are dealing with asthma. However, 50% of current costs of asthma come from treatments given to patients with severe asthma. This demonstrates the need for a more cost effective solution for patients with this form of asthma. According the World Health Organization, about 235 million people suffer from asthma, and there has been a 50% increase in asthma cases every decade. Asthma has one of the highest costs of chronic conditions including visits to the physician’s office and personal burdens. Though asthma is a common chronic disease, severe asthma can result from non-adherence. Proper education about asthma and cost effective prescriptions could help patients that suffer from severe asthma.

As of late, there have been four medications that have been studied for severe asthma. Tiotropium bromide is an anti-muscarinic agent and has shown to decrease asthma severity. Omalizumab is a recombinant IgG1 monoclonal anti-IgE antibody and is used for patients that have elevated IgE levels and react to one or more allergnes. This medication is given subcutaneously every two to four weeks. It has shown a great improvement in severe asthma but is one of the most expensive asthma medications. A third medication is Mepolizumab which is a humanized monoclonal antibody for interleukin 5. It is ment to prevent airway inflammation and is given intravenously every four weeks. It has shown to reduce asthma and lower blood and septum eosinophil counts. A fourth medication was mentioned. Thermoplasty is the newest method and is meant to reduce smooth muscle in airways of uncontrolled asthma. However, this is an invasive procedure and has yet to be made safe in the early stages after the procedure but has shown long term improvements over five years.

With asthma rates increasing, it is important to find cost effective ways to treat it. Not only will finding proper medications for patients would be helpful, but overall education about asthma would be useful to ensure that severe asthma does not happen. The future of these new severe asthma medications are promising though.

Al Efraij K, Fitzgerald JM. Current and emerging treatments for severe asthma. J Thorac Dis. 2015; 7(11).

Pharmacist-led screening program for an inner-city pediatric population

This study was conducted to see how inner city children are affected by asthma, hypertension, obesity, and environmental tobacco smoke (ETS) exposure. This study took place in lower socioeconomic communities throughout Pittsburgh and pharmacists and student pharmacists ran 12 health screenings on 144 children over the course of 2 years.

The study found that 16% of the children were already diagnosed with asthma before the screenings, and 18% had potential asthma. More than half of the children were not at a healthy weight (0.7% were underweight and the remaining were either overweight or obese), and 24% had abnormal blood pressure. 26% of the children had exposure to ETS comparable to that of smokers.

Over the course of this study, nearly 200 referrals were made by the pharmacists. This study is important because it shows how at risk the children in our own community are for conditions that could greatly affect their health outcomes. It also shows how critical of a role pharmacists could play in screening and preventing diseases among children who face numerous health disparities. Screening programs such as this can be implemented by pharmacists in other communities, especially those of even lower socioeconomic status than the one studied, to help lower health disparities among inner city populations of children.

Elliott JP, Harrison C, Konopka C, et al. Pharmacist-led screening program for an inner-city pediatric population. J Am Pharm Assoc. 2003;55:413-8.