New Severe Asthma Guidelines Recommend FeNO Monitoring

If your patients end up on high dose asthma therapy or have frequent exacerbations, reassessment is needed.  Exhaled nitric oxide testing provides a method for non-invasive point of care assessment for asthma and asthma control and can help direct therapy for severe asthma.  The latest iteration of GINA guidelines acknowledges this. Dr. Susarla

In a significant advancement in the treatment of severe asthma, the latest diagnosis and management guide from the Global Initiative for Asthma (GINA) makes new recommendations for assessment tools.

The new guide now recommends fractional exhaled nitric oxide (FeNO) monitoring as an assessment tool to determine whether patients who are on high-dose inhaled corticosteroids or low-dose oral corticosteroids have residual inflammation.

In a statement accompanying the new guidelines, Dr. Helen Reddel, Chair of the GINA Science Committee and a research leader at the Woolcock Institute of Medical Research in Sydney, Australia, explained that difficult-to-treat and severe asthma are currently high priority due to their “physical, emotional and financial burden for patients and their families.”

 “Clinicians in both low and high income countries need practical advice about how to assess and treat patients for whom conventional asthma therapies don’t seem to be working, and about how treatment strategies, including biologic therapies if available, can be implemented into patient care,” Reddel said.

Utilizing FeNO measurements can provide a potential predictor of positive responses to anti-immunoglobulin E (anti-IgE) therapy for patients with severe, allergic asthma, and is a tool to identify refractory type 2 inflammation in patients on high-dose inhaled corticosteroids therapy.

“The new GINA guidelines build on an earlier US Agency for Healthcare Research and Quality (AHRQ) report in terms of the strength of FeNO as a practical tool that improves outcomes for asthma patients,” said David Acheson, Senior Vice President of US Commercial at Circassia Pharmaceuticals, Inc., a specialty pharmaceutical company focused on respiratory disease which announced the new recommendations on December 5.

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CPAP or Surveillance Device?

An unfortunate spin on an extremely useful technology that can strengthen doctor/patient relationship and improve sleep apnea outcomes when used properly.  Step off regulators!  Dr. Susarla

Last March, Tony Schmidt discovered something unsettling about the machine that helps him breathe at night. Without his knowledge, it was spying on him.

From his bedside, the device was tracking when he was using it and sending the information not just to his doctor, but to the maker of the machine, to the medical supply company that provided it and to his health insurer.

Schmidt, an information technology specialist from Carrollton, Texas, was shocked. "I had no idea they were sending my information across the wire."

Schmidt, 59, has sleep apnea, a disorder that causes worrisome breaks in his breathing at night. Like millions of people, he relies on a continuous positive airway pressure, or CPAP, machine that streams warm air into his nose while he sleeps, keeping his airway open. Without it, Schmidt would wake up hundreds of times a night; then, during the day, he'd nod off at work, sometimes while driving and even as he sat on the toilet.

"I couldn't keep a job," he said. "I couldn't stay awake." The CPAP, he said, saved his career, maybe even his life.

Read article here.

Excess Weight Increases Asthma Risk

Proximity to holidays purely coincidental.  Nonetheless, watch the pounds folks! Dr. Susarla

Children who are overweight or obese are at increased risk for asthma, researchers report.

A retrospective study, published in Pediatrics, included 507,496 children followed for an average of four years. None of the children had incidents of asthma before the start of the study.

The researchers divided the children into three groups: overweight, defined as the 85th to 94th percentile for weight; obese, the 95th percentile or higher; and normal weight, the 25th to 64th percentile.

The study controlled for age, race, health insurance, food allergies, medications and other factors, and found that compared with children of normal weight, the overweight were 17 percent more likely to have been given a diagnosis of asthma and to take an asthma medication. The obese were 30 percent more likely.

The researchers estimate that 23 to 27 percent of asthma cases in obese children can be attributed to the obesity itself. Among all the children, 10 to 13 percent of asthma cases were attributable to obesity.

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Does anesthesia in children cause developmental delay?

