Prevention of Anaphylaxis: The Role of the Epinephrine Auto-Injector.

Anaphylaxis is a life-threatening condition, with at-risk individuals remaining at chronic high risk of recurrence. Anaphylaxis is frequently underrecognized and undertreated by healthcare providers. The first-line pharmacologic intervention for anaphylaxis is epinephrine, and guidelines uniformly agree that its prompt administration is vital to prevent progression, improve patient outcomes, and reduce hospitalizations and fatalities. Healthcare costs potentially associated with failure to provide epinephrine (hospitalizations and emergency department visits) generally exceed those of its provision. At-risk patients are prescribed epinephrine auto-injectors to facilitate timely administration in the event of an anaphylactic episode. Despite guideline recommendations that patients carry 2 auto-injectors at all times, a significant proportion of patients fail to do so, with cost of medicine cited as one reason for this lack of adherence. With the increase of high-deductible healthcare plans, patient adherence to recommendations may be further affected by increased cost sharing. The recognition and classification of epinephrine as a preventive medicine by both the US Preventive Services Task Force and insurers could increase patient access, improve outcomes, and save lives.

The 2nd National COPD Readmissions Summit and Beyond: From Theory to Implementation.

Chronic obstructive pulmonary disease (COPD) hospitalizations and readmissions adversely impact the health and quality of life of COPD patients. Under the Hospital Readmissions Reduction Program, the Centers for Medicare & Medicaid Services reduce payments to those hospitals exceeding expected rates of COPD readmissions within 30 days of hospital discharge. It was within this climate that the COPD Foundation held its 2nd COPD Readmissions Summit in March 2015. Experts in attendance: (1) categorized challenges to optimal COPD care, ( 2) analyzed the state of care delivery and readmissions reduction strategies and (3) identified the best available evidence-based approaches to improving care delivery across the continuum, including early diagnosis via spirometry, ongoing device, oxygen and medication reconciliation, treatment that addresses comorbidities and preventive care, robust patient education, prompt post-acute follow up, home health services and pulmonary rehabilitation. Results of this collaborative event formed the basis for PRAXIS, the COPD Foundation's initiative to improve COPD care across the health continuum and to reduce readmissions.

Hot Topics in Primary Care: Individualizing Inhaled Medications for Asthma and Allergic Rhinitis.

Inhaled medications are important treatment options for asthma and allergic rhinitis. Selecting among the different formulations and delivery devices is important as it impacts adherence and proper use, both of which affect health-related outcomes. The wide variety of inhalers now available allows individualizing inhaler selection.

Is there a rationale and role for long-acting anticholinergic bronchodilators in asthma?

Despite current guidelines and the range of available treatments, over a half of patients with asthma continue to suffer from poor symptomatic control and remain at risk of future worsening. Although a number of non-pharmacological measures are crucial for good clinical management of asthma, new therapeutic controller medications will have a role in the future management of the disease. Several long-acting anticholinergic bronchodilators are under investigation or are available for the treatment of respiratory diseases, including tiotropium bromide, aclidinium bromide, glycopyrronium bromide, glycopyrrolate and umeclidinium bromide, although none is yet licensed for the treatment of asthma. A recent Phase III investigation demonstrated that the once-daily long-acting anticholinergic bronchodilator tiotropium bromide improves lung function and reduces the risk of exacerbation in patients with symptomatic asthma, despite the use of inhaled corticosteroids (ICS) and long-acting ß2-agonists (LABAs). This has prompted the question of what the rationale is for long-acting anticholinergic bronchodilators in asthma. Bronchial smooth muscle contraction is the primary cause of reversible airway narrowing in asthma, and the baseline level of contraction is predominantly set by the level of 'cholinergic tone'. Patients with asthma have increased bronchial smooth muscle tone and mucus hypersecretion, possibly as a result of elevated cholinergic activity, which anticholinergic compounds are known to reduce. Further, anticholinergic compounds may also have anti-inflammatory properties. Thus, evidence suggests that long-acting anticholinergic bronchodilators might offer benefits for the maintenance of asthma control, such as in patients failing to gain control on ICS and a LABA, or those with frequent exacerbations.

