Angelina Lim

Systematic Review of the Safety of Regular Preventive Asthma Medications During Pregnancy

Objective: To review the safety of regular preventive asthma medications during pregnancy. Data Sources: The following databases were searched from inception to February 2011: Ovid MEDLINE, PubMed, Cochrane Library, EMBASE and CINAHL Plus. Study Selection and Data Extraction: The search was limited to human studies published in the English language. Titles of all articles were screened for relevance. Abstracts of relevant articles were scrutinized to confirm relevance before obtaining full text. Data Synthesis: Selected articles were read by 2 authors and the accuracy of the data extracted was confirmed. Results: Thirty-three articles were included in the final review. Small sample size, missing data, inadequate control for confounding factors, and poor documentation of dosage range were common limitations of the studies reviewed. The use of inhaled corticosteroids, cromolyns, and long-acting β2 agonists during pregnancy was not associated with any particular adverse event, although the fluticasone/salmeterol combination has been associated with poor outcomes in postmarketing studies. Congenital malformations have been reported with leukotriene receptor antagonist exposure during pregnancy, but those women also had exposure to other medications, including oral corticosteroids. Conclusions: Some negative outcomes of preventive asthma medications have been reported, although their direct link with medication use is inconclusive. Selection of preventive medications for asthma management during pregnancy should be based on an assessment of the risks and benefits of medication use versus the risks of poorly controlled asthma.

Multidisciplinary Approach to Management of Maternal Asthma (MAMMA): a randomized controlled trial.

BACKGROUND Uncontrolled asthma during pregnancy is associated with maternal and perinatal hazards. A pharmacist-led intervention directed at improving maternal asthma control, involving multidisciplinary care, education, and regular monitoring to help reduce these risks, was developed and evaluated. METHODS A randomized controlled trial was carried out in the antenatal clinics of two major Australian maternity hospitals. Sixty pregnant women < 20 weeks gestation who had used asthma medications in the previous year were recruited. Participants were randomized to either an intervention or a usual care group and followed prospectively throughout pregnancy. The primary outcome was Asthma Control Questionnaire (ACQ) score. Mean changes in ACQ scores from baseline were compared between groups at 3 and 6 months to evaluate intervention efficacy. RESULTS The ACQ score in the intervention group (n = 29) decreased by a mean ± SD of 0.46 ± 1.05 at 3 months and 0.89 ± 0.98 at 6 months. The control group (n = 29) had a mean decrease of 0.15 ± 0.63 at 3 months and 0.18 ± 0.73 at 6 months. The difference between groups, adjusting for baseline, was -0.22 (95% CI, -0.54 to 0.10) at 3 months and -0.60 (95% CI, -0.85 to -0.36) at 6 months. The difference at 6 months was statistically significant (P < .001) and clinically significant (> 0.5). No asthma-related oral corticosteroid use, hospital admissions, emergency visits, or days off from work were reported during the trial. CONCLUSIONS A multidisciplinary model of care for asthma management involving education and regular monitoring could potentially improve maternal asthma outcomes and be widely implemented in clinical practice. TRIAL REGISTRY Australian and New Zealand Clinical Trials Registry; No.: ACTRN12612000681853; URL: www.anzctr.org.au.

Asthma during Pregnancy: The Experiences, Concerns and Views of Pregnant Women with Asthma

Objective. To investigate how pregnant women manage their asthma during pregnancy and factors influencing their behavior. Methods. In-depth interviews (telephone or face-to-face) with a purposive sample of 23 asthmatic women at various stages of pregnancy and with varying severity of asthma. Results. Five major themes were discerned relating to health behavior of pregnant women with asthma. Many of the participants decreased or discontinued their asthma medications themselves and refrained from taking doses when necessary during pregnancy without consulting their doctors. Reasons behind their decisions revolved around lack of support and information about what to do, concerns about the safety of the medications, past experiences, and desire for an “all natural” pregnancy. Asthma monitoring during pregnancy was seen as a low priority for some women and their doctors. Communication between pregnant women and health professionals regarding asthma management was poor. The health behavior of pregnant women with asthma could be explained using the Health Beliefs Model. Conclusions. Pregnant women are not well supported in managing asthma during pregnancy, despite being concerned about outcomes. Interventions, education, and more support are warranted and wanted by pregnant women with asthma to optimize pregnancy and neonatal outcomes.