Many parents I counsel regarding need for flexible bronchoscopy hesitate when they realize anesthesia is involved, albeit even for a short procedure.  This study suggests risk may be exaggerated. Dr. Susarla

Young children who had surgical procedures with general anesthesia prior to primary school entry did not have an increased risk of detectable adverse neurodevelopment outcomes compared with their siblings who did not have surgery, according to a Canadian analysis.

After adjusting for confounding factors, no significant differences were found between exposed and unexposed children in early developmental vulnerability or in each of the major domains of the Early Development Instrument (EDI), a teacher-assessed measure of primary school readiness, reported James O'Leary, MD, and co-authors of the Hospital for Sick Children in Toronto, writing in JAMA Pediatrics.

"These findings further support that exposure to anesthesia and surgery in early childhood is not associated with detectable adverse child development outcomes," O'Leary told MedPage Today.

But "while the findings are generalizable to the majority of young children who have a single surgical procedure performed, it is still not known whether children with repeated or lengthy exposures to surgery and anesthesia are at increased risk of altered neurodevelopment," he added.

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Xyrem, narcolepsy therapy for adults AND children

Narcolepsy is debilitating.  In the right child with narcolepsy, sodium oxybate can be life changing.  Dr. Susarla


Sodium oxybate (Xyrem) has been approved by the US Food and Drug Administration (FDA) for the treatment of cataplexy and excessive daytime sleepiness in pediatric patients aged 7 to 17 years old with narcolepsy.

Sodium oxybate is a central nervous system depressant administered as an oral solution and can be given either alone or in combination with other central nervous system depressants. These can include opioid analgesics, benzodiazepines, sedating antidepressants or antipsychotics, sedating anti-epileptic drugs, general anesthetics, muscle relaxants, and/or illicit central nervous system depressants.

The recommended dose for sodium oxybate is 0.5 g/mL, which may only be dispensed to patients enrolled in the XYREM REMS Program because of the risk of serious outcomes that can occur from inappropriate prescribing, misuse, abuse, and diversion.

Narcolepsy resources:

narcolepsynetwork.org

healthysleep.med.harvard.edu/narcolepsy/resources

morethantired.com

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Welcome Dupixent!

When new anti-asthma biologics come to the door, always give them a welcome seat. Here is an anti- atopic dermatitis monoclonal antibody that also shuts down a key component of the allergy airway inflammation pathway, now a 12 and up asthma therapy.  Dr. Susarla

Dive Brief:

• Sanofi and Regneron have won an expanded U.S. approval for Dupixent in asthma, securing another indication for the biologic drug which the companies are counting on to deliver blockbuster sales. 
• On Friday, the Food and Drug Administration OK'd the drug for moderate-to-severe asthma patients with an eosinophilic phenotype, or with oral corticosteroid-dependent asthma regardless of phenotype, the companies said. The new indication adds to Dupixent's previously approved use for moderate-to-severe atopic dermatitis.
• Clinical results supporting the approval showed Dupixent cut severe asthma attacks by 67% compared to placebo in patients with high eosinophil counts. Among patients with lower levels of the inflammation marker, however, Dupixent did not separate from placebo in statistical comparison. 

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Digital Devices for Insomnia? Researchers say YES

Cognitive behavioral therapy is an intervention the incorporates coping strategies and behavioral modifications to treat a variety of conditions including insomnia.  When done properly it has been shown to be as effective as pharmacotherapy. Dr. Susarla

Digitally delivered cognitive-behavioral therapy not only improved insomnia, but also provided “around-the-clock” health, psychological, and quality-of-life improvements, according to investigators.

Compared with control subjects, patients who used a cognitive-behavioral therapy (CBT) program and associated iPhone app had small improvements in functional health and psychological well-being and large improvements in sleep-related quality of life, the investigators reported.

Those changes were mediated by a large improvement in insomnia, according to Colin A. Espie, PhD, professor of sleep medicine at the University of Oxford (England), and his colleagues.

