Download State of asthma and allergies in Canada from the reference point of

State of asthma and allergies in
Canada from the reference point of
a family practitioner
Alan Kaplan MD CCFP(EM) FCFP
Chair, FPAGC
Family Physician, Richmond Hill, Ontario
Objectives
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•
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What are the asthma statistics?
What do we aim for in Asthma management?
Why don’t 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 Care
• People with asthma present to a variety of
places:
– Primary care physicians
– Pharmacists
– Nurse practitioners
– Pediatricians
– Respiratory specialists
– Allergists
– Alternative care practitioners
There 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
Men
Women
% of asthma patients
50
37.6
40
30
26.5 28.2
27.6
16.9
20
19.8
8
10
9.4
5
7.6
0
Wheezing
Chest
tightness
Manfreda J, et al: CMAJ 2001; 164(7):995-1001.
Nocturnal
dyspnea
Nocturnal
cough
Asthma
medication
Are you in Asthma control?
Actual vs. perceived asthma control
47
53
97
88
90
Patients
GPs
Specialists
N=893
N=386
N=77
Controlled N=418
Not controlled N=474
47
Actual control by
patients
Fitzgerald 2005
Patient expectation can be raised
Percentage of respondents who said that they were very satisfied with the
standard of their asthma management,
before and after being shown international guidelines
Before
After
0
10%
20%
30%
40%
50%
60%
“That can’t be right. My treatment doesn’t do that”
Haughney 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 visit
• Ensure you are using your inhaler device
properly
• Ensure that you have an asthma action plan
• Review comorbid conditions that can affect
asthma (rhinitis, sinusitis, GERD, obesity)
• Review any fears/concerns you have regarding
your asthma medications
Can you see why this patient has
uncontrolled Asthma?
What can you do?
• Go and see your doctor about your asthma
• Make it a priority, not one of a dozen things you go to
talk to them about
• It 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 regularly
• Deal with your environmental triggers
• Ensure that you have had at least one breathing test
(spirometry)
• Have an Asthma Action Plan
Asthma treatment plan is easy to follow?
Patients
Total N=496
98
Controlled
N=207
99
Not controlled
N=289
Fitzgerald 2005
98
Stop smoking, really!!
The problem of nonadherence in healthcare
WHO report 2003:
• Estimated that between 30 -50%
medicines prescribed for long term
illnesses are not taken as directed
• If prescription was appropriate then
this represents a loss for patients,
and healthcare providers
• Effective interventions are elusive
(Haynes et al 1996, 2003)
The necessity-concerns framework and
adherence
Low adherence
Doubts about
NECESSITY
CONCERNS
about potential
adverse effects
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)
Profile of concerns about ICS
Patients (%) endorsing individual concerns
51%
Long-term effects
40%
Dependence (2 items)
30%
Is harmful
27%
Having to use it w orries me
24%
Will be less effective if used regularly
16%
Have not received enough information
14%
Gives me unpleasant side-effects
13%
Should stop treatment now and again
This inhaler disrupts my life
9%
Is a mystery to me
8%
Does more harm than good
R Horne University of Brighton 2004
2%
How can you prevent asthma in your
kids?
• Controversial stuff!
Smoking – primary prevention
• All pregnant women
should be advised not
to smoke
• Exposure to ETS
independent risk factor
for allergic sensitization
• In occupational health
cigarette smoking may
increase risk of asthma
Image http://vienna-doctor.com/ENG/Articles_ENG/smoking_in_pregnancy.html
Breast feeding – primary
prevention
•
Halken (2004) concludes breast feeding
should be encouraged for at least 4-6
months
•
Conflicting evidence
– Probably 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-babygirl-three-3-days-old-closeup-2-DHD.jpg.html
House dust mite
• Multifaceted 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
causative
• The 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.
Summary
• See your physician or educator
• Aim for proper control
• Vaccinate..new indication for pneumonia
vaccination in all asthmatics (as well as flushot!)
• Have someone watch your technique
• Control your environment, where possible