James Sherman

Telephoning the patient's pharmacy to assess adherence with asthma medications by measuring refill rate for prescriptions.

OBJECTIVEnTo determine whether a prescription refill history obtained by telephoning patients pharmacies identifies poor adherence with asthma medications more frequently than physician assessment.nnnMETHODSnThe study population consisted of 116 children with persistent asthma who were Medicaid recipients; patients who received medication samples were excluded. During a clinic visit pulmonologists interviewed patients, caretakers, or both and estimated adherence on a checklist. A nurse asked the caretakers where they obtained medications and telephoned 66 identified pharmacies for refill histories. The maximum possible adherence was calculated as the number of doses refilled/number of doses prescribed x 100 for a mean duration of 163 days (range, 63 to 365 days). The accuracy of the refill information was determined from Medicaid reimbursement records.nnnRESULTSnInformation provided by pharmacies was 92% accurate. The mean (95% CI) of maximum potential adherence was 72% (65%,77%) for theophylline, 61% (55%,68%) for inhaled corticosteroids, and 38% (23%,53%) for cromolyn; only cromolyn and theophylline were significantly different. Physicians were able to identify 21 (49%) of 43 patients who refilled </=50% of prescribed doses of long-term symptom controllers and only 3 (27%) of 11 patients who used albuterol excessively.nnnCONCLUSIONSnPhysicians often were unable to identify patients with very poor adherence. Checking prescription refills is an accurate and practical method of identifying such patients.

Adherence to oral montelukast and inhaled fluticasone in children with persistent asthma.

Study Objective. To evaluate adherence to oral montelukast and inhaled fluticasone in children with persistent asthma and to determine if age, monotherapy, and duration of therapy affect adherence.

Bronchoconstrictor additives in bronchodilator solutions

Nebulized bronchodilator solutions are available in the United States as both nonsterile and sterile-filled products. Sulfites, benzalkonium chloride (BAC), or chlorobutanol are added to nonsterile products to prevent bacterial growth, but there have been reports of contaminated solutions containing preservatives. Ethylenediamine tetraacetic acid (EDTA) is added to some products to prevent discoloration of the solution. With the exception of chlorobutanol, all of these additives are capable of inducing bronchospasm in a concentration-dependent manner. However, it is rarely apparent to the patient or health care provider that the additive diminishes the bronchodilator effects. Older products (eg, isoproterenol and isoetharine) contain enough sulfites to produce bronchospasm in most patients with asthma, even in those without a prior history of sulfite sensitivity. Bronchoconstriction from inhaled BAC is cumulative, prolonged, and correlates directly with basal airway responsiveness. The multidose dropper bottle of albuterol contains 50 microg BAC/dose, which is below the threshold for bronchoconstriction whereas the screwcap unit-dose vial contains 300 microg/dose, which is above the threshold for many patients. If the screwcap product is used in the emergency department, a patient could receive as much as 1800 microg of BAC in the first hour. Three sterile-filled unit dose albuterol products contain no additives, whereas a fourth, (manufactured by Dey Laboratories) contains 300 microg of EDTA, which is also below the threshold dose for bronchoconstriction. Only additive-free sterile solutions should be used for hourly or continuous nebulization of albuterol. The multidose dropper bottle or the Dey product can be used when the interval between doses is longer, whereas the screwcap product should not be used for acute therapy. Ipratropium is available only as a sterile, additive-free unit-dose vial, as is levalbuterol.

Reliability of the Medtrac MDI Chronolog

BACKGROUNDnThe Medtrac MDI Chronolog is an electronic device for monitoring adherence to metered-dose inhalers. It replaces previous models of the Nebulizer Chronolog and uses a different mechanism of recording actuations.nnnOBJECTIVEnThis study was carried out to determine whether the new model can accurately record and report the date, time, and number of metered-dose inhaler actuations.nnnMETHODSnFour canisters of beclomethasone (Beclovent) were discharged through four Chronologs with fresh batteries at a rate of 1, 2, 4, or 8 times twice daily for 7 days. Four additional canisters were used as controls and discharged simultaneously through the standard actuator. The weight of all canisters and Chronolog battery voltage were measured before and at the end of the 7-day experiment. The data retrieved from the Chronologs were compared with the information recorded manually during each discharge.nnnRESULTSnThe loss in canister weight was consistent for the number of puffs discharged from all four Chronolog units and controls. However, the accuracy of the Chronologs in recording the number of actuations varied between 50% and 100%. The largest amount of data loss occurred with the unit used to discharge 8 puffs and was associated with a dead battery at the end of the 7-day trial. For actuations that were retrievable, the Chronologs accurately recorded the date and time.nnnCONCLUSIONSnUnexpected battery voltage drain and other mechanical problems that we encountered may cause data loss and the false appearance of missed doses. Thus the units that we tested were not sufficiently reliable to monitor patient adherence.

Intervention Strategies for Children Poorly Adherent with Asthma Medications; One Center's Experience

Poor adherence to medications and other aspects of the treatment plan is common in pediatric patients with asthma, and is a common reason for inadequate asthma control. In selected patients we have used electronic monitoring of pulmonary function, behavior contracts, home nursing visits, and medical neglect reports in an attempt to improve adherence and asthma control. Improved outcomes were seen with the most aggressive intervention, home nursing, and medical neglect referral, but not with less aggressive measures.

The Effect of Cys LT1 Receptor Blockade on Airway Responses to Allergen

Study Objective. To evaluate the effect of a potent experimental leukotriene receptor antagonist, MK‐571, on airway responses to inhaled allergen.

Fatal Asthma in Children: A Nurse Managed Model for Prevention

In response to the rise in pediatric asthma-related deaths and the absence of guidance in the literature for prevention of such deaths, a nurse managed program was designed to prevent death in children at risk for death from asthma. Published guidelines for identification of children with life-threatening asthma were used to develop a comprehensive health care network designed to provide early, aggressive medical attention and rapid access to care for selected children. The program has been successful in assuring more aggressive and timely intervention for asthma attacks and there have been no deaths from lack of access to appropriate care since the programs inception.