Siebrig Schokker

Fluticasone or montelukast for preschool children with asthma-like symptoms: Randomized controlled trial

RATIONALE Beneficial effects of anti-inflammatory therapy such as fluticasone propionate (FP) and montelukast (Mk) have been demonstrated in preschool children with asthma. However, comparative studies are lacking in this age group. Therefore, we conducted a study to evaluate and compare the effect of FP and Mk in preschool children with asthma-like symptoms. METHODS In this multicenter, randomized, placebo-controlled, double-blind, double-dummy trial, children aged 2-6 years with asthma-like symptoms were included. In total, 63 children were randomly allocated to receive FP (25), Mk (18) or placebo (20) for 3 months. The primary outcome was the daily symptom score (wheeze, cough, shortness of breath) as recorded by caregivers in a symptom diary card. Secondary endpoints were rescue medication free days, blood eosinophils and lung function (interrupter technique and forced oscillation technique (FOT)). RESULTS During the 3 months study period, symptoms improved in all 3 groups, with a statistically significant difference between FP and placebo in favor of the FP group (p=0.021). A significant reduction in circulating eosinophils after 3 months of treatment was found in the Mk group only (p=0.008), which was significantly different from the change found in the placebo group (p=0.045). With the exception of frequency dependence (measured by FOT), which showed a difference between FP and Mk after 3 months of treatment in favor of the FP group (p=0.048), no differences in lung function within or between groups were found. CONCLUSIONS In spite of a lack of power, our results suggest that FP has a beneficial effect on symptoms and Mk on blood eosinophil level as compared to placebo. Except for a difference in one lung function parameter after 3 months between FP and Mk in favor of the FP group, this study revealed no differences between FP and Mk.

Prescribing of asthma medication in primary care for children aged under 10

OBJECTIVE To evaluate prescriptions of asthma medication for children in primary care. METHODS Data on prescriptions of asthma medication for children aged 0-9 years were collected from a general practice-based network in the north eastern part of the Netherlands. Prevalence, incidence, indications, continuation beyond the age of 6 years, and predictors of continuation, were determined. RESULTS Prevalence of prescriptions was about 80 per 1000 person years. An asthma diagnosis was registered in 40% of the children with a first prescription and in 70% of the children with six or more prescriptions. Discontinuation of asthma medication was between 60 and 90%. Continuation was more likely in children with a first prescription at age 2 or 3 as compared to children starting treatment at age < or =1 year. Children with prescriptions for beta2-agonists and inhaled corticosteroids were more likely to continue treatment than children with beta2-agonist monotherapy prescriptions. CONCLUSION Continuation of asthma medication in children is low. Age at first prescription and the type of asthma medication are predictors of continuation of asthma medication from preschool into school-age.

Development of a brief questionnaire (ICQ‐S) to monitor inhaled corticosteroid side‐effects in clinical practice

Side‐effect concerns impede adherence with inhaled corticosteroids (ICS) and often underlie poor asthma control. We developed a brief version (ICQ‐S) of the 57‐item Inhaled Corticosteroids side‐effect Questionnaire (ICQ) to facilitate side‐effect monitoring in busy clinics.

Primary Prevention of Chronic Obstructive Pulmonary Disease in Primary Care

Chronic obstructive pulmonary disease (COPD) is a prevalent disease, with cigarette smoking being the main risk factor. Prevention is crucial in the fight against COPD. Whereas primary prevention is targeted on whole populations, patient populations are the focus of primary care; therefore, prevention in this setting is mainly aimed at preventing further deterioration of the disease in patients who present with the first signs of disease (secondary prevention). Prevention of COPD in primary care requires detection of COPD at an early stage. An accurate definition of COPD is crucial in this identification process. The benefits of detecting new patients with COPD should be determined before recommending screening and case-finding programs in primary care. No evidence is available that screening by spirometry results in significant health gains. Effective treatment options in patients with mild disease are lacking. Smoking cessation is the cornerstone of COPD prevention. Because cigarette smoking is not only a major cause of COPD but is also a major cause of many other diseases, a decline in tobacco smoking would result in substantial health benefits.

Inhalation technique education in asthma or COPD: The value of a visual instruction card

Background: Although the importance of teaching a correct inhalation technique in patients with asthma or COPD is recognised, the optimal method of inhalation technique education is unknown. To improve this, inhaler-specific visual instruction cards as an adjunct to standard education have been developed. Aim: To evaluate the value of these visual instruction cards in optimising inhalation technique in patients with asthma or COPD. Methods: Randomised controlled trial in 100 outpatients with asthma or COPD (49% male, mean age 63 years). Patients received either usual inhalation technique education (Usual Care) or received the visual instruction card in addition to the usual inhalation technique education (Usual Care+). At baseline and follow-up (at 6-8 weeks) inhalation technique was assessed using inhaler-specific checklists. Disease control was measured by ACQ or CCQ. Results: In both groups the proportion of patients with an adequate inhalation technique significantly improved. The improvement in the Usual Care+ group was significantly higher as compared to the Usual Care group (4% to 85% and 12% to 57% respectively, p Conclusion: This study emphasises the importance of proper inhalation technique education, and in particular, the value of the newly developed visual instruction cards.

