1. Based on current evidence, which of the following would be the most appropriate    recommendation regarding his asthma medication regimen?  Case Study-13

A. Maintain current medication regimen; no adjustment is indicated

B. Discontinue the inhaled corticosteroid; maintain on an inhaled beta-agonist as needed

C. Decrease the inhaled corticosteroid to 1 puff daily

D. Discontinue the inhaled corticosteroid; start a leukotriene modifier at bedtime

E. Discontinue the inhaled corticosteroid; start low-dose inhaled corticosteroid/long-acting beta-agonist, 1 inhalation at bedtime

ANS:  correct answer = option E

EXPLANATION : The goal of asthma therapy is to minimize risk and maintain asthma control with the least amount of medication (1).  In patients with mild persistent asthma, recent studies have demonstrated several options for “step-down therapy.”  The American Lung Association Asthma Clinical Research Centers network study found that patients who stepped down from twice daily low-dose fluticasone to once daily combination therapy with fluticasone/salmeterol had equivalent asthma control scores, FEV₁, and frequency of exacerbations compared with continued therapy with twice daily fluticasone (2).  Once-daily montelukast demonstrated a slightly higher treatment failure compared with either of the regimens containing inhaled steroids.  Despite the slight increase in treatment failure with montelukast, each of the treatment groups had equivalent symptom-free days and rates of clinically significant asthma exacerbations.  Thus, while either regimen would be appropriate, stepping down to once-daily combination therapy with fluticasone/salmeterol appears to be more beneficial.

Recent studies also suggest that those with mild persistent asthma taking inhaled corticosteroids in combination with either a long-acting beta-agonist or a short-acting beta-agonist when symptomatic, had no increase in adverse outcomes compared with those taking scheduled daily inhaled doses.  Boushey et al. (3) compared patients with mild persistent asthma using twice-daily budesonide versus twice-daily zafirlukast verses placebo. All three groups used budesonide as-needed following a symptom-based action plan. The study found that in comparison with patients on a daily controller (budesonide or zafikulast), participants using only as-needed budesonide had no significant difference in morning peak expiratory flow, postbronchodilator FEV₁, quality of life, or frequency of asthma exacerbations. Results of this study raise the possibility of treating mild persistent asthmatics with as-needed inhaled corticosteroids. More recently, Papi et al. (4) found as-needed use of an inhaler containing both beclomethasone and albuterol for symptom relief was associated with fewer exacerbations and higher morning peak flow readings than using an inhaler with albuterol alone.  The morning peak flow readings in the as-needed combination beclomethasone/albuterol group was equivalent to those taking scheduled daily doses of beclomethasone alone, or scheduled daily doses of beclomethasone/albuterol combined.  The combination of an inhaled steroid and a short-acting beta-agonist in a single inhaler is not currently available in the United States.

In the mild persistent asthmatic there is now strong evidence to support multiple treatment approaches which provide good asthma control.  Matching the drug regimen with the patient’s preferences, lifestyle, comorbidities, and financial limitations will help ensure drug adherence and maintain asthma control.

2.Which of the following should be done routinely with each follow-up visit?  Case Study-13

A. Methacholine challenge testing

B. Sputum for eosinophils

C. In-office peak flow recordings

D. Review of proper inhaler technique and adherence

E. Measurement of exhaled nitric oxide (NO)

ANS: correct answer = option D

EXPLANATION: Assessing inhaler technique at each office visit allows the provider an opportunity to assess compliance, reinforce proper use, and identify motor or physical limitations affecting technique (8).

When studied, only approximately 25% of patients are able to properly demonstrate use of a meter dose inhaler when asked.  The remaining 75% improved with specific instruction and practice which reinforces the need to incorporate proper inhaler use during the office visit (9,10).  The use of a spacer significantly improves accuracy and dose delivery, particularly in patients with poor coordination skills (9,10).

Assessing patient adherence is best approached with a non-judgmental attitude.  Adherence to inhaled corticosteroids is estimated at < 50% (11).  Causes of nonadherence are multifactorial but may be improved by providing asthma education, encouraging self management through use of an asthma action plan, and facilitating open communication (11).  Financial barriers often transcend all other efforts to improve adherence and must be taken into account when prescribing asthma therapy (11).

Methacholine challenge testing is useful to demonstrate airway hyperresponsiveness in those with normal spirometry and a suspicion of asthma, but is not recommended as a serial procedure.  Biomarkers for inflammation such as eosinophils or nitric oxide are being investigated in clinical trials but currently have no indication in routine asthma care (1).  Peak flow monitoring is useful for long-term home assessment of asthma control and medication response, but is not indicated for regular office assessment or diagnostic purposes (1).

