Key factors associated with uncontrolled asthma - the Asthma Control in Latin America Study.

Objective: This study aimed to estimate asthma control at specialist treatment centers in four Latin American countries and assess factors influencing poor asthma control.Methods: Patients aged ≥12 years with an asthma diagnosis and asthma medication prescription, followed at outpatient specialist centers in Argentina, Chile, Colombia, and Mexico, were included. The study received all applicable ethical approvals. The Asthma Control Test (ACT) was used to classify patients as having controlled (ACT 20-25) or uncontrolled (ACT ≤19) asthma. Frequency and statistical tests were used to assess the association between hospital admissions/exacerbations/emergency department (ED) visits and uncontrolled asthma; multivariate logistic regression was used to assess the association of uncontrolled asthma with clinical/demographic variables.Results: A total of 594 patients were included. Overall controlled-asthma prevalence was 43.4% (95% confidence interval [CI]: 39.0, 47.4). Patients with uncontrolled asthma were more likely to be women (adjusted odds ratio [aOR]: 1.85; p = 0.003), non-white (aOR: 2.14; p < 0.001), obese (aOR: 1.71; p = 0.036), to have a low monthly family income (aOR: 1.75; p = 0.004), to have severe asthma (aOR:1.59; p = 0.26), and, compared with patients with controlled asthma, to have a higher likelihood of asthma exacerbations (34.5% vs. 15.9%; p < 0.001), hospital admissions (6.9% vs. 3.1%; p = 0.042), and ED visits (34.5% vs. 15.9%; p < 0.001) due to asthma.Conclusions: Even in specialist ambulatory services, fewer than half of patients were classified as having controlled asthma. The proportion of uncontrolled patients varied according to clinical and demographic variables.

Assessment of acute asthma severity in the ED: are heart and respiratory rates relevant?

BACKGROUND: Assessment of acute asthma severity in the emergency department (ED) determines the appropriate initial therapy. The aim of this study was to evaluate the usefulness of heart and respiratory rates as determinants of severity of asthma exacerbations. METHODS: It was a pooled analysis of individual patient data from different controlled clinical trials performed over a 9-year period. The sample was characterized by patients with a diagnosis of asthma, age 18 to 50 years, and a forced expiratory volume in the first second (FEV1) or a peak expiratory flow less than or equal to 50% of predicted at ED presentation. RESULTS: One thousand one hundred ninety-two severe acute asthmatics (age 33.9 ± 10.3 years and FEV1 = 27.4% ± 9.7%) were enrolled. Two-thirds of patients were categorized as having severe acute asthma (FEV1, 31%-50% of predicted) and the remaining third as life-threatening asthma (FEV1, ≤30% of predicted). There were no relationships between the intensity of airway obstruction as measured by the FEV1 and the degree of tachycardia (r = 0.05, P > .1) or tachypnea (r = 0.06, P > .1). Only 22% and 19% of the patients, respectively, met the heart rate and respiratory rate requirements for acute severe asthma (≥120/min and ≥25/min, respectively). In contrast to FEV1 and arterial oxygen saturation, baseline heart and respiratory rates did not predict admissions of patients at the end of treatment. CONCLUSIONS: This pooled analysis suggests a poor performance of heart and respiratory rates as determinants of acute asthma severity in the ED.

[Argentine guidelines for urticaria and angioedema]. / Guía argentina de urticaria y angioedema.

This interdisciplinary paper summarizes the news in the diagnosis and treatment of chronic urticaria (CU), and provides concepts, definitions and evidence-based suggestions for its management. Urticaria occurs in at least 20% of the population at some point in their lives. Acute urticaria (less than 6 weeks' duration), differs from CU in its etiology, but the onset of this disease is always acute. CU may occur as spontaneous (SCU) or induced (ICU). The diagnosis is simple, although a careful evaluation is necessary for differential diagnosis. ICU's diagnosis is mainly clinical, even if provocation tests can be useful. Supplementary studies should be limited and based on the clinical suspicion. Treatment may be divided into three approaches: avoidance, elimination or treatment of the cause, and pharmacological treatment. Recently treatment has been modified with the use of second-generation antihistamines as first-line and increased doses of nonsedating H1 antihistamines, up to 4 times, as second line. Antihistamines are essential to treat CU; however, 40% of patients do not achieve good control despite increased doses and require additional treatment. The most recent evidence indicates a group of drugs to be used as third line in these cases, to improve quality of life and to limit toxicity from frequent or chronic use of systemic steroids. Only 3 drugs are recommended as third line: omalizumab, cyclosporin A or anti-leukotrienes.

