A 67 year old man came to see me recently, he had COPD, and found that it was getting harder to breathe. “I wanted to make sure that I’m on the right inhaler. My doctor switched me from Advair to Breo– is that better?
GSK would certainly say so, in fact their reps often do. Speaking with drug reps about their inhalers often makes me think of food. Actually I think of food quite often, but that’s more of a personal issue. Thinking of inhalers for COPD and asthma make me think of cheap Mexican food, specifically of the fast food variety. I think it has less to do with my poor dietary habits than the fact that I believe expensive inhalers have quite a lot in common with cheap Mexican food.
Thinking about that patient’s question from the perspective of cheap Mexican fast food, switching from advair to Breo would be like ordering one beefy rice burrito, only to be provided with two; but they would keep you full all day. Surely that’s an upgrade if there ever was one, and one which I endorsed. The problem though, and the real reason why he was asking, was not because he doubted the expertise of the prescribing physician but something else entirely. “It’s costing me $450 for 3 months. That’s more than triple what the other one was. I guess I’ll pay for it if you think it’s worth it”
The Impact study showed that inhaled steroids reduced the incidence of COPD exacerbation, in contrast to previous studies which suggested that LABA/LAMA combinations (Anoro, Stiolto, Bevespi) reduced exacerbations similar or greater degree. However the study’s findings are not without controversy. Should you prescribe a triple inhaler (Trelegy), or stick with dual LABA/LAMA, or dual LAMA/ICS like Breo, advair? I discuss these issues in our first Pulmonary, Critical Care (PulmCC) Podcast and how Trelegy might fit into the treatment of people with COPD.
I’m back at it again, talking about my continued love/hate relationship with EMR’s. From my conversations with doctors at different hospitals in our region, it seems that most docs appear to be falling into the “hate” column. Meanwhile, I’m still chugging along with the Allscripts Professional EHR that’s been installed in my office. And while it works just fine for the needs of a 3 physician single-specialty outpatient practice, it’s hardly the type of technology that, by itself, can change medical care for the better for a large number of people.
A recent study challenges that notion. In a study published in Chest, researchers in England sought to determine if inhaled steroids are a risk factor for pneumonia among asthmatics. It has already been shown inhaled corticosteroids are associated with an increased risk of pneumonia among patients with COPD. To determine this they looked at a database of medical information known as The Health Information Network (THIN).
In the UK, EMR’s have been in use for years, and general practitioners are encouraged (but not required) to participate in THIN. When a general practice elects to participate in THIN, software is installed in their EMR which runs in the background. The program collects data, while de-identifying it. The anonymized data is then uploaded to THIN, where approved researchers may have access to it. There is no cost to the practices for participating, and in return for their participation practices not only receive in depth practice metrics, they also receive a percentage of any research revenue generated from the use of the THIN data. At the time that the study was conducted, the database contained data from 9.1 million patients.
But back to the question at hand. From a cohort of 359,172 people with asthma the researchers were able to identify 6857 people with pneumonia, along with 36,312 control subjects. They were thus able to find a positive correlation between inhaled steroids and pneumonia. (for more on these findings, see my previous post: ) Continue reading “A Dream About U.S. EMR’s; A Reality in th U.K.”
Press Release: Annual Conference of the Universal College of Chest Physicians October 2085; New Chicago, Mars.
The annual conference enjoyed another record attendance today as attendees flocked to Dr. Ramachandran III’rds keynote address reviewing exploits of physicians in the early part of the century. Dr. Ramachandran highlighted some key decisions and their consequences, such as the ACGME’s decree in 2032 that all residents should be swaddled before their scheduled hourly nap times. This of course led to the now infamous Great Hospital Apocalypses of 2033, 2034, and 2035.
Perhaps nearly as intriguing was the plight of inhaled corticosteroids for the treatment of respiratory diseases like asthma and COPD in the beginning of the 21st century. The period began with greater awareness and concern regarding the use of long acting beta agonist (LABA) bronchodilators such salmeterol. That risk was highlighted by findings published in the SMART trial (access through Chest archives here). There was increased concern regarding the potential harm caused by LABA which culminated in the placement of warnings on medications which contained LABA bronchodilators. These medications, experts said, were to be prescribed with extreme caution because of the possible increase in harm, particularly among children.
Scholars of the early 21st century thus highly recommended that asthmatics, especially children, be started on steroid inhalers before having to resort to using inhaled LABAs. Many also theorized that inhaled steroids had a protective effect when combined with LABA’s, possibly ameliorating their potential danger. Thus many at the time recommended a strategy of not using LABA inhalers at all, unless also simultaneously prescribing an inhaled steroid.
However, problems with this approach started to appear late in the first decade of the century. The TORCH study, a trial using combined inhaled LABA/inhaled steroids in adults with COPD suggested that there was an increased incidence of pneumonia among those treated with inhaled steroids. Early in the second decade a pivotal study then demonstrated that asthmatic children treated with inhaled steroids ended up being about half an inch shorter than they might have otherwise been (interestingly, a later study in 2035 correlated the reduced height with a statistically significant decrease in NBA dunking). Continue reading “Remember When We Used to Prescribe Inhaled Steroids for Asthma and COPD?”
I have a confession to make, it pains me to write this post, about the removal of over-the-counter epinephrine (a.k.a. primatene) inhalers, the only inhaler available to asthmatics without a prescription. I mean, it literally causes me a visceral pain. But it’s not for the reason you might think. It has nothing to do with all the hoopla concerning the politics of right vs. left . Neither is it necessarily the strange notion of telling people that they have to breathe worse, so we can save the ozone layer, so they can breathe better (though you must admit that does sound weird).
No, it has more to do with the simple fact that I (and undoubtedly other physicians as well) hate this inhaler. It is a dangerous, possibly addictive, unforgivably poor substitute for a real asthma regimen, and should have been banned from the market long ago.
And so for me, here’s the painful part; I don’t think that simply removing it from the market is the right thing to do. Continue reading “In Asthma vs. Ozone Layer, Ozone Layer Wins.”