Kwok Yan

Rapid method for measurement of bronchial responsiveness.

A rapid, simple method for measuring bronchial responsiveness to inhaled histamine is described. The method was used to obtain dose response curves in 50 atopic subjects with varying respiratory and nasal symptoms. The cumulative dose of histamine which caused a 20% fall in the one second forced expiratory volume (PD20-FEV1) varied between 0.046 and greater than 3.9 mumol and correlated with the severity of symptoms. The reproducibility of the PD20-FEV1, determined from duplicate measurements in 15 subjects with varying degrees of bronchial responsiveness was found to be satisfactory. When the PD20-FEV1 from this rapid method was compared with that obtained from the dosimeter method no significant difference was found. The dose delivered by this method was shown to be cumulative.

Effect of therapy on bronchial hyperresponsiveness in the long‐term management of asthma

The aim of this study was to determine if prophylactic therapy leads to a reduction in the severity of bronchial hyperresponsiveness (BHR) in subjects with severe asthma. Measurements of bronchial responsiveness to histamine were made in two groups of subjects for periods up to 2 years. Thirteen subjects in the study group took regular medication and used a home monitor of airway function to determine the medication requirements needed to maintain optimal airway function. A control group of eleven subjects was managed with the same drugs but without daily monitoring and without any attempt to keep daily lung function at optimal levels. Subjects in the study group had a 10‐ to 100‐fold decrease in the severity of BHR, which was independent of the improvement in baseline lung function. All but one subject in the study group became symptom free and six were able to maintain the improvement in BHR and symptoms on reduced medication. There was no change in the severity of BHR or in the baseline lung function in the control group. It is concluded that it is possible to reduce the severity of BHR in subjects with severe asthma by the use of pharmacological agents. This reduction in severity appears to require the long‐term use of medications, including aerosol corticosteroids, with daily home monitoring to allow adjustment of the amount of treatment required.

Effectiveness and response predictors of omalizumab in a severe allergic asthma population with a high prevalence of comorbidities: the Australian Xolair Registry

Severe asthma is a high impact disease. Omalizumab targets the allergic inflammatory pathway; however, effectiveness data in a population with significant comorbidities are limited.

Real‐life effectiveness of omalizumab in severe allergic asthma above the recommended dosing range criteria

Omalizumab (Xolair) dosing in severe allergic asthma is based on serum IgE and bodyweight. In Australia, patients eligible for omalizumab but exceeding recommended ranges for IgE (30–1500 IU/mL) and bodyweight (30–150 kg) may still receive a ceiling dose of 750 mg/4 weeks. About 62% of patients receiving government‐subsidized omalizumab are enrolled in the Australian Xolair Registry (AXR).

Tell me about your hay fever: a qualitative investigation of allergic rhinitis management from the perspective of the patient

Allergic rhinitis (AR) is sub-optimally managed in the community and is responsible for a significant health and economic burden. Uncontrolled AR increases the risk of poorly controlled asthma and presents an increased susceptibility to thunderstorm asthma. With the availability of treatments over-the-counter, bypassing the health care professional (HCP), the role of the patient is paramount. Research on the role of the patient in AR management in the current environment is limited. This study aims to explore the patient perspective of AR management and understand why it is sub-optimally managed in the community. Patient perspectives of AR management were explored utilizing a qualitative, phenomenological approach. Adults with AR were included in the study and interviewed. Transcripts were analyzed for recurrent themes and emergent concepts. Forty-seven participants with AR were interviewed about their experiences. Patient reports of delayed diagnosis, treatment fatigue and confidence in the ability to manage their AR themselves, heavily influenced their management preferences. Patients also described barriers associated with AR management including financial expense as well as being mistaken for having an infectious disease. Patients described examples of the impact on their quality of life caused by their AR, yet they strongly believed they could manage it themselves. This belief that AR is a condition that should be entirely self-managed, contributes to its burden. It amplifies patients’ separation from HCPs and having access to guidelines aimed at optimizing their AR control.Allergic rhinitis: Reaching beyond over-the-counter medicationsHealthcare professionals must engage fully with allergic rhinitis patients to optimize treatment and avoid issues triggered by constant self-care. Allergic rhinitis, or hay fever, can impact hugely on individuals’ health but remains poorly managed, partly because of the multiple medications available that allow people to bypass doctors and treat themselves. Biljana Cvetkovski at the University of Sydney, Australia, and co-workers, interviewed 47 adults with hay fever to analyze perceptions of the condition and its management. Many patients reported disenchantment with professional guidance for hay fever, often citing delayed diagnosis and endless tests leading to long-term ‘treatment fatigue’ and a loss of confidence in healthcare services. Patients often prefer self-treatment with limited medical help, repeatedly switching between medications and opting for ‘quick fixes’ rather than treating the chronic condition, with sometimes serious consequences.

