Microsoft word - notes dwp

TAKE-AWAYS FROM THE AMERICAN COLLEGE OF ALLERGY The emphasis on asthma treatment now is centering less on severity and more on assessment and maintenance of control. Spirometry, and in the future nitrous oxide quantification of exhalation, should be helpful in predicting which asthmatics will get into trouble in the next 18 months. Once Mannitol is available from Australia, this may be used as a replacement for methacholine challenges and to be used for the same purpose as spirometry and the exhaled nitrous oxide. It was found that patients with increased IgE may be better protected against loss of lung function when they take inhaled corticosteroids, as compared with those who have normal IgE levels. For the moderate asthmatic, the combination of a long-acting beta agonist and inhaled corticosteroid was superior to doubling the dose of inhaled corticosteroids or adding a leukotriene modifier to inhaled corticosteroids. An exciting observation was from Europe where they had a combination rescue inhaler (it had both albuterol and inhaled corticosteroid). This combination may allow acceptable control of asthma with less total inhaled corticosteroids over time. The combination of salmeterol plus fluticasone on a once a day basis allowed stepping down from twice the total dose of fluticasone given solo and this was done without any loss of asthma control. Allergic exposure and sensitization to perennial allergens in early childhood seemed to increase the chance of significant airway obstruction by school age. Seasonal allergens, however, do not seem to have this effect. More studies are needed to see if immunotherapy or inhaled corticosteroids at this age would be protective. A wait-and-see approach to antibiotics has been shown to lessen the use of antibiotics in acute otitis media with minimal changes in outcome. Similar studies are necessary for sinusitis. Studies in Europe, reported in the Journal of Clinical Allergy, note that amphotericin B lavages were of no benefit in chronic rhinosinusitis cases. 20% of anaphylactic patients experienced return of symptoms within 10 hours. It seems to be very important that there is aggressive management of the initial reaction and this may lessen the chances of a secondary or late phase reaction. An important observation was that those whose initial reaction took longer than 30 minutes to clear, are at a high risk of a delayed late phase reaction later. Studies on the inhalation of Asmanex in children showed that they must get greater than 30 liters per minute in order to activate the device and get it into their lungs. The use of the Pulmicort flow whistle can be used to make sure these patients have enough inhalation capability to get the medicine into their lungs. Hence, it can be used for both Pulmicort and Asmanex to make sure children have enough inspiratory velocity to inhale the medicine. The question raised at 1 session was "Does a local reaction to an allergy shot predict future reactions of equal or more severe quality in immunotherapy?" The findings were that the local reactions to immunotherapy are not predictive of future systemic reactions. Dose adjustments due to large locals are important so the patient does not become noncompliant to avoid a large swelling. The chance of a repeat large local reaction is 6 to 25%. If the patient had no reaction previously, they had a chance that the next dose 85% of the time would not have any reaction. Hence, the purpose of this was to show that dose adjustments for large locals create additional visits, cost and delay in attainment of the maintenance dose and delay in the onset of efficacy. A take-away from this discussion was that allergists should stop the practice of routinely adjusting for local reactions and instead focus on methods and treatment to prevent and relieve local reaction discomfort. The Mayo Clinic reported that regarding systemic reactions to allergy immunotherapy, there was no relationship to gender, asthma status, phase of either buildup or maintenance, beta blocker, ACE inhibitor medicines or initial skin prick test size in the patients they studied with systemic reactions. There is in development, a submicronic particle formulation of budesonide for nebulized treatment of children that is found to be effective and safe. The issue of obesity and increased asthma was discussed. It was found that gaining greater than 5 pounds in 1 year was associated with increased asthma flares, requirement of steroid bursts and worse quality of life in the severe patients with asthma. The combination of fluticasone plus salmeterol at 100/50 dose twice a day was found to be superior to doubling the dose of fluticasone (200 mcg b.i.d.) in asthmatic children. The take-away was that you can use half the inhaled corticosteroid dose for control if you combine it with salmeterol. The new form of fluticasone furoate nasal spray (Veramyst) has been recently released as the only once a day inhaled nasal steroid. It has a unique side-actuated chemical structure which seems to result in 24 hour efficacy regarding total nasal symptom scores. This was found to be better than fexofenadine and placebo in relieving nighttime nasal symptoms. Studies regarding nasal allergies in children demonstrated control of the nasal allergies, improved activity level and productivity in children. Control also improves sleep quality and daytime activity. Nasal sprays such as Nasonex and Veramyst were studied and neither showed mucosal atrophy in the nose and both showed decreased epithelial and subepithelial inflammatory cell infiltrate. Regarding ACE receptor blockers, there is a study showing that there is anywhere from a 0 to a 9% chance of angioedema with the use of that drug. A new treatment for Behcet's is the use of a TNF alpha blocker (etanercept). Emergency room studies were comparing high dose inhaled corticosteroids to prednisone in efficacy and it was shown that patients giving 16 puffs of budesonide in the emergency room had the equivalent effect of 30 mg of prednisone. New information from Dr. Tom Platts-Mills indicated that it is critical that when we recommend encasements for dust mites, that these are the high quality tightly woven encasements. The cheaper and less tightly woven encasements, allow dust mite penetration and fecal particle penetration. There are further studies on thunderstorm asthma which previously was felt to be due to submicronic particles of grass being split apart. Now they are finding additionally that Alternaria multiple particles seem to be possible association. There was a session discussing that the tailored intervention in asthma utilizing sputum eosinophils to assess the intensity of asthma seemed to be beneficial in reducing frequency of asthma exacerbation. A new surgical procedure called "bronchial thermoplasty" used in some of difficult asthma cases, seemed to show marked improvement in symptom control and asthma control during the year following this heat treatment to the bronchial muscle. A session on life-threatening asthma and fatal asthma found the following observations: -Prior hospitalization on mechanical ventilation. It was noted that ipratropium, Combivent and Duo-Neb can cause eye pupillary dilatation and narrow angle glaucoma. Hence, it is very important that these inhalers and nebulizations are not accidentally sprayed into the eyes. Inhaled corticosteroids alone are the best treatment for most children with asthma.

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