State of asthma and allergies in Canada from the reference point of a family practitioner

State of asthma and allergies in Canada from the reference point of a family practitionerAlan Kaplan MD CCFP(EM) FCFPChair, FPAGCFamily Physician, Richmond Hill, Ontario

ObjectivesWhat are the asthma statistics?What do we aim for in Asthma management?Why dont we get it?Adherence!Primary prevention, does it exist?

Where are we (Ontario data)?

Is Asthma getting better?

Incidence rates falling in the very young

Hospitalizations falling

But ER visits seem to continue

And there are still hospitalizations!

But, less claims for Physician visits

In Primary CarePeople with asthma present to a variety of places:Primary care physiciansPharmacistsNurse practitionersPediatriciansRespiratory specialistsAllergistsAlternative care practitionersThere are guidelines for management

MD Lougheed, C Lemiere, FM Ducharme, et al; Canadian Thoracic Society Asthma Clinical Assembly. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012;19(2):127-164.Management of Asthma in Canada

Manfreda J, et al: CMAJ 2001; 164(7):995-1001. A 2001 survey of asthma in Canada quantified symptoms and treatment of 21 449 patients in centres from coast to coast. The investigators found that there were significant percentages of patients reporting symptoms of uncontrolled asthma (i.e., nocturnal symptoms, wheezing), but that only a small percentage of patients had been taking medication over the previous 12 months.These findings illustrate a treatment gap in the management of asthma.

Reference:Manfreda J, Becklake MR, Sears MR, et al: Prevalence of asthma symptoms among adults aged 20-44 years in Canada. CMAJ 2001; 164(7):995-1001. Are you in Asthma control?

Actual vs. perceived asthma controlFitzgerald 2005N=893 N=386N=77

47978890Actual control bypatientsPatientsGPsSpecialists

Patient expectation can be raised That cant be right. My treatment doesnt do that

BeforeAfter020%50%40%60%30%10%Percentage of respondents who said that they were very satisfied with the standard of their asthma management,

before and after being shown international guidelinesHaughney J, Barnes G, Partridge M, Cleland J. The living and breathing study: a study of patients views of asthma and its treatment. Primary Care Respiratory J. 2004; 13: 28-35.What can we (family docs) do?Ask about asthma control every visitEnsure you are using your inhaler device properlyEnsure that you have an asthma action planReview comorbid conditions that can affect asthma (rhinitis, sinusitis, GERD, obesity)Review any fears/concerns you have regarding your asthma medicationsCan you see why this patient has uncontrolled Asthma?

What can you do?Go and see your doctor about your asthmaMake it a priority, not one of a dozen things you go to talk to them aboutIt is not about just getting a blue rescue inhaler that you ran out of!Understand that you need to have good asthma control!Take your preventative medications regularlyDeal with your environmental triggersEnsure that you have had at least one breathing test (spirometry)Have an Asthma Action PlanAsthma treatment plan is easy to follow?Patients

Fitzgerald 2005

Stop smoking, really!!

The problem of nonadherence in healthcareWHO report 2003:Estimated that between 30 -50% medicines prescribed for long term illnesses are not taken as directedIf prescription was appropriate then this represents a loss for patients, and healthcare providersEffective interventions are elusive (Haynes et al 1996, 2003)

21But, as a recent report by the WHO has identified between one third and a half of medicines prescribed for long-term illness are not taken as directed.

If we assume that the prescription was appropriate then this level of non-adherence is a concern for those, receiving, providing or funding care because it not only entails a waste of resources but also a missed opportunity for therapeutic benefit and health gain.

Low adherenceDoubts aboutNECESSITYCONCERNS about potential adverse effectsThe necessity-concerns framework and adherence

asthma (Horne & Weinman, 2002), renal disease (Horne, et al 2001), renal transplantation (Butler et al 2004) cancer and coronary heart disease (Horne & Weinman, 1999), hypertension (Ross et al 2004), HIV/Aids (Horne et al., 2001), haemophilia (Llewellyn, et al, 2003), depression (Aikens et al 2005)& rheumatoid arthritis (Neame & Hammond, 2005) 22Profile of concerns about ICSPatients (%) endorsing individual concerns

R Horne University of Brighton 200423How can you prevent asthma in your kids?Controversial stuff!Smoking primary preventionAll pregnant women should be advised not to smokeExposure to ETS independent risk factor for allergic sensitizationIn occupational health cigarette smoking may increase risk of asthma

Image http://vienna-doctor.com/ENG/Articles_ENG/smoking_in_pregnancy.html

Breast feeding primary preventionHalken (2004) concludes breast feeding should be encouraged for at least 4-6 months

Conflicting evidenceProbably protective against asthma risk overall, and in children with a family history of atopy (Goalevich 2001)Protective effect against wheezing strongest in non-atopic children, and this effect mainly due to prevention of wheezing during viral respiratory infections. (Burr 1993, Wright 1995) Breastfeeding may be associated with an increased risk of asthma development in older children and in adult life (Wright 1995, Sears 2002)

Image http://mirror-au-wa1.gallery.hd.org/_c/baby/_more2005/_more12/breastfeeding-breast-feeding-suckling-newborn-baby-girl-three-3-days-old-closeup-2-DHD.jpg.html

House dust miteMultifaceted environmental interventions that include dietary and house dust mite avoidance components reduced asthma symptoms and atopic sensitization at 8 years (Arshad 2003)

House dust mite avoidance measures comprise part of the management of HDM allergic children (Halken 2004)

Techniques: washing bedding in very hot water, freeze of fry them,

Image http://www.topsleep.co.uk/images/images/images_hdm.jpg

Pets

Not able to make a clear recommendation

Is dose of allergen important? A lot of cat early may be protective, but a little bit of cat may be causativeThe CHILD Study has recruited over 3500 families !Expectant mothers, most of whom in their second trimester, have been recruited from the general population in several areas in Canada including: Vancouver, British Columbia; Edmonton, Alberta; Manitoba (Winnipeg and 2 rural sites); and Toronto, Ontario. The children and their mothers are monitored throughout the remainder of pregnancy and until the babies reach 5 years of age. All children will be clinically assessed at: delivery, at a 3-month home visit, and at ages 1, 3, and 5 years.Home assessment with dust sample collection at 3 months is complemented by repeated detailed environmental questionnaires from pregnancy to age 5. Anthropometric measures, pulmonary function and viral infections are assessed longitudinally.

SummarySee your physician or educatorAim for proper controlVaccinate..new indication for pneumonia vaccination in all asthmatics (as well as flushot!)Have someone watch your techniqueControl your environment, where possible

Chart70.0240.0780.0850.1330.1410.1570.2440.2740.2960.4010.512

Sheet1I use only as a reserve13%I stop altogether21%Do not take regularly25%Do not follow the label29%Aviod if I can31%Only when breathless37%Take only when needed51%I forget54%Does more harm than good2%Is a mystery to me8%This inhaler disrupts my life9%Should stop treatment now and again13%Gives me unpleasant side-effects14%Have not received enough information16%Will be less effective if used regularly24%Having to use it worries me27%Is harmful30%Dependence (2 items)40%Long-term effects51%

Sheet1

Sheet2

Sheet3