Identifying the hidden burden of allergic rhinitis (AR) in community pharmacy: a global phenomenon

BackgroundPatients with allergic rhinitis often trivialise their condition, self-manage inappropriately, and would benefit from health care intervention. The primary point of health care contact for these self-managing allergic rhinitis patients is the community pharmacy. With the majority of allergic rhinitis treatments being available for purchase over the counter, without health care professional contact, we know little about how the patients self-manage. This study aims to identify the burden of allergic rhinitis in the community pharmacy and to identify key opportunity for intervention.MethodsPharmacy customers, who purchased nasal treatment in a community pharmacy, were approached with a research-administered questionnaire that collected data on medical history, symptoms and products purchased for the treatment of nasal symptoms.ResultsOf the 296 participants, 69.9% self-managed with over-the-counter medications; with 68% experiencing allergic rhinitis symptoms and only 44.3% of this subgroup had a doctor’s diagnosis. Nasal congestion (73.6%) was most commonly experienced and oral antihistamines were most commonly purchased (44.3%), indicating a pattern of suboptimal management. A third of participants (36.5%) experienced moderate-severe symptoms, persistently, which impacted on their daily living. Medication selection was mainly based on pharmacy customers’ perceptions of medication effectiveness (47.6%).ConclusionA majority of participants that self-selected over-the-counter medications have symptoms consistent with allergic rhinitis, with almost half not having received a diagnosis. Medication purchasing patterns suggest that sub-optimal therapeutic decisions made by participants, even when they are experiencing significant symptoms. This study uncovers the hidden burden of allergic rhinitis in the community pharmacy and a missed opportunity to intervene and refer if necessary. Patients need to be guided through appropriate treatment as this study showed that many should be referred to a medical practitioner.

Lack of asthma and rhinitis control in general practitioner-managed patients prescribed fixed-dose combination therapy in Australia

ABSTRACT Objectives: The first aim of the study (i) assess the current asthma status of general-practitioner-managed patients receiving regular fixed-dose combination inhaled corticosteroid and long-acting beta2 agonist (FDC ICS/LABA) therapy and (ii) explore patients’ perceptions of asthma control and attitudes/behaviors regarding preventer inhaler use. Methods: A cross-sectional observational study of Australian adults with a current physician diagnosis of asthma receiving ≥2 prescriptions of FDC ICS/LABA therapy in the previous year, who were recruited through general practice to receive a structured in-depth asthma review between May 2012 and January 2014. Descriptive statistics and Chi-Square tests for independence were used for associations across asthma control levels. Results: Only 11.5% of the patients had controlled asthma based on guideline-defined criteria. Contrarily, 66.5% of the patients considered their asthma to be well controlled. Incidence of acute asthma exacerbations in the previous year was 26.5% and 45.6% of the patients were without a diagnosis of rhinitis. Asthma medication use and inhaler technique were sub-optimal; only 41.0% of the preventer users reported everyday use. The side effects of medication were common and more frequently reported among uncontrolled and partially controlled patients. Conclusions: The study revealed the extent to which asthma management needs to be improved in this patient cohort and the numerous unmet needs regarding the current state of asthma care. Not only there is a need for continuous education of patients, but also education of health care practitioners to better understand the way in which patients perceptions impact on asthma management practices, incorporating these findings into clinical decision making.