Guía Argentina de urticaria y angioedema

Se actualiza el diagnóstico de la urticaria crónica (UC) y los conceptos, definiciones y sugerencias basados en la evidencia para su tratamiento. La urticaria ocurre en al menos 20% de la población en algún momento de la vida. Su etiología difiere en la forma aguda (menos de 6 semanas), y en la crónica. No es posible pronosticar si las formas agudas evolucionarán a UC, ya que todas son agudas al comienzo. La UC ocurre como espontánea (UCE) o inducible (UCI). El diagnóstico es sencillo, pero incluye un minucioso estudio para descartar diagnósticos diferenciales; para UCI son útiles las pruebas de provocación en la caracterización y manejo. Los estudios complementarios se deben limitar y orientar según sospecha clínica. El tratamiento se divide en tres enfoques: evitación, eliminación o tratamiento del estímulo desencadenante o de la causa, y tratamiento farmacológico. Recientemente éste se modificó, con empleo de antihistamínicos de segunda generación como primera línea y aumento de dosis de antihistamínicos H1 no sedantes, hasta 4 veces, como segunda línea. Los antihistamínicos son fundamentales para tratar la UC; sin embargo, un 40% de los pacientes no logra un buen control pese al aumento de dosis y requiere otro medicamento adicional. La evidencia más reciente considera que un grupo de fármacos puede utilizarse como tercera línea en estos casos, para mejorar la calidad de vida y limitar la toxicidad por el uso frecuente o crónico de esteroides sistémicos. Se recomiendan para esta tercera línea solo 3 fármacos: omalizumab, ciclosporina A o antileucotrienos.

This interdisciplinary paper summarizes the news in the diagnosis and treatment of chronic urticaria (CU), and provides concepts, definitions and evidence-based suggestions for its management. Urticaria occurs in at least 20% of the population at some point in their lives. Acute urticaria (less than 6 weeks' duration), differs from CU in its etiology, but the onset of this disease is always acute. CU may occur as spontaneous (SCU) or induced (ICU). The diagnosis is simple, although a careful evaluation is necessary for differential diagnosis. ICU´s diagnosis is mainly clinical, even if provocation tests can be useful. Supplementary studies should be limited and based on the clinical suspicion. Treatment may be divided into three approaches: avoidance, elimination or treatment of the cause, and pharmacological treatment. Recently treatment has been modified with the use of second-generation antihistamines as first-line and increased doses of nonsedating H1 antihistamines, up to 4 times, as second line. Antihistamines are essential to treat CU; however, 40% of patients do not achieve good control despite increased doses and require additional treatment. The most recent evidence indicates a group of drugs to be used as third line in these cases, to improve quality of life and to limit toxicity from frequent or chronic use of systemic steroids. Only 3 drugs are recommended as third line: omalizumab, cyclosporin A or anti-leukotrienes.

Asthma mortality, inhaled steroids, and changing asthma therapy in Argentina (1990-1999).

BACKGROUND: The asthma managing strategy has evolved and inhaled corticosteroids (ICS) are now the cornerstone of asthma treatment. Their effect on symptoms and exacerbations are well ascertained, whereas their effects on asthma mortality are still matter of debate. This ecological study evaluated asthma mortality rates and drug sales in the decade 1990-1999 in Argentina. METHODS: Mortality (overall and adjusted for 5-34 years) was obtained from the Argentinean Epidemiological Institute, and data on the sales of antiasthma drugs were provided by the International Marketing Survey. RESULTS: There was a significant change in drug sales in the spanned period: ICS +479%, inhaled beta2 agonists +32%, theophylline -63%. The crude and adjusted mortality rates were 3.38 and 0.72 in the 1980-1989 decade, and 2.58 (P<0.05) and 0.38 (P<0.01) in the subsequent one. There was inverse correlation between inhaled corticosteroid sale and age-adjusted (5-34) asthma mortality (r=-0.84; P=0.003), and the same with global mortality rates (r=-0.81; P=0.005). A positive correlation was also seen between theophylline sales and mortality. CONCLUSION: The increased sale of ICS and possibly the decrease of theophylline use seem to be the more relevant factors associated with decreased asthma mortality in Argentina.