Inhaler reminders improve adherence with controller treatment in primary care patients with asthma

Juan Carlos Ivancevich Tuesday, 11 November 2014 12:58


BACKGROUND: Poor adherence contributes to uncontrolled asthma. Pragmatic adherence interventions for primary care settings are lacking.

OBJECTIVE: To test the effectiveness of 2 brief general practitioner (GP)-delivered interventions for improving adherence and asthma control.

METHODS: In a 6-month cluster randomized 2 × 2 factorial controlled trial, with GP as unit of cluster, we compared inhaler reminders and feedback (IRF) and/or personalized adherence discussions (PADs) with active usual care alone; all GPs received action plan and inhaler technique training. GPs enrolled patients prescribed combination controller inhalers, with suboptimal Asthma Control Test (ACT) scores (ACT score ≤19). Inhaler monitors recorded fluticasone propionate/salmeterol adherence (covertly for non-IRF groups) and, in IRF groups, provided twice-daily reminders for missed doses, and adherence feedback. PAD GPs received communication training regarding adherence. Outcomes collected every 2 months included ACT scores (primary outcome) and severe exacerbations. Intention-to-treat mixed-model analysis incorporated cluster effect and repeated measures.

RESULTS: A total of 43 GPs enrolled 143 patients with moderate-severe asthma (mean age, 40.3 ± 15.2 years; ACT score, 14.6 ± 3.8; fluticasone propionate dose, 718 ± 470 μg). Over 6 months, adherence was significantly higher in the IRF group than in non-IRF groups (73% ± 26% vs 46% ± 28% of prescribed daily doses; P < .0001), but not between PAD and non-PAD groups. Asthma control improved overall (mean change in ACT score, 4.5 ± 4.9; P < .0001), with no significant difference among groups (P = .14). Severe exacerbations were experienced by 11% of the patients in IRF groups and 28% of the patients in non-IRF groups (P = .013; after adjustment for exacerbation history; P = .06).

CONCLUSIONS: Inhaler reminders offer an effective strategy for improving adherence in primary care compared with a behavioral intervention or usual care, although this may not be reflected in differences in day-to-day asthma control.

KEYWORDS: Medication adherence; ambulatory monitoring; antiasthmatic agents; asthma; health communication; intervention studies; treatment effectiveness

J Allergy Clin Immunol. 2014 Jul 18. pii: S0091-6749(14)00802-1. doi: 10.1016/j.jaci.2014.05.041. [Epub ahead of print]


The Allergic Asthma Phenotype

Juan Carlos Ivancevich Thursday, 06 November 2014 13:07

Michael Schatz, MD, MSThis email address is being protected from spambots. You need JavaScript enabled to view it.
Lanny Rosenwasser, MD
Allergic asthma is the most common asthma phenotype. It usually is defined by the presence of sensitization to environmental allergens, although a clinical correlation between exposure and symptoms further supports the diagnosis. The average age of onset of allergic asthma is younger than that of nonallergic asthma. Although the spectrum of allergic asthma may vary from mild to severe, studies have reported that allergic versus nonallergic asthma is less severe. There is an increased prevalence of allergic rhinoconjunctivitis and atopic dermatitis in patients with allergic asthma. Total IgE levels usually are higher in allergic versus nonallergic asthma, but levels substantially overlap between the 2 groups. Increased Th2 cytokines have been demonstrated in secretions and peripheral blood of patients with allergic asthma. Atopy has been reported to be inversely associated with persistent airflow obstruction and airway remodeling. Clusters with a high prevalence of early onset atopic asthma have been frequently reported in statistical phenotyping studies, but the various clusters of patients with atopy were quite heterogeneous in terms of symptom severity, pulmonary function, and tendency for exacerbations. Implications for future research regarding the allergic asthma phenotype are described.


The latest edition of the BTS/SIGN guideline on the management of asthma (2014) is available now

Juan Carlos Ivancevich Monday, 03 November 2014 03:00

The 2014 update includes a new section highlighting key recommendations for implementation (section 2), completely re-written sections on supported self management (section 4) and organisation and delivery of care (section 13), and an extensively revised section on non-pharmacological management. All other sections, with the exception of diagnosis and monitoring (section 3) and asthma in adolescents (section 10) have also been revised and updated to reflect new evidence that has become available.

Current Guidelines 


Publication Date



BTS/SIGN Asthma Guideline 2014 October 2014

BTS/SIGN British Guideline on the Management of Asthma, October 2014

BTS/SIGN Asthma Guideline Quick Reference Guide 2014 October 2014   Valid





Asthma Phenotypes: Nonallergic (Intrinsic) Asthma

Juan Carlos Ivancevich Thursday, 06 November 2014 12:53
Stephen P. Peters, MD, PhD, FAAAAIThis email address is being protected from spambots. You need JavaScript enabled to view it.
Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC


The definition of nonallergic asthma includes that subset of subjects with asthma and with whom allergic sensitization cannot be demonstrated. These individuals should have negative skin prick test or in vitro specific-IgE test to a panel of seasonal and perennial allergens. Nonallergic asthma occurs in 10% to 33% of individuals with asthma and has a later onset than allergic asthma, with a female predominance. Nonallergic asthma appears to be more severe than allergic asthma in many cases and may be less responsive to standard therapy. Although many of the immunopathologic features of nonallergic asthma are similar to those observed with allergic asthma, some differences have been described, including a higher expression of RANTES in mucosa and bronchoalveolar lavage fluid, as well as a higher GM-CSF receptor alpha expression. Unbiased statistical methods, such as cluster analysis and latent class analysis, indicate that the lack of atopy is not the most important defining factor in assigning an individual to many specific phenotypes but rather is more important in some phenotypes than others, and appears to modulate the clinical expression of the disease. Despite an appreciation of this clinical entity for many years, many of its clinical implications remain unclear.

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Effect of low birth weight on childhood asthma: a meta-analysis

Juan Carlos Ivancevich Friday, 31 October 2014 04:18
Open Access
Xue-Feng Xu1Ying-Jun Li2Yuan-Jian Sheng1Jin-Ling Liu1Lan-Fang Tang1 and Zhi-Min Chen1*
  • *Corresponding author: Zhi-Min Chen This email address is being protected from spambots. You need JavaScript enabled to view it.

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BMC Pediatrics 2014, 14:275  doi:10.1186/1471-2431-14-275



Low birth weight is strongly correlated with an increased risk of adult diseases. Additionally, low birth weight might be a risk factor for asthma later in life.


A systematic literature search of the PubMed database from 1966 to November 2013 was conducted. The criteria for inclusion of papers were as follows: case–control or cohort studies; the odds ratio (OR) or risk ratio (RR) estimates with the corresponding 95% confidence intervals (CIs) were presented, or there were sufficient data for calculation; and studies were published in English up to October 2013. Random-effect and fixed-effect meta-analyses, meta-regression, and cumulative meta-analysis were conducted.


Thirteen cohort studies and 1,105,703 subjects were included. The overall pooled RRs (95% CIs) of asthma risk for low birth weight were 1.162 (fixed-effects model, 95% CI, 1.128–1.197) and 1.152 (random-effects model, 95% CI, 1.082–1.222). In stratified analyses, the effect of low birth weight on childhood asthma was strong, particularly in studies conducted in Europe, those with a small sample size, and those published recently. A meta-regression analysis did not find significant determinants.


This meta-analysis shows that low birth weight significantly increases the risk of childhood asthma.

Keywords:  Birth weight; Childhood asthma; Meta-analysis; Systematic review 

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