Dennis M. Williams

Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

J. Bousquet, N. Khaltaev, A. A. Cruz, J. Denburg, W. J. Fokkens, A. Togias, T. Zuberbier, C. E. Baena-Cagnani, G. W. Canonica, C. van Weel, I. Agache, N. A t-Khaled, C. Bachert, M. S. Blaiss, S. Bonini, L.-P. Boulet, P.-J. Bousquet, P. Camargos, K.-H. Carlsen, Y. Chen, A. Custovic, R. Dahl, P. Demoly, H. Douagui, S. R. Durham, R. Gerth van Wijk, O. Kalayci, M. A. Kaliner, Y.-Y. Kim, M. L. Kowalski, P. Kuna, L. T. T. Le, C. Lemiere, J. Li, R. F. Lockey, S. Mavale-Manuel , E. O. Meltzer, Y. Mohammad, J. Mullol, R. Naclerio, R. E. O Hehir, K. Ohta, S. Ouedraogo, S. Palkonen, N. Papadopoulos, G. Passalacqua, R. Pawankar, T. A. Popov, K. F. Rabe, J. Rosado-Pinto, G. K. Scadding, F. E. R. Simons, E. Toskala, E. Valovirta, P. van Cauwenberge, D.-Y. Wang, M. Wickman, B. P. Yawn, A. Yorgancioglu, O. M. Yusuf, H. Zar Review Group: I. Annesi-Maesano, E. D. Bateman, A. Ben Kheder, D. A. Boakye, J. Bouchard, P. Burney, W. W. Busse, M. Chan-Yeung, N. H. Chavannes, A. Chuchalin, W. K. Dolen, R. Emuzyte, L. Grouse, M. Humbert, C. Jackson, S. L. Johnston, P. K. Keith, J. P. Kemp, J.-M. Klossek, D. Larenas-Linnemann, B. Lipworth, J.-L. Malo, G. D. Marshall, C. Naspitz, K. Nekam, B. Niggemann, E. Nizankowska-Mogilnicka, Y. Okamoto, M. P. Orru, P. Potter, D. Price, S. W. Stoloff, O. Vandenplas, G. Viegi, D. Williams

An Evaluation of Smoking Cessation-Related Activities by Pharmacists

OBJECTIVES To (1) describe the types of smoking cessation intervention activities performed by community pharmacists and (2) assess the perceived barriers to this type of intervention. DESIGN Confidential mail questionnaire. SETTING AND PARTICIPANTS 541 community pharmacists in North Carolina and 946 community pharmacists in Texas. RESULTS North Carolina and Texas differ with respect to the sale of cigarettes at the practice site, with North Carolina pharmacies being more likely to sell tobacco products. Overall, 555 (92.5%) respondents reported that they do not routinely ask new patients if they smoke or use tobacco products. Pharmacists described themselves as knowledgeable about smoking cessation therapies, and 42% of respondents had attended an educational program on smoking cessation. A total of 230 (39.5%) reported consistently counseling individual patients about smoking cessation treatment strategies on at least a weekly basis. Exploratory factor analysis identified four dimensions of barriers that inhibit pharmacists from engaging in smoking cessation-related activities: (1) pharmacist interpersonal characteristics, (2) practice site considerations, (3) patient characteristics, and (4) financial concerns. CONCLUSION Pharmacists have an opportunity to identify health risks and counsel patients about disease-preventing lifestyle changes. These findings suggest that although pharmacists believe they are qualified to perform smoking cessation interventions, they do not routinely identify smokers and they perceive several barriers to participating in such activities. Pharmacists should investigate increased involvement in smoking cessation activities for the benefit of their patients and for the potential professional and economic rewards.

Provider Demonstration and Assessment of Child Device Technique During Pediatric Asthma Visits

OBJECTIVE: The purposes of this study were to (a) describe the extent to which children use metered dose inhalers, turbuhalers, diskuses, and peak flow meters correctly, and (b) investigate how often providers assess and demonstrate use of metered dose inhalers, turbuinhalers, diskuses, and peak flow meters during pediatric asthma visits. PATIENTS AND METHODS: Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at 5 pediatric practices in nonurban areas of North Carolina. All of the medical visits were audiotape-recorded. Children were interviewed after their medical visits, and their device technique was observed and rated by the research assistants. RESULTS: Of the patients, 296 had useable audiotape data. Only 8.1% of children performed all of the metered dose inhaler steps correctly. Older children were more likely to get more of the metered dose inhaler steps correct. Of the children, 22% performed all of the diskus steps correctly, 15.6% performed all of the turbuhaler steps correctly, and 24% performed all of the peak flow meter steps correctly. The majority of providers did not demonstrate or assess child use of metered dose inhalers, turbuhalers, diskuses, or peak flow meters during pediatric asthma visits. CONCLUSIONS: There is a need for providers to demonstrate proper asthma medication and monitoring device techniques to children and to have children demonstrate to proficiency. The 2007 National Heart, Lung, and Blood Institute expert panel report on the diagnosis and management of asthma encourages providers to educate children on these techniques.

