Dennis Bowie

Adult Asthma Consensus Guidelines Update 2003

BACKGROUND Several sets of Canadian guidelines for the diagnosis and management of asthma have been published over the past 15 years. Since the last revision of the 1999 Canadian Asthma Consensus Report, important new studies have highlighted the need to incorporate new information into the asthma guidelines. OBJECTIVES To review the literature on adult asthma management published between January 2000 and June 2003; to evaluate the influence of the new evidence on the recommendations made in the 1999 Canadian Asthma Consensus Guidelines and its 2001 update; and to report new recommendations on adult asthma management. METHODS Three specific topics for which new evidence affected the previous recommendations were selected for review: initial treatment of asthma, add-on therapies in the treatment of asthma and asthma education. The resultant reviews were discussed in June 2003 at a meeting under the auspices of the Canadian Thoracic Society, and recommendations for adult asthma management were reviewed. RESULTS The present report emphasises the importance of the early introduction of inhaled corticosteroids in symptomatic patients with mild asthma; stresses the benefit of adding additional therapy, preferably long-acting beta2-agonists, to patients incompletely controlled on low doses of inhaled corticosteroids; and documents the essential role of asthma education. CONCLUSION The present report generally supports many of the previous recommendations published in the 1999 Canadian Asthma Consensus Report and provides higher levels of evidence for a number of those recommendations.

Canadian Thoracic Society Asthma Management Continuum – 2010 Consensus Summary for Children Six Years of Age and Over, and Adults

BACKGROUND/OBJECTIVE To integrate new evidence into the Canadian Asthma Management Continuum diagram, encompassing both pediatric and adult asthma. METHODS The Canadian Thoracic Society Asthma Committee members, comprised of experts in pediatric and adult respirology, allergy and immunology, emergency medicine, general pediatrics, family medicine, pharmacoepidemiology and evidence-based medicine, updated the continuum diagram, based primarily on the 2008 Global Initiative for Asthma guidelines, and performed a focused review of literature pertaining to key aspects of asthma diagnosis and management in children six years of age and over, and adults. RESULTS In patients six years of age and over, management of asthma begins with establishing an accurate diagnosis, typically by supplementing medical history with objective measures of lung function. All patients and caregivers should receive self-management education, including a written action plan. Inhaled corticosteroids (ICS) remain the first-line controller therapy for all ages. When asthma is not controlled with a low dose of ICS, the literature supports the addition of long-acting beta2-agonists in adults, while the preferred approach in children is to increase the dose of ICS. Leukotriene receptor antagonists are acceptable as second-line monotherapy and as an alternative add-on therapy in both age groups. Antiimmunoglobulin E therapy may be of benefit in adults, and in children 12 years of age and over with difficult to control allergic asthma, despite high-dose ICS and at least one other controller. CONCLUSIONS The foundation of asthma management is establishing an accurate diagnosis based on objective measures (eg, spirometry) in individuals six years of age and over. Emphasis is placed on the similarities and differences between pediatric and adult asthma management approaches to achieve asthma control.

What Is New Since the Last (1999) Canadian Asthma Consensus Guidelines

The objective of the present document is to review the impact of new information on the recommendations made in the last (1999) Canadian Asthma Consensus Guidelines. It includes relevant published studies and observations or comments regarding what are considered to be the main issues in asthma management in children and adults in office, emergency department, hospital and clinical settings. Asthma is still insufficiently controlled in a large number of patients, and practice guidelines need to be integrated better with current care. This report re-emphasises the need for the following: objective measures of airflow obstruction to confirm the diagnosis of asthma suggested by the clinical evaluation; identification of contributing factors; and the establishment of a treatment plan to rapidly obtain and maintain optimal asthma control according to specific criteria. Recent publications support the essential role of asthma education and environmental control in asthma management. They further support the role of inhaled corticosteroids as the mainstay of anti-inflammatory therapy of asthma, and of both long acting beta2-agonists and leukotriene antagonists as effective means to improve asthma control when inhaled corticosteroids are insufficient. New developments, such as combination therapy, and recent major trials, such as the Childrens Asthma Management Project (CAMP) study, are discussed.