“These findings indicate that digital CBT improves both daytime and nighttime aspects of insomnia, lending further weight to the clinical guideline recommendation of CBT as the treatment of choice for insomnia,” Dr. Espie and his colleagues reported in JAMA Psychiatry.

Their study included 1,711 adults with symptoms of insomnia that were self-reported and a score of 16 or less on the Sleep Condition Indicator (SCI), which has a range of 0-32. A total of 853 were randomized to receive digital CBT, of whom 413 completed six scheduled 20-minute sessions; an additional 276 adults completed at least one session. The control arm included 858 individuals randomized to sleep hygiene education, of whom 759 went on to receive that intervention.

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10 Treatable Traits That Could Predict Asthma Attacks

The science and art of predicting asthma risk may go beyond asthma symptoms and lung physiology and intersect with the presence of chronic disease. Dr. Susarla

With increasing attention on a “treatable traits”—a new classification and precision medicine strategy for asthma and other chronic airway diseases,1 a team of researchers set out to examine whether and which treatable traits could be identified from registry data in persons with severe asthma and used to predict the future risk of asthma exacerbations.2

In their study, published in the journal Respirology, the investigators recorded the prevalence of the treatable asthma traits of 434 participants with severe asthma and 102 participants with non-severe asthma, all of whom were enrolled in the Australasian Severe Asthma Web‐Based Database. The prevalence of participants’ treatable asthma traits were described. They assessed participants at the study’s outset and then every 6 months thereafter for 24 months.

Of the 24 treatable traits the researchers identified, 10 predicted exacerbation risk in the participants with severe asthma, with the 5 strongest as follows:

• Being prone to exacerbations
• Depression
• Inhaler device polypharmacy
• Vocal cord dysfunction
• Obstructive sleep apnea

“Treatable traits can be assessed using a severe asthma registry,” the authors concluded. “In severe asthma, patients express more treatable traits than non‐severe asthma. Traits may be associated with future asthma exacerbation risk demonstrating the clinical utility of assessing treatable traits.”

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Marijuana in E-Cigarettes: A Growing Public Health Concern Among US Youth

Popularity among youth for e-cigarette use has another dimension.  Will marijuana use with e-cigarettes increase proportionally?  Susceptible children and adolescents, including those with asthma are likely the highest risk.  Dr. Susarla

Among American students in grades 6 to 12, trying marijuana in e-cigarettes is common.1

According to new findings published in JAMA Pediatrics, the number of students who had used cannabis in e-cigarettes had reached an alarming 1 in 11 in 2016, including one-third of students who had ever tried e-cigarettes.

Moreover, approximately 1 in 3 middle-school students and about 1 in 4 high-school students identifying as e-cigarette users had experimented with cannabis in e-cigarettes at some point in their lives.

These statistics are a cause for concern, as neither cannabis nor e-cigarettes come without health hazards, said lead author Katrina Trivers, PhD, MSPH, from the Office on Smoking and Health at the Centers for Disease Control and Prevention in Atlanta, Georgia.

Dr Trivers recently shared her insights with Consultant360, explaining the effects of these substances on the young brain, factors that may perpetuate the cannabis/e-cigarette trend, and ways for physicians, parents, and policymakers to help address this issue.

Consultant360: Your study found that cannabis use in e-cigarettes is prevalent among middle and high school students. What factors do you think contributed to this finding?

Katrina Trivers: There are likely multiple factors that may be influencing the use of cannabis in e-cigarettes among our nation’s youth. The tobacco product landscape has changed in recent years, and e-cigarettes have become increasingly popular to the point where they have been the most commonly used tobacco product among youth since 2014. In recent years, many youths have also been using other psychoactive substances in e-cigarettes, including cannabinoids and other illicit drugs.

Young people may use cannabis for a variety of reasons, including curiosity, peer pressure, misperceptions that cannabis is harmless, as well as shifts in availability and opportunity as social norms and public policies related to cannabis have changed in recent years. Exposure to marijuana or other substance use through friends or family members may also cause the use of these products to be seen as more normative behavior. For example, our study found that youth who lived with a tobacco user were significantly more likely to use an e-cigarette with cannabis than those who did not live with a tobacco user.

