Asthma Rates Are Going Up. Time to Think About Other Approaches to Care

Peak Flow Meter

According to the CDC's Morbidity and Mortality Report (MMWR), the prevalence of asthma in the United States has increased from 7.3% (20.3 million persons) in 2001 to 8.2% (24.6 million persons) in 2009.  Just over half of these individuals (52.6%) have had at least one asthma attack, and of these, 42% (or 4.6 million) have lost a day of school or work in the course of a year.  Of all persons with asthma, only 42% have been taught to use a peak flow meter and only 34% have an action plan.

This is important because widely accepted asthma treatment guidelines recommend that a peak flow meter be made available to patients with asthma so that they can detect subtle changes in air flow which could herald an asthma attack.  In addition, a written asthma "action plan" should be prepared so that patients with asthma know what to do if their symptoms spiral out of control.  Those are two key interventions that could significantly reduce the huge number of school and work days lost described above.

Unsurprisingly, the MMWR report ignores all that and ends with a bland call for programs that "empower" persons with asthma, address gaps in access to care, support preventive measures, promote self-management education and expand reimbursement for asthma education.

That may sound good, but it ain't happening.  It doesn't take an epidemiologist to conclude that there is absolutely no chance that the current one-on-one health care system is going to educate more than 10 million persons with asthma about peak flow meters or action plans.  There are not enough physicians, physician assistants, nurse practitioners, appointments, office visit minutes, patient centered medical homes or integrated delivery systems to handle it all.

Given the rising rates of asthma, what other options are out there?  Maybe it's time to get serious about virtual clinics, turbo-charged community based organizations, remote telephonic coaching including cellphones as well as web-based interactions with monitoring. School budgets are being cut back, but asthma may be a reason to keep school nurses around as an option for children and adolescents.  Perhaps lay people can be asthma educators.  Social media such as Twitter may also be able to play a role.

The good news is that the population health and disease management industry, in partnership with insurers, primary care, the medical home community and employers, is already working on these and other new approaches to caring for asthma.  As experience with them grows, the DMCB is looking forward to reading about their positive outcomes.  They'll not only be reported on this blog, but who knows... maybe they'll even be a topic of a future edition of MMWR.

Long Acting Beta Agonist Inhalers 'CAUSE' Asthma? The DMCB Explains and Reviews the Implications for Disease Management

A Food and Drug Administration (FDA) expert panel has recommended that the ‘long acting beta agonist inhalers Foradil and Serevent no longer be approved for treatment of asthma. Apparently they can cause asthma. Drugs that treat asthma can cause asthma? How can this be true? And what are the implications for disease management?

The Disease Management Care Blog at your service!

First of all, “beta agonists” are a type of drug that works by activating “beta receptors.” Receptors are a type of protein that sits on the external surfaces of cells. There are many different types of receptors that stick out from the surfaces of individual cells in the human body, each of which has a different function and each of which lead to a cascade of chemical signals on the inside of the cell. This in turn leads to changes in cell function. The DMCB thinks these receptors were named “beta” because they were the second type of receptor that scientists discovered after they found the ‘alpha receptors.’

Think of this as a lock (the receptor) and a key (the agonist*). The human body uses these receptor-‘locks’ to orchestrate responses to changes in the external environment. For example, epinephrine is one of many agonist-‘keys’ that are transported via the bloodstream throughout the body. A boost in epinephrine levels causes stimulation of beta receptors in the body, which prompts cells to act. In the case of the muscle cells that line the airways of the lung, the cells relax, which causes the airways to dilate. That makes sense, because if you are in a situation that is physically stressful, you want your lungs to be wide open.

The problem? Scientists have known for decades that when beta receptors are stimulated repeatedly and excessively, human cells ‘uncouple’ them from the cells’ internal machinery and remove them from the surface of the cell. There are beta receptors in the heart, for example, and repeated doses of epinephrine-like drugs over days of treatment become less effective. Among persons with asthma, the impact of epinephrine inhalers can also decrease. In other words, beta agonist drugs work great at first, but with time, they can become less and less effective. This loss of effectiveness is far more likely to occur if large and repeated doses are used over many days.

Asthma is a condition in which inflammation of the air passages causes the muscles that surrounds those air passages to go into spasm. Inhaled beta agonist drug mists cause those muscles to relax. The good news is that small, judicious doses of beta agonists do not cause loss of effectiveness. The bad news is that asthma is a variable disease and beta agonists may not be enough for a bad attack. There is a temptation among doctors and patients to increase doses of the beta agonist drug when symptoms are getting worse, which leads to poor receptors which can lead to a paradoxical loss of effectiveness.