Geographical variations in the prevalence of atopic sensitization in six study sites across Canada.

To cite this article: Chan‐Yeung M, Anthonisen NR, Becklake MR, Bowie D, Sonia Buist A, Dimich‐Ward H, Ernst P, Sears MR, Siersted HC, Sweet L, Van Til L, Manfreda J. Geographical variations in the prevalence of atopic sensitization in six study sites across Canada. Allergy 2010; 65: 1404–1413.

Sore Throat Progressing to Embolic Sepsis: A Case of Lemierre’s Syndrome

Lemierres syndrome is a rare clinical syndrome defined as orophyngeal sepsis, thrombophlebitis of the internal jugular vein and septic thombo-emboli. It is typically encountered in young, immunocompetent individuals, with a mean incident age of 20 years. The organism that is most commonly associated is an anaerobic Gram-negative bacterium: Fusobacterium species. The defined treatment course is at least six weeks of antibiotics, with the role of anticoagulation being unclear. The present article documents a case of Lemierres syndrome complicated by acute renal failure and loculated pleural effusion in an otherwise healthy 16-year-old patient.

Canadian Thoracic Society Asthma Committee commentary on long-acting beta-2 agonist use for asthma in Canada.

1Queen’s University, Kingston, Ontario; 2University of Montreal, Montreal, Quebec; 3University of Toronto, Toronto, Ontario; 4University of British Columbia, Vancouver, British Columbia; 5University of Calgary, Calgary, Alberta; 6University of Western Ontario, London, Ontario; 7University of Alberta, Edmonton, Alberta; 8Dalhousie University, Halifax, Nova Scotia; 9University of Manitoba, Winnipeg, Manitoba; 10Laval University, Quebec City, Quebec Correspondence: Dr M Diane Lougheed, Division of Respirology, Department of Medicine, Queen’s University, 102 Stuart Street, Kingston, Ontario K7L 2V6. Telephone 613-548-2348, fax 613-549-1459, e-mail mdl@queensu.ca CommenTAry

Oral Corticosteroids in Asthma: A Review of Benefits and Risks

Oral corticosteroids (OCS) play an integral role in the pharmacological management of asthma, as well as a number of other inflammatory and autoimmune disorders. However, although their broad spectrum of effect is beneficial in controlling inflammation, it can also lead to undesirable effects on other cells, resulting in adverse effects. The purpose of the present review is to discuss the particular benefits of OCS and to outline the optimal role of these agents in the management of asthma, drawing on evidence-based medicine and current clinical practice guidelines. The mandate for the present review also covers an analysis of the risk:benefit ratio as it pertains to OCS use in asthma. The more common adverse effects will be discussed and weighed against the possible benefits.

Airflow Obstruction in Young Adults in Canada

OBJECTIVE Airflow obstruction is relatively uncommon in young adults, and may indicate potential for the development of progressive disease. The objective of the present study was to enumerate and characterize airflow obstruction in a random sample of Canadians aged 20 to 44 years. SETTING The sample (n=2962) was drawn from six Canadian sites. DESIGN A prevalence study using the European Community Respiratory Health Survey protocol was conducted. Airflow obstruction was assessed by spirometry. Bronchial responsiveness, skin reactivity to allergens and total serum immunoglobulin E were also measured. Logistic regression was used for analysis. RESULTS Airflow obstruction was observed in 6.4% of the sample, not associated with sex or age. The risk of airflow obstruction increased in patients who had smoked and in patients who had lung trouble during childhood. Adjusted for smoking, the risk of airflow obstruction was elevated for subjects with past and current asthma, skin reactivity to allergens, elevated levels of total immunoglobulin E and bronchial hyper-responsiveness. Of the subjects with airflow obstruction, 21% were smokers with a history of asthma, 50% were smokers without asthma, 12% were nonsmokers with asthma and 17% were nonsmokers with no history of asthma. Bronchial hyper-responsiveness increased the prevalence of airflow obstruction in each of these groups. CONCLUSION Smoking and asthma, jointly and individually, are major determinants of obstructive disorders in young adults. Bronchial hyper-responsiveness contributes to obstruction in both groups.