Original ResearchMultidisciplinary Approach to Management of Maternal Asthma (MAMMA): A Randomized Controlled Trial

BACKGROUND Uncontrolled asthma during pregnancy is associated with maternal and perinatal hazards. A pharmacist-led intervention directed at improving maternal asthma control, involving multidisciplinary care, education, and regular monitoring to help reduce these risks, was developed and evaluated. METHODS A randomized controlled trial was carried out in the antenatal clinics of two major Australian maternity hospitals. Sixty pregnant women < 20 weeks gestation who had used asthma medications in the previous year were recruited. Participants were randomized to either an intervention or a usual care group and followed prospectively throughout pregnancy. The primary outcome was Asthma Control Questionnaire (ACQ) score. Mean changes in ACQ scores from baseline were compared between groups at 3 and 6 months to evaluate intervention efficacy. RESULTS The ACQ score in the intervention group (n = 29) decreased by a mean ± SD of 0.46 ± 1.05 at 3 months and 0.89 ± 0.98 at 6 months. The control group (n = 29) had a mean decrease of 0.15 ± 0.63 at 3 months and 0.18 ± 0.73 at 6 months. The difference between groups, adjusting for baseline, was -0.22 (95% CI, -0.54 to 0.10) at 3 months and -0.60 (95% CI, -0.85 to -0.36) at 6 months. The difference at 6 months was statistically significant (P < .001) and clinically significant (> 0.5). No asthma-related oral corticosteroid use, hospital admissions, emergency visits, or days off from work were reported during the trial. CONCLUSIONS A multidisciplinary model of care for asthma management involving education and regular monitoring could potentially improve maternal asthma outcomes and be widely implemented in clinical practice. TRIAL REGISTRY Australian and New Zealand Clinical Trials Registry; No.: ACTRN12612000681853; URL: www.anzctr.org.au.

Multidisciplinary approach to management of maternal asthma (MAMMA [copyright]): the PROTOCOL for a randomized controlled trial

BackgroundUncontrolled asthma during pregnancy is associated with the maternal hazards of disease exacerbation, and perinatal hazards including intrauterine growth restriction and preterm birth. Interventions directed at achieving better asthma control during pregnancy should be considered a high priority in order to optimise both maternal and perinatal outcomes. Poor compliance with prescribed asthma medications during pregnancy and suboptimal prescribing patterns to pregnant women have both been shown to be contributing factors that jeopardise asthma control. The aim is to design and evaluate an intervention involving multidisciplinary care for women experiencing asthma in pregnancy.Methods/designA pilot single-blinded parallel-group randomized controlled trial testing a Multidisciplinary Approach to Management of Maternal Asthma (MAMMA©) which involves education and regular monitoring. Pregnant women with asthma will be recruited from antenatal clinics in Victoria, Australia. Recruited participants, stratified by disease severity, will be allocated to the intervention or the usual care group in a 1:1 ratio. Both groups will be followed prospectively throughout pregnancy and outcomes will be compared between groups at three and six months after recruitment to evaluate the effectiveness of this intervention. Outcome measures include Asthma Control Questionnaire (ACQ) scores, oral corticosteroid use, asthma exacerbations and asthma related hospital admissions, and days off work, preventer to reliever ratio, along with pregnancy and neonatal adverse events at delivery. The use of FEV1/FEV6 will be also investigated during this trial as a marker for asthma control.DiscussionIf successful, this model of care could be widely implemented in clinical practice and justify more funding for support services and resources for these women. This intervention will also promote awareness of the risks of poorly controlled asthma and the need for a collaborative, multidisciplinary approach to asthma management during pregnancy. This is also the first study to investigate the use of FEV1/FEV6 as a marker for asthma control during pregnancy.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12612000681853)

Mild Deficits of Cortical Bone in Young Adults With Klinefelter Syndrome or Anorchia Treated With Testosterone.