Current Allergic Rhinitis Experiences Survey (CARES): Consumers' awareness, attitudes and practices.

Allergic rhinitis (AR) affects ~60 million people in the United States. This study evaluates awareness, attitudes, and behaviors of AR sufferers on the management of their condition. This U.S.-based survey evaluated 1600 adult AR sufferers to assess their perceptions of AR diagnosis, treatment preferences, and interactions with health care practitioners (HCPs). Two consumer groups of AR sufferers were assessed: users of over-the-counter (OTC) medications only (n = 1020) and users of prescription (Rx) ± OTC medications (n = 580). The Rx group included 451 intranasal steroid (INS) users. Eighty-two percent of respondents indicated that they require minimal to no HCP guidance to manage AR; 51% had not visited an HCP in the past 2 years. Eighty-six percent of respondents agreed that they can self-recognize AR symptoms, and 69% suspected allergies before diagnosis. On suspecting nasal allergies, 52% of sufferers purchased an OTC medication. Seventy-two percent of AR sufferers said they are likely to go to an HCP if symptoms persist after they tried multiple OTC options. Rx users perceived INSs to be more beneficial in treating AR and showed a high level of satisfaction (a score of 7.4 out of 10). Forty-eight percent of AR sufferers felt the need for more efficacious OTC medications to better manage their AR symptoms. This study indicated that AR sufferers perceive that they self-recognize AR symptoms and initiate their management with OTC options. The availability of OTC medications did not deter AR sufferers from visiting HCPs for advice when symptoms worsen. Nonetheless, more efficacious OTC options are still desired.

Current Allergic Rhinitis Experiences Survey (CARES): Health-care practitioners' awareness, attitudes and practices.

Allergic rhinitis (AR) is a common health problem in the United States, with significant comorbidities and impairment of quality of life despite the availability of many prescription (Rx) and over-the-counter (OTC) medications. The health-care practitioners (HCPs) arm of the Current Allergic Rhinitis Experiences Survey (CARES) assessed HCPs' perceptions about the current management of AR. This U.S.-based national survey included 375 primary care physicians and 375 nurse practitioners/physician assistants. Participants were screened to ensure that they treat ≥15 AR sufferers per month during allergy season. The majority of HCPs (86%) agreed that AR patients can easily recognize allergy symptoms after diagnosis and that 57% of their patients come to them self-recognizing their symptoms. A total of 82% strongly agreed that AR sufferers are primarily diagnosed via history and physical and do not typically undergo diagnostic testing until after pharmacologic intervention. HCPs reported that 63-77% of AR sufferers can easily manage AR once treatment is established. According to surveyed HCPs, OTC medication should precede an Rx medication for AR management. A total of 82% HCPs considered intranasal steroids (INSs) to be the gold standard AR treatment and have minimal safety concerns about INS use. HCPs perceive that patients can easily recognize and self-manage their AR symptoms. Patient history/symptoms and physical examination are the primary methods of AR diagnosis. INSs are considered the gold standard for treatment of AR. However, most HCPs feel OTC medication should be tried before Rx medication for AR management.

Anaphylaxis challenges on the front line: perspectives from community medicine.