Single maintenance and reliever therapy (SMART) of asthma

We write to raise concerns about the recent paper by Chapman et al on single maintenance and reliever therapy (SMART) of asthma,1 on the basis that it misrepresents published scientific evidence. The errors include: 1. Reporting outcome measures for one treatment arm from several double-blind studies (table 1 and accompanying text), but omitting the published data2 for comparator arms from the same studies which would have been highly …

A patient-centric analysis to identify key influences in allergic rhinitis management

Allergic rhinitis (AR) is increasingly becoming a patient self-managed disease. Just under 70% of patients purchasing pharmacotherapy self-select their treatment with no health-care professional intervention often resulting in poor choices, leading to suboptimal management and increased burden of AR on the individual and the community. However, no decision is made without external, influencing forces. This study aims to determine the key influences driving patients’ decision-making around AR management. To accomplish this aim, we utilised a social network theory framework to map the patient’s AR network and identify the strength of the influences within this network. Adults who reported having AR were interviewed and completed an AR network map and AR severity and quality of life questionnaires. Forty one people with AR completed the study. The AR networks of the participants had a range of 1–11 influences (alters), with an average number of 4 and a median of 5. The larger the impact of AR on their quality of life, the greater the number of alters within their network. The three most commonly identified alters were, general practitioners, pharmacists and the participants’ ‘own experience’. The strength of the influence of health-care professionals (HCPs) was varied. The proportion of HCPs within the AR network increased as the impact of AR on their quality of life increased. By mapping the AR network, this study demonstrated that there are multiple influences behind patient’s decisions regarding AR management but the role of the HCP cannot be dismissed.Allergies: Understanding self-managementIn-depth interviews with allergy sufferers about their treatment decisions highlights a need for healthcare professionals to help optimize allergy management. Allergic rhinitis (AR), a set of conditions including hayfever, is often poorly managed by patients, partly due to the growing availability of over-the-counter medications. However, little is known about what influences patients’ self-management decisions. Biljana Cvetkovski at the University of Sydney, Australia, and co-workers interviewed 41 adults with AR. The participants also completed quality of life questionnaires and created network maps of key influencers. Cvetkovski found that patients followed many different influences when making treatment decisions, including online resources, family, friends and healthcare professionals. Three of the key influencers were general practitioners, pharmacists and patients’ own experience. Those with severe AR had a larger, more diverse network of influences and often reported treatment fatigue.

The Burden of Rhinitis and the Impact of Medication Management within the Community Pharmacy Setting

BACKGROUND The burden of rhinitis is high. It is unknown to what extent this burden is related to inappropriate medication use. OBJECTIVE This study aimed to identify the way in which people with rhinitis medicate their condition and to evaluate the appropriateness of this medication management. METHODS Pharmacy customers who visited Sydney metropolitan community pharmacies and purchased medication for nasal symptoms were the sampling frame for this study. To determine the condition for which the participants were seeking medication and the appropriateness of their medication selection, the following data were collected with a researcher-administered questionnaire: participants demographics, symptoms, medication selected. An expert panel of clinical researcher pharmacists and specialist respiratory physician evaluated the appropriateness of medication selection based on the Allergic Rhinitis and its Impact on Asthma international guidelines. RESULTS Two hundred and ninety-six participants were recruited from 8 pharmacies; 63.2% had a doctors diagnosis for the symptoms for which they were selecting treatment. Seventy percent of participants self-selected their medications. Seventy-one percent of the participants were identified as having rhinitis. Overall, 16.5% of participants who had rhinitis selected optimal medications. Sixteen percent of participants with allergic rhinitis reported wheezing (6.3% selected optimal medications). CONCLUSIONS The majority of the participants with rhinitis selected suboptimal medications from community pharmacy highlighting the significant burden of rhinitis in community pharmacy and the contribution of medication management. Pharmacists need to take a proactive and evidence-based role in the management of rhinitis supported by clinical pathways when need to be articulated and promoted in all rhinitis guidelines.