Commentaire du Comité sur l'asthme de la Société canadienne de thoracologie au sujet de l'utilisation des bêta-2 agonistes à longue durée d'action dans le traitement l'asthme au Canada

1Universite Queen’s, Kingston (Ontario); 2Universite de Montreal, Montreal (Quebec); 3Universite de Toronto, Toronto (Ontario); 4Universite de la Colombie-Britannique, Vancouver (Colombie-Britannique); 5Universite de Calgary,Calgary (Alberta); 6Universite Western Ontario, London (Ontario); 7Universite de l’Alberta, Edmonton (Alberta); 8Universite Dalhousie, Halifax (Nouvelle-Ecosse); 9Universite du Manitoba, Winnipeg (Manitoba); 10Universite Laval, Quebec (Quebec) Adresse de correspondance : Dr M Diane Lougheed, Division de la respirologie, Departement de medecine, Universite Queen’s, 102 rue Stuart, Kingston (Ontario) K7L 2V6. Telephone 613-548-2348, telecopieur 613-549-1459, courriel mdl@queensu.ca Le Comite sur l’asthme de la Societe canadienne de thoracologie (SCT) a etudie l’annonce faite par la Food and Drug Administration (FDA) des Etats-Unis (E.-U.) le 18 fevrier 2010 au sujet de nouvelles mesures de controle de l’innocuite et d’exigences relatives a l’etiquetage des beta-2 agonistes a longue duree d’action (BALA) dans le traitement de l’asthme aux E.-U. Le present commentaire vise a contextualiser la recommandation de la FDA pour les membres de la SCT, compte tenu de la nouvelle edition 2010 du continuum de la SCT sur la prise en charge de l’asthme publie dans le numero de fevrier de la Revue canadienne de pneumologie (1). Les recommandations de la FDA semblent fondees sur l’etude multicentrique relative a l’utilisation du salmeterol dans le traitement de l’asthme (SMART) (2), l’etude nationale de surveillance sur le salmeterol (SNS) et une meta-analyse de 110 etudes realisees en 2008 par le comite consultatif de la FDA pour les medicaments dans le traitement des allergies respiratoires (PADAC) portant sur l’innocuite des BALA et ciblant specifiquement leur utilisation dans l’asthme pediatrique. Les preoccupations relatives a l’innocuite sont liees a un risque accru observe d’exacerbations graves de l’asthme chez les enfants et les adultes necessitant une hospitalisation et a un risque accru de deces chez certains patients atteints d’asthme constate au cours dans ces etudes. Le continuum et le sommaire du consensus sur la prise en charge de l’asthme publie en 2010 par la SCT (1) est en accord avec les recommandations de la FDA. Depuis la mise sur le marche des BALA au Canada, l’edition 1996 des lignes directrices canadiennes de consensus sur l’asthme (3), les mises a jour subsequentes (4-6), une perspective sur les BALA (7), une revue des donnees probantes (8) et le resume du consensus le plus recent soulignent tous sur les aspects suivants :

Six-Month CTS Update Report

With this report, I hope to bring the membership up-to-date regarding the activities of the Canadian Thoracic Society (CTS) during the past six to seven months. We have just had our biannual board meeting in Alberta, which was the most successful one that I have personally attended. This achievement was a result of the marked increase in the business of all the working committees and in the number of reports tabled at this meeting that chronicled the many activities taking place over the past six months.