This report reflects a discussion from the multidisciplinary Partnership for Anaphylaxis Round Table meeting, held in November 2012, in Dallas, Texas. Community medicine participants included John R. Bennett, MD, an internist who practiced in Cumming, Georgia, and whose patients were adults; Leonard Fromer, MD, a family practitioner in Los Angeles, California, who was the medical director of a network of 600 medical groups, including pediatricians, internists, and family physicians, and who in his previous practice treated children and adults, many of them with severe allergies; and Mary Lou Hayden, MS, RN, FNP-BC, AE-C, a nurse practitioner who treated adults in a university employee health clinic and in an allergy clinic in Charlottesville, Virginia, and whose prior practice focused on allergy and immunology in children and adults. This discussion was moderated by Dr Bennett. Participants provided their perspectives as primary care providers (PCPs) concerning anaphylaxis, which has become a major public health concern. The rising prevalence of severe allergies and incidence of anaphylaxis and other severe allergic reactions among children and adults is shifting more care to PCPs. This discussion provides insights into challenges faced by PCPs in treating patients at risk for anaphylaxis in the community setting and provides potential solutions to those challenges.

Insights on allergic rhinitis from the patient perspective.

Although intranasal steroid sprays are the preferred treatment of the majority of health care providers, this opinion is not carried through to patient treatment. Approximately two-thirds of adults with nasal allergy symptoms report that they use over-the-counter, nonprescription medicines, and only one-third report that they use an intranasal steroid spray. Lack of familiarity and poor patient awareness are key barriers to intranasal steroid spray use. Dissatisfaction related to side effects among users of these medications leads some of those who are familiar with intranasal steroid sprays to discontinue use after it has been prescribed. Improved health care provider­patient communication and education is a vital step toward improving the long-term management of allergic rhinitis.

Reconsidering sex-based stereotypes of COPD.

Chronic obstructive pulmonary disease (COPD) has historically been considered a disease of older, white, male smokers, as illustrated in Frank Netter's classic images of the 'pink puffer' and 'blue bloater'. However, women may be more susceptible to COPD than men, and the disease course may be reflective of that increased susceptibility. From a review of epidemiological data of COPD, we found differences in the way men and women present with COPD symptoms, a bias in the way COPD symptoms are treated in men and women, and differences in susceptibility to airway obstruction based on age, sex, and smoking history. These data show that classic stereotypes of COPD - including male predominance - should be abandoned, and that there are not two but multiple COPD phenotypes, which are characterised by differences between women and men in susceptibility, symptoms, and disease progression. These differences impact on physician perception. Although further research into this concept is needed, the differences we found should prompt, in the short term, changes in the way (and in whom) COPD is evaluated, diagnosed, and treated; in the long term, these differences should prompt research into the prognosis of COPD based on sex differences.

Managing asthma: an evidence-based approach to optimizing inhaled corticosteroid treatment.

Asthma is a chronic disease characterized by airway inflammation and hyperresponsiveness and is associated with significant yet avoidable mortality and morbidity resulting in considerable individual and societal burden. Inhaled corticosteroids are the most effective class of controller medication available today for treating persistent asthma and are the evidence-based guideline-recommended first-line treatment for controlling asthma. Although inhaled corticosteroids have proven to reduce asthma-related exacerbations that lead to hospitalizations and death, recent studies have shown that only a small percentage of patients receive appropriate treatment and monitoring for their asthma. Delivering optimal asthma management requires an understanding and application of basic science and evidence-based guidelines in clinical practice. Management of a chronic disease in the primary care setting requires overcoming several barriers due to competing priorities and time constraints of the physician, as well as the reluctance of patients to actively participate in their own care. However, evidence has shown that the patient-centered medical home model can overcome some of these issues and improve patient outcomes and adherence to therapy.

Improving diagnosis and management of alpha-1 antitrypsin deficiency in primary care: translating knowledge into action.

Alpha-1 antitrypsin (AAT) deficiency is an established genetic risk factor for pulmonary disease and may lead to severe emphysema. Despite accessible, inexpensive, and straightforward testing procedures, the disorder is still widely undiagnosed due mainly to a lack of awareness among the medical community. AAT deficiency often results in the development of non-specific respiratory symptoms that can be confused with those of other non-hereditary chronic obstructive pulmonary disease or asthma. However, there are published guidelines that provide detailed recommendations on patient testing. Early diagnosis of AAT deficiency is fundamental to improve patient outcomes; it allows preventive measures to be taken, such as smoking cessation, and allows monitoring and initiation of appropriate therapy while lung function is still relatively preserved. Diagnosis should not solely be the domain of the specialist pulmonologist; testing can be easily initiated in the primary care setting. The establishment of process maps and diagnosis algorithms, as suggested in this review, should encourage appropriate suspicion, testing, and follow-up of AAT deficiency in the patient's primary care medical home setting. Primary care physicians have a key role in increasing the awareness, diagnosis, and effective management of this disorder.