Amlodipine Pharmacokinetics in Healthy Volunteers

In the present study we investigated the pharmacokinetics and comparative bioavailability of three oral doses of amlodipine in 12 healthy male volunteers. A randomized, open‐label, three period crossover study design was employed. Each subject received, on three separate occasions a single oral dose of 2.5, 5 and 10 mg amlodipine. Standing diastolic blood pressure was reduced by 1.1,4.8 and 8 mmHg six hours after 2.5, 5 and 10 mg amlodipine, respectively. There were no significant changes in pulse rate, nor on the EKG. The curves for the mean plasma concentrations versus time for the three doses showed parallel time‐courses. Highly significant positive correlations were observed between dose and AUC (0–72 hrs) and between dose and Cmax. However, dose corrected AUC and Cmax were 10–20% lower with 2.5 mg, than with 5 and 10 mg. Peak levels were achieved 5.6 to 6.4 hours postdose. Half lives were 31.2, 33 and 36.8 hours for 2.5, 5 and 10 mg respectively. Headache was the most common side effect, and was more frequently observed with the highest dose. In summary, linear relationhips were found between the dose and the plasma levels of amlodipine. Decreases in standing diastolic blood pressure were also dose related. Because of its long half‐life and gradual absorption, amlodipine should be effective in lowering blood pressure given once daily and the incidence of side effects due to rapid absorption should be minimized.

Communication During Pediatric Asthma Visits and Self-Reported Asthma Medication Adherence

OBJECTIVE: Our objectives were to examine how certain aspects of provider-patient communication recommended by national asthma guidelines (ie, provider asking for child and caregiver input into the asthma treatment plan) were associated with child asthma medication adherence 1 month after an audio-taped medical visit. METHODS: Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at 5 pediatric practices in nonurban areas of North Carolina. All medical visits were audio-tape recorded. Children were interviewed 1 month after their medical visits, and both children and caregivers reported the child’s control medication adherence. Generalized estimating equations were used to determine if communication during the medical visit was associated with medication adherence 1 month later. RESULTS: Children (n = 259) completed a home visit interview ∼1 month after their audio-taped visit, and 216 of these children were taking an asthma control medication at the time of the home visit. Children reported an average control medication adherence for the past week of 72%, whereas caregivers reported the child’s average control medication adherence for the past week was 85%. Child asthma management self-efficacy was significantly associated with both child- and caregiver-reported control medication adherence. When providers asked for caregiver input into the asthma treatment plan, caregivers reported significantly higher child medication adherence 1 month later. CONCLUSIONS: Providers should ask for caregiver input into their child’s asthma treatment plan because it may lead to better control medication adherence.

Child and caregiver involvement and shared decision-making during asthma pediatric visits.

Objective. The purpose of this study was to examine (1) the extent to which caregivers and children asked asthma management questions during pediatric asthma visits; (2) the extent to which providers engaged in shared decision-making with these caregivers and children; and (3) the factors associated with question asking and shared decision-making. Methods. Children aged 8–16 years with mild persistent asthma, moderate persistent asthma, or severe persistent asthma and their caregivers were recruited at five pediatric practices in non-urban areas of North Carolina. All of the medical visits were audio tape recorded. Generalized estimating equations were used to analyze the data. Results. Only 13% of children and 33% of caregivers asked one or more questions about asthma management. Caregivers were more likely to ask questions about their child’s medications. Providers obtained child input into their asthma management plan during only 6% of encounters and caregiver input into their child’s asthma management plan during 10% of visits. Conclusion. Given the importance of involving patients during healthcare visits, providers need to consider asking for and including child and caregiver inputs into asthma management plans so that shared decision-making can occur more frequently.

Communication during Pediatric Asthma Visits and Child Asthma Medication Device Technique 1 Month Later

Objective. This study investigated how provider demonstration of and assessment of child use of asthma medication devices and certain aspects of provider–patient communication during medical visits is associated with device technique 1 month later. Methods. Two hundred and ninety-six children aged 8–16 years with persistent asthma and their caregivers were recruited at five North Carolina pediatric practices. All of the medical visits were audio-tape recorded. Children were interviewed 1 month later and their device technique was observed and rated. Results. If the provider asked the child to demonstrate metered dose inhaler technique during the medical visit, then the child was significantly more likely to perform a greater percentage of inhaler steps correctly 1 month later. Children with higher asthma management self-efficacy scores were significantly more likely to perform a greater percentage of diskus steps correctly. Additionally, children were significantly more likely to perform a greater percentage of diskus steps correctly if the provider discussed a written action plan during the visit. Children were significantly more likely to perform a greater percentage of turbuhaler steps correctly if they asked more medication questions. Conclusions. Providers should ask children to demonstrate their inhaler technique during medical visits so that they can educate children about proper technique and improve child asthma management self-efficacy. Providers should encourage children to ask questions about asthma medication devices during visits and they should discuss asthma action plans with families.