Inhalatiecorticosteroïden zijn niet zinvol bij jonge kinderen met luchtwegklachten

SamenvattingSchokker S, Kooi EMW, De Vries TW, Brand PLP, Mulder PGH, Duiverman EJ, Van der Molen T. Inhalatiecorticosteroïden zijn niet zinvol bij jonge kinderen met luchtwegklachten?Huisarts Wet 2008;51(13):657-62.Inleiding Veel jonge kinderen met recidiverende luchtwegklachten worden behandeld met inhalatiecorticosteroïden (ICS). Het is echter onduidelijk of dit zinvol is.Doel We onderzochten de effectiviteit van behandeling met ICS bij jonge kinderen met recidiverende luchtwegklachten in de huisartsenpraktijk.Methode We voerden een gerandomiseerd dubbelblind placebogecontroleerd onderzoek uit bij kinderen tussen de 1 en 5 jaar met recidiverende luchtwegklachten. Kinderen kwamen in aanmerking voor het onderzoek als de huisarts een onderhoudsbehandeling overwoog te starten in verband met astma-achtige klachten. De kinderen kregen 6 maanden lang fluticason propionaat of een placebo (2 maal daags 2 pufjes 50 microg via dosisaerosol met voorzetkamer). Na 1, 3 en 6 maanden kwamen de kinderen naar de onderzoekscentra voor de metingen. De ouders noteerden de luchtwegklachten en het gebruik van noodmedicatie in dagboekjes. De longfunctie werd gemeten met twee kindvriendelijke technieken.Resultaten We konden 96 van de 136 gescreende kinderen includeren. Zij worden at random toegewezen aan 1 van de 2 behandelgroepen. In beide groepen verbeterden de klachten gedurende de onderzoeksperiode. Aan het eind was de mate van luchtwegklachten in beide groepen vergelijkbaar. Ook de longfunctie verschilde niet tussen de groepen.Conclusie ICS zijn niet effectief bij alle jonge kinderen met recidiverende luchtwegklachten bij wie de huisarts behandeling overweegt. Bij het merendeel van de jonge kinderen verdwijnen de klachten in de loop van de tijd vanzelf. Een afwachtend beleid, eventueel met symptomatische behandeling, zal volstaan voor deze groep.

Recidiverende luchtwegklachten bij jonge kinderen: diagnostiek en behandeling

SamenvattingHuisartsen worden vaak geconsulteerd voor recidiverende luchtwegklachten bij kinderen jonger dan 5 jaar. Het is dan aan de huisarts om de diagnose astma te stellen en de juiste behandeling voor te schrijven. De dilemma’s die de diagnostiek en behandeling van deze groep kinderen met zich meebrengen, worden in dit artikel besproken. Het stellen van de diagnose astma is niet eenvoudig en er is nog geen duidelijkheid over de behandeling van deze groep kinderen in de huisartsenpraktijk, met name over de rol van inhalatiecorticosteroïden daarbij. Aangezien de diagnose astma moeilijk te stellen is bij kinderen onder de 5 jaar, is het lastig te bepalen welke kinderen baat hebben bij behandeling met deze ontstekingsremmers.

Diagnosis and therapy in pre-school children with asthma or asthma-like symptoms

Diagnosing asthma in pre-school children with asthma or asthma-like symptoms is a major problem because of the similarity of the symptoms. The initial treatment of these young patients is often performed by general practitioners. Currently very much attention is paid to the use of inhalation corticosteroids (ICS) in these young children while optimal treatment regiments are still unclear. The precise place of ICS has yet to be clarified in children with recurrent wheezing. Although several studies have shown that ICS is effective in the treatment of asthma we do not know which of these children should be given maintenance therapy with inhaled corticosteroids and which not.Only a small percentage of early wheezers go on to develop classic asthma. It is possible that children with transient wheeze do not respond to ICS in the same way true asthmatics do. The ability to predict accurately those wheezy pre-school children who will develop asthma eludes us. To focus on these diagnostic and therapeutic dilemmas. A multicentre, parallel group, randomised, double blind study to investigate the efficacy of ICS in 1 to 5 year old children with asthma or asthma-like symptoms. Study population: children with asthma or asthma-like symptoms in which in normal daily practice the general practitioner considers treatment with ICS because of symptoms. In this study we try to answer the question which children will benefit from maintenance treatment with ICS; as part of this study we have developed an Asthma Diagnostic Questionnaire. By using this questionnaire and by collecting additional lung function data (Forced Oscillation Technique and Resistance Interrupter Technique) we try to distinguish children with probably asthma from children with probably non-asthma. The results of our study may lead to an improvement in the diagnosis and treatment of asthma or asthma-like symptoms in pre-school children.