Treatment of congestion in upper respiratory diseases.

Congestion, as a symptom of upper respiratory tract diseases including seasonal and perennial allergic rhinitis, acute and chronic rhinosinusitis, and nasal polyposis, is principally caused by mucosal inflammation. Though effective pharmacotherapy options exist, no agent is universally efficacious; therapeutic decisions must account for individual patient preferences. Oral H(1)-antihistamines, though effective for the common symptoms of allergic rhinitis, have modest decongestant action, as do leukotriene receptor antagonists. Intranasal antihistamines appear to improve congestion better than oral forms. Topical decongestants reduce congestion associated with allergic rhinitis, but local adverse effects make them unsuitable for long-term use. Oral decongestants show some efficacy against congestion in allergic rhinitis and the common cold, and can be combined with oral antihistamines. Intranasal corticosteroids have broad anti-inflammatory activities, are the most potent long-term pharmacologic treatment of congestion associated with allergic rhinitis, and show some congestion relief in rhinosinusitis and nasal polyposis. Immunotherapy and surgery may be used in some cases refractory to pharmacotherapy. Steps in congestion management include (1) diagnosis of the cause(s), (2) patient education and monitoring, (3) avoidance of environmental triggers where possible, (4) pharmacotherapy, and (5) immunotherapy (for patients with allergic rhinitis) or surgery for patients whose condition is otherwise uncontrolled.

Customizing inhaled therapy to meet the needs of COPD patients.

Chronic obstructive pulmonary disease (COPD) is a progressive disease characterized by airflow limitation resulting from emphysema and chronic bronchitis. Inhaled therapy is the major therapeutic approach for treating COPD. Multiple inhaler medications are available in the United States and are delivered by a variety of different devices: metered-dose inhalers, dry powdered inhalers, and nebulizers. Each inhaler device has unique requirements for use that must be correctly performed by the patient for successful drug delivery. Patients with COPD represent a medically diverse population, with each patient having distinct characteristics, such as lung function, comorbidities, cognitive functions, hand strength, and lifestyle. These characteristics impact the patient's ability to properly use specific inhaler devices and therefore affect adherence to therapy, therapeutic outcomes, and quality of life. It is estimated that between 28% to 68% of patients do not use metered-dose inhalers or dry powder inhalers correctly. Worsening symptoms or increased frequency of exacerbations may not always indicate disease progression but may indicate a patient's inability to use their inhaler device properly. This review discusses the patient- and device-specific factors to be considered when choosing an inhaled therapy, which will be concordant with the patient's medical needs, preferences, and lifestyle. The review also considers how the ideas underlying the patient-centered medical home model can be incorporated into the choice and use of inhaler device for a given patient with COPD to improve treatment outcomes.

Treatment options for the relief of chronic idiopathic urticaria symptoms.

Chronic urticaria is a cutaneous condition in which recurrent pruritic wheals (hives) manifest on the body and typically last for longer than 6 weeks. Chronic urticaria, including physically induced urticarias, such as cold, solar exposure or delayed pressure urticaria, is estimated to occur in approximately 25% of urticaria patients. Of these patients, 75% present with idiopathic disease, which is essentially an exclusionary diagnosis when no contributing factors can be determined that cause the cutaneous reaction. Chronic urticaria symptoms can have a profound effect on a patient's quality of life (QoL); therefore, treatment should address both physical symptom relief and improvements in QoL. This review will discuss the benefits and limitations of several treatment options available to relieve urticarial symptoms, including H1- and H2-receptor antagonists, doxepin, antileukotriene therapy and corticosteroids. Other experimental therapies, such as immunomodulatory agents, plasmapheresis treatment, i.v. immunoglobulins, and omalizumab will also be discussed.