3.What findings would suggest that the patient requires a step-up in asthma medication?  Case Study-13

A. Two or more night time awakenings per month due to Asthma.

B. Two or more interruptions in daytime activities per month due to asthma

C. Peak flow readings 85% of personal best

D. Short-acting beta-agonist for rescue once a week

E. Short-acting beta-agonist 4 days/week prior to exercise

ANS:  correct answer = option A

EXPLANATION: Inadequate asthma control and a need for step-up therapy is based on two or more daytime symptoms per week, two or more nighttime symptoms per month, interference with activities of daily living, use of short-acting beta-agonist > 2 days/week (excluding use for prevention of exercise-induced bronchospasm),or peak flow or FEV₁ <80% predicted/personal best (1). 

Asthma symptoms should be assessed at each office visit to determine asthma control.  Validated self-assessment tools such as the Asthma Control Test (ACT), Asthma Therapy Assessment Questionnaire (ATAQ), or Asthma Control Questionnaire (ACQ) can facilitate consistent measurement and documentation of asthma symptoms during office visits (1, 8).  All asthmatics are at risk for a severe asthma attack regardless of their asthma classification; therefore, providers are encouraged to teach patients to recognize symptoms of inadequate asthma control and provide them with specific instructions for adjusting their medications or seeking medical care (1)

4. The patient was provided with an asthma action plan to follow at home. Which component of the asthma action plan is considered the most critical element for improving asthma outcomes?  Case Study-13

A. A list of the patient’s controller and rescue medications

B. A list of symptoms indicative of worsening asthma

C. Medication changes based on personal-best peak flow readings

D. Instructions describing when, how, and how long to increase medications when symptomatic

E. Medication changes based on symptoms

ANS:  correct answer = option D

EXPLANATION : All of the elements are important components of an asthma action plan. However, Gibson and Powell (5) found a 40% reduction in hospital admissions and a 20% reduction in emergency room visits when the plan contained personalized instructions regarding the medications to add, criteria for adding the medication, duration of use, and when to seek medical help when patients are symptomatic. An asthma action plan serves as a patient guide for early recognition and treatment of an exacerbation. Treatment guidelines may be based on symptoms, peak flow readings, or both. When peak flow readings are used, personal-best readings were consistently associated with improved health outcomes compared with percentage-predicted readings (5).

5. How often is spirometry testing recommended if the previous readings are normal and the patient’s asthma is well controlled?  Case Study-13

A. Every 1 to 2 years

B. Only if asthma controller medications are changed

C. Only if symptomatic

D. Every 4 to 6 months

E. Every follow-up visit

ANS:  correct answer = option A

EXPLANATION: Spirometry is a simple test that can be performed in-office and can be used to assist the provider in determining the degree of airway obstruction (1, 6).  There are no widely accepted data correlating frequency of spirometry with clinical outcomes in asthmatics, thus one must rely on expert opinion and individual patient needs.  Spirometry is recommended during the initial evaluation after treatment is initiated and the patient’s symptoms have stabilized during periods of progressive or prolonged loss of asthma control and at least every 1-2 years (1).

When spirometry is used to diagnose or confirm asthma, testing must include pre- and post-bronchodilator readings (1).  A change in FEV₁ of >200 ml and ≥ 12% from the baseline measure following the administration of a short-acting bronchodilator is indicative of significant airway reversibility which has been shown to correlate with airway inflammation (7).  

The Expert Panel (1) classifies asthma severity by FEV₁, FEV₁/FVC, short-acting beta-agonist use, or frequency of asthma symptoms.   Parameters are measured at baseline with asthma severity determined by the worse parameter, e.g., daily symptoms with normal FEV₁ is classified as moderate persistent asthma.  Correct identification of asthma severity guides the provider in choosing the appropriate type and amount of therapy

REFERENCES:

1. Expert Panel Report 3 (EPR 3). Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health; 2007. NIH Publication No. 08-4051.
2. The American Lung Association Asthma Clinical Research Centers. Randomized comparison of strategies for reducing treatment in mild persistent asthma. N Engl J Med 2007;356:2027-2039.
3. Boushey HA, Sorkness CA, King TS, et al. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med 2005;352:1519-1528.
4. Papi A, Giorgio GW, Maestrelli P, et al. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med 2007;356:2040-2052.
5. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2007;59:94-99.
6. Miller MR, Hankinson J, Brusasco V, et al. Series ATS/ERS Task Force: Standardization of lung function testing. Eur Respir J 2005;26:319-338.
7. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. N Engl J Med 2005;26:948-968.
8. Global Initiative for Asthma. Pocket guide for asthma management and prevention. Bethesda, Md: National Institutes of Health; 2006.
9. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19(2):246-251.
10. Johnson DH, Robart P. Inhaler technique of outpatients in the home. Respir Care 2000;45(10):1182-1187.
11. Elliott RA. Poor adherence to anti-inflammatory medication in asthma reasons, challenges, and strategies for improved disease management. Dis Manage Health Outcomes 2006;14(4):223-233.Top of Form