Check out this report from the New England Journal of Medicine from as far back as 1992 that showed that beta agonists were associated with increased asthma death rates. In this instance, there were over 12,000 asthma patients and 129 died from an asthma related death. The odds were very small, but death seemed to be associated with the ‘regular’ use of the beta agonist. Think of it this way: beta agonist treatment leads to improvement in most persons with asthma, but a small fraction of persons will be exposed to excessive doses, leading to loss of disease control and death.

What about ‘long acting’ beta agonists? These drugs were just recently invented and are chemically formulated to resist metabolism, which means they stick around longer. That means patients don't need to use them as often, which is good. Recall that repeated stimulation of beta receptors can cause dwindling of effectiveness, so long acting beta agonists could theoretically be worse than their shorter acting and older cousins. Research scientists were looking for that side effect in this study and found that there was a small increase in deaths. There were about 10 excess deaths among more than 26,000 patients.

The FDA says that there are clinical trials that show that if you are going to use a long acting beta agonist inhaler, it should be paired with a drug that reduces inflammation. By reducing the inflammation, the airways are more likely to respond to the agonist which reduces the chance of repeated dosing and the paradoxical loss of effectiveness. The opposite may be true also: use of the long acting beta agonist drug may permit the use a lower dose of the anti-inflammatory drug. These are steroids, which may have their own problems including osteoporosis and eye problems such as cataracts and glaucoma.

What does the DMCB think about all this?

1. The mechanism behind the paradoxical loss of effectiveness from over-stimulation of beta receptors have been known about for a long time. Smaller judicious doses are safe.

2. While the excess death rate from long acting beta agonists is small, it’s real and it’s been known about for a long time. Adding an anti-inflammatory medicine makes sense. Using both medications makes the risk of each lower.

3. The DMCB suspects asthma disease management organizations were already managing this risk during the course of their coaching and patient education. That was true in the DMCB’s former life when it was helping to run a disease management organization. Too bad there don’t appear to be any publications about it (do any readers know otherwise?)

4. If you are working for a disease management organization while you are reading this the day after the FDA announcement, ask yourself if your company is currently telephoning all the persons on just a long acting beta agonist inhaler to help them switch one that also contains an anti-inflammatory component. If not, maybe you should be.

5. If you are working in a medical home and have an electronic medical record that lists everyone’s diagnosis and medications, ask yourself if your clinic is currently telephoning all the persons on just a long acting beta agonist inhaler to help them switch to one that contains an anti-inflammatory component. If not, maybe you should be.

* as an aside, there are drugs that can block receptors, causing them to be inactivated. These dummy keys are called 'antagonists.' Now you know how beta blockers got their name.

Pursuing Weight Loss Among Obese Asthma Sufferers: Time for Disease Management Organizations to Step Up

Most physicians are well aware of the association between obesity and asthma. While persons with obesity may complain of shortness of breath or have altered lung function because of their anatomy, it's been clear for a long time that there's more to the story. Genes promoting both may occur together, leading to a disposition to develop both diseases. Obesity provokes a systemic "inflammatory" state which may involve the airways leading to bronchospasm. Increased levels of leptin may also lower the threshold for airways to become reactive. Dietary factors may be responsible for both the increase in asthma incidence as well as the development of obesity. Persons with obesity tend to be more prone to gastroesophageal reflux, which can also provoke airway irritation and asthma.

Just because there is an association, however, doesn't necessarily mean one causes the other. Yet, that just may be the case here. Obesity tends to predate the development of asthma and there have been reports that reductions in body weight tend to lead to a reduction in asthma severity. Obesity may be guilty as charged.

The likely causal link and the benefit from weight loss should be of great interest to disease management organizations. They're probably on the phone right now asking thousands of enrollees if they are using their peak flow meters, if they have access to a rescue plan and if they are being compliant with their inhalers. The association of obesity and asthma, however, probably hasn't been enough for the DMOs to start asking about their asthma enrollees' BMI and, if obesity is present, readiness to enter a weight loss program.

Well, maybe after reading this article by Eneli and colleagues, it may be time to pursue obesity as a modifiable risk factor in asthma care management and start asking patients about weight. Eneli et al performed a literature review and found there are 15 studies on the topic and all have shown an improvement in at least one asthma outcome measure when there was obesity-reducing weight loss.

The Disease Management Care Blog recognizes that purists would argue that a prospective randomized clinical trial comparing weight loss to no weight loss among asthma sufferers is necessary first, preferably using an outcome of interest (for example, emergency room utilization) to the DMOs. Others may wish to wait until organizations such as the NQF or the NCQA get around to establishing weight loss among persons with asthma one of their measures. Or maybe they're hoping that the managed care organizations they contract with don't bring it up.

The DMCB disagrees. The causal link between obesity and asthma makes too much sense to wait. Asking height and weight among persons with asthma is a start (if medical records are not readily available). If the BMI is elevated, an assessment of readiness to change lifestyle may be warranted. If the patient is ready, DMOs have programs available that can help, or the physician can be alerted, or the patient can be referred.