Assessment of Patient Attitudes About Mometasone Furoate Nasal Spray: The Ease-of-Use Patient Survey.

BACKGROUND: : Intranasal corticosteroids (INS) are recommended as first-line therapy for allergic rhinitis. To date, no studies have evaluated the impact of an INS delivery system on patient satisfaction. Unless patients use a medication appropriately and consistently, they will not fully benefit from its therapeutic effects. OBJECTIVE: : To determine whether the characteristics of the mometasone furoate nasal spray (MFNS) delivery device are an impediment to its use. METHODS/DATABASE:: A random sample of preidentified MFNS users was recruited through e-mail (N = 1544). In online interviews, participants were asked about MFNS ease of use and attributes. RESULTS: : Ninety-eight percent of respondents reported that MFNS is easy to use, and 96% said that the applicator is easy to administer. Nearly all elderly users and users with arthritis said that the applicator fits comfortably in the nostril (96% and 97%, respectively) and is appropriately sized (97% and 96%, respectively); 96% of pediatric users agreed that the applicator fits comfortably. All users said the applicator's ease of use and comfortable fit were its most important attributes. CONCLUSIONS: : The perceived ease of use of MFNS may help providers appropriately treat patients with allergic rhinitis and may improve patient adherence to INS use.

Therapeutic options for reducing sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis.

BACKGROUND: Patients with inflammatory disorders of the upper airways, such as allergic rhinitis, rhinosinusitis, and nasal polyposis, often have significant sleep disturbances. Poor sleep can lead to fatigue, daytime somnolence, impaired daytime functioning as reflected in lower levels of productivity at work or school, and a reduced quality of life. Although the exact mechanisms by which these inflammatory nasal conditions disturb sleep is not fully understood, congestion appears to be a key factor and is generally the most common and bothersome symptom for patients with these conditions. Successful therapy should improve patients' sleep and well-being without introducing any negative effects on sleep. SCOPE OF LITERATURE SEARCH: Literature searches of Medline, Embase, and abstracts from medical/scientific conferences were conducted for the period of 1995 through mid-2006 for primary and review articles and conference presentations about sleep disturbance related to allergic rhinitis, rhinosinusitis, and nasal polyposis. These searches also sought to identify articles examining how treatments for those diseases improved sleep and, consequently, patients' quality of life. Surveys of the impact of congestion on patients' quality of life and their sleep also were consulted. Clinical studies were selected for discussion if they were randomized, double-blind, and placebo-controlled. Limitations of this review include the absence of any direct comparisons of the effectiveness of different drugs on improving sleep and shortcomings in the statistical methods of the patient surveys. FINDINGS: Intranasal corticosteroids (INSs) are the most effective medication for reducing congestion in patients with inflammatory nasal conditions. There is a growing amount of evidence that a reduction in congestion with INSs is associated with improved sleep, reduced daytime sleepiness, and enhanced patient quality of life. CONCLUSION: Relief of sleep impairment associated with inflammatory disorders of the nose and sinuses can be addressed with INS therapy.

Treatment options for the management of perennial allergic rhinitis, with a focus on intranasal corticosteroids.

Perennial allergic rhinitis (PAR) can have a significant impact on a patient's quality of life. While allergen avoidance is the first line of management for PAR, complete avoidance is difficult. Therapeutic options available for PAR include intranasal corticosteroids (INS), H1-antihistamines, decongestants and local chromones, as well as immunotherapy. For mild symptoms, INS and antihistamines are the standard of care, whereas for moderate-to-severe PAR, INS are the preferred therapy due to their proven efficacy. Patient quality of life and therapy preference play a role in maintaining adherence to treatment.