Asthma clinicians: Listen up, then question
Eight questions you should always consider
It’s easy to treat most cases of asthma, says Bruce Berlow, MD, an allergist at the Sansum Medical Clinic in Santa Barbara, CA. "If you follow the guidelines, it’s really not difficult," Berlow says. "The first-line therapies are the inhaled anti-inflammatories and bronchodilators. That’s the easy part." The hard part, Berlow says, is dealing with patients who aren’t doing well on those drugs.
So what do you do about these recalcitrant cases? Start by asking questions. Eight questions, to be exact. Berlow says that with a little inquiry you might find your patients are as confused about their disease as you are by their lack of therapeutic response.
Question #1: What’s your home environment like?
Cats, dogs and tobacco smoke can trigger an asthmatic attack, but Berlow says you can’t just guess at allergic sensitivity. RAST testing for allergens will provide a definitive answer, but it’s helpful to know what’s going on in the home. As many as 85% of pediatric asthma cases can be traced to environmental factors, Berlow says, as can 50% of adult cases.
Question #2: How do you feel on weekends?
In other words, might something at work be causing the asthma? Find out whether patients work with chemicals and whether co-workers have complained of respiratory symptoms. Another possible sign of workplace asthma: conjunctivitis or rhinitis, indicating chemical irritation to the mucous membranes. Even though only 15% of asthma cases are traceable to the workplace, occupational asthma can be devastating, Berlow says, with permanent damage possible after some exposures.
Question #3: How many inhalers are you using every month and which kind?
The issue here is compliance. "Two things we’re concerned about: the underuse of anti-inflammatory sprays and the overuse of bronchodilators," Berlow says. "If there’s any single concern, it’s the underuse of anti-inflammatory drugs. It’s the most common denominator in therapeutic failures." Berlow suggests that pharmacists look out for patients who use more than two canisters of a bronchodilator a month and less than one canister of an anti-inflammatory. Be especially wary of sudden overuse of a bronchodilator it could mean an impending emergency, Berlow says.
One of the simplest ways to handle noncompliers is to see them frequently. Even weekly visits to a pharmacist-run asthma clinic might not be unreasonable for some patients.
Question #4: How much do you know about your disease?
This goes along with questions of compliance. Generally, studies have found that patients who understand asthma are more likely to use their medications. Increased compliance means fewer office and emergency room visits.
Question #5: Are you able to tell how bad your asthma is?
"Patients really can’t tell when they’re in trouble," Berlow says; hence, the importance of the peak flow meter. When pharmacists dispense these devices, they should tell patients they only need to remember a traffic light and two numbers 50 and 80, Berlow says. Peak flow results of 80% or greater indicate a green light. Asthma is under control, and the patient shouldn’t experience serious problems. Between 50% and 80% is yellow-light time. Patients should take caution; breathing is impaired. Anything under 50% is a slam-on-the-brakes, red-light emergency.
Question #6: Can you show me how you use your inhaler?
You likely will find an astounding number of patients have no idea how to use an inhaler correctly. "Physicians are not experts on this. They will prescribe an inhaler, and patients will have no clue as to how to use them. People talk about that all the time," Berlow says. In fact, up to 75% of patients use inhalers incorrectly, with about 5% not even knowing enough to take off the cap first, Berlow says.
Inhalers are a good way to treat asthma, but as a drug-delivery system, they leave much to be desired. On average, only about 10% of the drug ever gets to the tracheobronchial tree even less when technique is poor. Little wonder: The aerosol shoots out at more than 100 miles per hour leaving much of it sprayed inside the mouth and throat. Teach proper technique and use a spacer device, and you could increase the amount to 15%, Berlow says.
Question #7: Is this medicine right for you?
Again, Berlow says most asthmatics get by just fine on anti-inflammatories and bronchodilators. But sometimes you need to add something else; theophylline, for example. "It still does have a role. It’s good for getting people through the night and for difficult patients on a maximal regimen who are still not doing well," Berlow says. Theophylline also is a good drug for older patients suffering from chronic obstructive pulmonary disease, because it actually strengthens the diaphragmatic muscles used to breathe.
New kids on the block
"The other new kids on the block are the antileukotrienes," Berlow says. "It’s kind of weird either patients do very well on them or they don’t respond at all. About half of patients have a prominent leukotriene role in asthma." You can’t predict upfront who will respond to the drugs, Berlow says, but a two-week trial of an antileukotriene should give you a hint.
Other drugs to consider for the difficult patient: the mast-cell stabilizers nedocromil and cromolyn, and for poorly responding children embarrassed to use an inhaler in school, salmeterol (Serevent), a bronchodilator used no more than once every 12 hours.
Question #8: How does your stomach feel?
Asthma patients have gastroesophageal reflux disease (GERD) in numbers far beyond the norm. Nobody knows which comes first the GERD or the asthma but Berlow says treating the reflux makes the asthma better. "It needs to be treated aggressively. An H-2 blocker isn’t enough."
In fact, some asthmatics need surgical treatment for GERD, Berlow says. For most patients, however, a two-week course of a proton pump inhibitor will provide relief as well as act as a diagnostic test for GERD.
One unusual disease masquerades as asthma: vocal cord spasm. Berlow says it’s difficult to diagnose, fairly easy to treat, and more common than once thought. "A lot of these people who get on the steroid escalator have vocal cord dysfunction," he says, and not asthma. Clues for vocal cord dysfunction: Patients can talk during "attacks"; onset and recovery are abrupt; and panting or singing can relieve the symptoms. Young, high-achieving women are most commonly affected. Treatment includes psychotherapy.
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