CONTEXT There are currently no data evaluating volumetric bone mineral density (BMD), bone geometry, and body composition in adults with Klinefelter syndrome (KS) or anorchia who have been treated with T from adolescence. OBJECTIVE To determine volumetric BMD, bone geometry using peripheral quantitative computed tomography (pQCT), and body composition using dual-energy x-ray absorptiometry (DXA) in men with classical KS or anorchia treated with T from adolescence (age, <16 y), compared with matched controls. METHODS Twenty subjects (12 KS, eight anorchia) and 20 controls underwent a pQCT (66% tibia, 4% radius) and total body DXA. RESULTS Using adjusted regression models, there was reduced tibial cortical area (95% confidence interval [CI], -88.8 to -4.4 mm(2); P = .03) and thickness (95% CI, -0.98 to -0.10 mm; P = .02) in subjects. All other bone parameters were similar between groups. Subjects had significantly higher fat mass (95% CI, 1.6 to 14.9 kg; P = .02), trunk:leg fat ratio (95% CI, 0.09 to 0.60; P = .01), and visceral adipose mass (95% CI, 0.057 to 0.283 kg; P = .004). Lean mass was similar in both groups. Lean mass was positively associated with tibial cortical area and radial total, trabecular, and volumetric density (P < .05). CONCLUSION This first report using pQCT and DXA in men with KS or anorchia treated from adolescence showed normal volumetric BMD but reduction in cortical area and thickness, only at the 66% tibia site. Our study also demonstrated for the first time that men with KS or anorchia have increased visceral adiposity despite T treatment.

Asthma, bones and corticosteroids: Are inhaled corticosteroids associated with fractures in children with asthma?

The prevalence of asthma worldwide among older children varies between 10 and 20%. One of the most effective therapies to treat asthma and prevent exacerbations is inhaled corticosteroids (ICSs). Systemic corticosteroids are known to decrease bone mineral density and increase the risk of fractures among children, but little is known about the effect of ICSs on fracture risk in children with asthma. The aim of this study was to investigate the fracture rates in children with asthma using ICSs.

Bone mineral density is related to lung function outcomes in young people with cystic fibrosis—A retrospective study

Improvements in the medical management of cystic fibrosis (CF) in recent years have resulted in increased prevalence of long‐term sequelae of the condition, such as low bone mineral density (BMD) and hence an increased risk of fractures in later life.

A comparative study of quality of life, functional and bone outcomes in osteogenesis imperfecta with bisphosphonate therapy initiated in childhood or adulthood

Bisphosphonates have been used for treatment of bone fragility disorders for over 25 years to increase bone mineral density (BMD). Anecdotally, bisphosphonate-treated Osteogenesis Imperfecta (OI) has a different trajectory to the natural history of untreated OI in terms of fracture incidence, quality of life and physical function, with minimal published evidence to support this clinical observation. This study describes functional outcomes of a cohort of adults with OI, stratified according to severity and treated with intravenous bisphosphonates as children. Reported outcomes included fracture incidence before and after puberty, mobility and BMD outcomes of this cohort. The cohort was compared to adults with OI who were never treated as children. All participants completed four questionnaires: a study specific questionnaire addressing fracture and treatment history, WHOQOL-BREF (quality of life), SF-36 (musculoskeletal function) and IPAQ (physical activity), and medical records were reviewed. Fifty-two adults with OI (80% response rate) completed the questionnaires; 33 of whom were treated with bisphosphonates in childhood. The childhood treated cohort had higher lumbar spine BMD than the adult treated cohort (z-score - 0.4 at mean age 21.3 years versus -2.1 at mean age 40.9 years; p = 0.003). Pre-pubertal fracture incidence was reduced for all severities of OI in the childhood treated cohort (less severe OI, p = 0.01; more severe OI, p < 0.001), but post-pubertal fracture incidence was higher for less severe OI (p < 0.001). In less severe OI, childhood treated individuals had higher levels of physical activity (p = 0.004) and physical functioning (p = 0.01) than adult treated individuals. Incidence of scoliosis was not different between cohorts. There were no differences in quality of life scores between the two cohorts. Improvements in BMD do not appear to influence the prevalence of scoliosis. Results suggest that treatment with bisphosphonates at an earlier age improves physical activity, particularly in less severe forms of OI but may not alter quality of life.