C360: In your experience, what are some of the biggest misconceptions about the health-related effects of cannabis use, especially among youth?

KT: One of the biggest misconceptions is that cannabis use is harmless.

This is a public health concern because the use of any form of tobacco product is unsafe among youth, irrespective of whether it is smoked, smokeless, or electronic. The US Surgeon General has concluded that the aerosol emitted from e-cigarettes is not harmless. It can contain harmful ingredients, including nicotine, carbonyl compounds, and volatile organic compounds known to have adverse health effects.

The use of marijuana in these products is of particular concern because cannabis use among youth can adversely affect learning and memory and may impair later academic achievement and education.

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World Lung Day

Awareness about chronic lung conditions can help foster education and prevention strategies for both adult and pediatric disease. Dr. Susarla.

Statement of Harold P. Wimmer, National President and CEO of the American Lung Association, in response on World Lung Day, September 25, 2018, and in response to the pending vote on the declaration on the prevention and control of non-communicable diseases by the United Nations General Assembly:

“Today marks World Lung Day, a day that recognizes a fundamental truth: that breathing is essential to life. Unfortunately, millions of people around the world, including more than 33.6 million Americans, suffer from chronic lung diseases, making the essential act of breathing much more difficult.  The American Lung Association joins with others who have signed the Charter for Lung Health and pledge to continue to work to save lives by improving lung health and preventing lung disease.

“Today, we urge the United Nations to join us in this pledge. We urge the U.N. General Assembly at their meeting this week to adopt a declaration in support of efforts to reduce the burden of non-communicable lung diseases, such as asthma, chronic obstructive pulmonary disease (COPD), and lung cancer. We urge them to fully support measures to tackle the sources that cause or worsen these diseases, especially tobacco use, indoor and outdoor air pollution, and climate change. Too many people die each year from preventable diseases that these sources cause or exacerbate.  

“We have made progress in our fight against lung diseases, but millions of people face threats to their lung health every day, making it more difficult to breathe. We at the American Lung Association urge the United Nations to join in the fight to protect their health.”

Read article here.

Impulse Oscillometry: From Bench to Clinical Practice.

Impulse Oscillometry: From Bench to Clinical Practice.

Lung function testing is one of the pillars of care in childhood asthma.  There are few substitutes to actually measuring the way the lungs perform in an objective way.  However, testing in children is often very difficult to perform, making interpretation of the results even more difficult.

Airway resistance testing as performed using a technique known as impulse oscillometry (IOS) offers a convenient alternative.  This test takes seconds to perform and allows us to measure the reactivity in a child's airway WITHOUT forceful breathing maneuvers or breath holding.  These data are invaluable in diagnosing asthma especially in young children down to 3 years of age. In addition, it has been shown to help predict risk of exacerbations in children with known asthma.

One of the many benefits of care in a pediatric pulmonology office is focus on the latest and greatest diagnostic testing.  What was previously only a research tool is now available as a state-of-the-art test available in the clinic.  Ask about our impulse oscillometry testing in our Frostwood location.

From Vyaire Medical

Asthma and migraines connected?

To complicate matters, some migraine medication (beta-blockers) can interfere with asthma rescue inhalers and may worsen the disease process.  Dr. Susarla

Adolescents who have asthma or allergic rhinitis may be at higher risk for developing migraine, according to a study published in The Clinical Respiratory Journal.

Previous studies illustrated a relationship between asthma and migraines (primarily in adult populations). This large cross-sectional study also included the classification of specialist-diagnosed asthma and migraine.

Using data from the Israel Defense Forces recruitment database, study authors identified 113,671 adolescent draftees (n=66,547 young men; n=47,124 young women; all were 17 years old) diagnosed with asthma or migraine between 1987 and 2010. Investigators examined migraine prevalence in this cohort. Certified specialists in neurology and pulmonology, respectively, confirmed the diagnoses for migraine and asthma.

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