Child- and caregiver-reported problems and concerns in using asthma medications

Objectives. The purpose of the study was to (a) describe the types of medication problems/concerns that asthmatic children and their caregivers reported and (b) examine the association between child and caregiver demographic and sociocultural characteristics and reported asthma medication problems/concerns. Methods. Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at five pediatric practices in nonurban areas of North Carolina. Children were interviewed and caregivers completed questionnaires after their childs medical visits about reported problems/concerns in using asthma medications. Multivariate logistic regression was used to analyze the data. Results. Three hundred and twenty children were recruited. Eighty-seven percent of the children reported a problem or concern in using their asthma medications. Approximately 40% of children reported side effects and a similar percent stated that it was hard to understand the directions on their medicines; in addition 60% reported that it was hard to remember when to take their medicines. Females and non-White children were significantly more likely to report they were not sure how to use an inhaler than males and White children. Younger and non-White children were significantly more likely to report it was hard to understand the directions on their medicines than older and White children. Caregivers were most likely to report that their children were bothered a little or a lot by side effects (31%) and a similar percent (29%) were not sure their children were using their inhalers properly. Caregivers without Medicaid were significantly more likely to report difficulty paying for the asthma medications. Conclusions. Medication side effects are a significant problem area for both children and their caregivers, and inhaler skill–based training is particularly needed for non-White children. Health care providers should discuss with children and their caregivers the types of problems/concerns that children may have when using their asthma medications.

Inhaled Antibiotics in Cystic Fibrosis: A Review

OBJECTIVE: To provide an overview of aerosol drug therapy, including physical considerations and aerosol drug delivery systems, and to review clinical experience with inhaled antibiotics in cystic fibrosis (CF) when used as adjunctive therapy to intravenous therapy for acute pulmonary exacerbations and chronic, suppressive therapy. DATA SOURCES: A MEDLINE search (1966-1995) of English-language literature describing the use of inhaled antibiotics for the management of CF. STUDY SELECTION AND DATA EXTRACTION: All articles were considered for possible inclusion in the review. Pertinent information as judged by the authors was selected for discussion. DATA SYNTHESIS: The use of inhaled antibiotics as adjunctive therapy to systemic therapy for acute exacerbations did not improve pulmonary function tests, increase hospital discharge rate, or permanently eradicate sputum Pseudomonas. Clinical trials of inhaled antibiotics as suppressive therapy yielded variable results. Individually, four trials documented a significant improvement in pulmonary function, three trials documented a slower decline in pulmonary function, and four trials reported a reduced frequency of hospitalizations. However, the trials were unable to collectively document a prolonged beneficial effect of inhaled antibiotics on pulmonary function, sputum bacterial density, and frequency of hospitalizations. CONCLUSIONS: Clinical trials conducted thus far suggest no role for inhaled antibiotics in the treatment of acute pulmonary exacerbations in patients with CF. Aerosolized antibiotics used as suppressive therapy may be useful in certain patients, but their use should be limited to select patients based on individual response to therapy. Additional long-term, well-controlled trials of inhaled antibiotics as suppressive therapy are needed before routine use can be recommended.

Preparing pharmacy students and pharmacists to provide tobacco cessation counselling.

ISSUES Tobacco use and abuse is a major health risk for people across the world and is responsible for nearly 500 000 deaths in the USA annually. Currently, the accepted role of pharmacists is the provision of pharmaceutical care, which includes health promotion and prevention of disease. Pharmacists should work collaboratively with other health-care professionals to provide tobacco-cessation counselling to smokers. APPROACH Recently, in the USA, a curriculum has been developed by faculty at a school of pharmacy and distributed to pharmacy schools across the nation in a train-the-trainer format. This curriculum has been implemented in varying degrees in schools across the USA. In addition, there are national efforts to increase the involvement of practising pharmacists in promoting tobacco cessation by offering comprehensive programs or by increasing awareness and referrals. KEY FINDINGS The acceptance of the Rx for Change programs by schools of pharmacy has been high and the education and skills are being taught to most current pharmacy graduates. There is an increased emphasis on the role of pharmacists to assist in meeting national health goals including reducing tobacco-related risks. IMPLICATIONS Numerous opportunities exist for pharmacists to provide tobacco cessation counselling. Barriers to implementation of programs include lack of confidence by pharmacists and a perceived lack of demand by patients. CONCLUSION The consequences of tobacco use are well known. Pharmacists should enhance their involvement in health promotion and disease prevention and actively develop tobacco cessation counselling programs using available resources for the benefit of their patients.