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Posted By: Kurtis S. Elward, MD, MPH
June 26, 2020
PCE recently held our Series 1 Live Stream events. During the Live Streams, attendees have the chance to ask expert faculty specific questions, though we often run out of time to address all of the questions. For our last Series 1 Live Stream, Dr Kurtis Elward, faculty for the asthma presentation, clinical professor at Virginia Commonwealth University and family physician at Sentara Family Medicine, was kind enough to provide written responses to the asthma questions that were not able to be addressed live. We hope you will find his answers relevant and helpful to your clinical practice.
These questions will be answered in 2 posts; this is post 1.
Why is it so important to avoid oral corticosteroids (OCS) in asthma?
Great question. We want to avoid frequent use of oral steroids. Oral steroids are really important to treat exacerbations and they are clearly needed at these times. However, frequent use is related to significant long-term problems, so our goal is to keep patients in sufficient control so that the use of OCS is minimized.
How often is too often for OCS in asthma?
Most experts would say that if patients have more than 2, and certainly 3 or more, episodes per year requiring OCS that their asthma regimen needs to be reassessed. If there are clear-cut triggers that are easily correctable—such as being exposed to a specific allergen or pet—and the risk of subsequent exposure is very low, patients may be fine continuing their current regimen, but with specific instructions and techniques on avoidance and/or pretreatment. However, if this cannot be assured, then their management needs to be reevaluated and specialty consultation should be initiated.
When an OCS is called for, do you use a Medrol Dosepak or a specific taper dose?
I almost never use a Medrol Dosepak. I think it underdoses quite a bit. The recommended treatment of OCS for most adults is 40 mg daily for 5 days, with or without a taper. The equivalent use of Medrol would be 36 mg daily.
In most EMRs, you can create an order set you can use as a favorite and label it "Medrol Asthma OCS" or something similar that you can click on to order this automatically.
Tapers are not considered necessary for most people, but this needs to be individualized. Some people feel better with a short taper, while others don’t need it. Weeks-long tapers are not needed for most patients.
I work in a long-term care facility. For someone who has severe asthma, is it prudent to give Solumedrol IM 60-80 mg x 1 dose and then start a Medrol pack?
That is reasonable and could be very helpful. It is similar to what I have often done, and in certain circumstances it may be the best way to assure that the steroids are in their system. I might suggest considering a 4- to 5-day course of OCS at a fixed dose, instead of a Medrol taper or a Dosepak.
What has your experience been in implementing an asthma action plan with illiterate patients? Any tips?
Great question! The use of action plans has been studied in illiterate patients and, in some ways, they are a great complement to verbal instruction. The use of pictures to describe the zones, as used in children, can be helpful. There are asthma action plans that have reading levels designed for low literacy, as well. In fact, there are action plans in more than 30 languages.
This site has examples of asthma action plans with pictures of medications: pediatrics.aappublications.org/content/137/1/e20150468.
What are some practical techniques to get patients to use peak flow meters in the morning? I find patients rarely use them even if they are asked to do so.
Another great question—and a big challenge. Not everyone needs to use peak flows for their asthma. It may be helpful to talk with patients about checking their peak flow when they have a cough or asthma symptoms, to be able to differentiate what is a cold and what is asthma. This can be especially helpful in children: Using peak flow meters when they are not feeling as well, will perhaps be more acceptable and give them a "reason." They may find over time that it really helps them. Most action plans can be symptom or peak flow driven, or both. Peak flow and symptom-based action plans are equivalent in most studies, but the real answer is what the patient and their primary care clinician find are most helpful in evaluating their status.
At which step in the pharmacology step-up plan is it best to consider referral to an asthma specialist for both adults and children?
This depends somewhat on whether you are trying to get a clear diagnosis, or whether you need help with treatment. Asthma specialists can be very helpful in terms of more sophisticated allergy testing, or if you do not have access to spirometry. I think most primary care clinicians feel very comfortable with GINA step 1 to 3 asthma, and many of us even in step 4. Some of the guidelines recommend specialist consultation fairly early, but in terms of both access and actual utility, this is not necessary and can be a logistical challenge.
I think management of mild intermittent, mild persistent, and moderate persistent asthma is clearly within our primary care wheelhouse. If you are a PA or NP, it makes sense to discuss approaches with your primary care physician colleagues; ideally your entire practice group will have a consistent management strategy.
Often insurance companies do not pay for spacers, especially in children. Why?
Spacers were initially determined to be "durable medical equipment" that was not a pharmacy benefit, and they got lost in the bureaucracy of the insurance world. This has changed a great deal, and all Medicaid plans cover spacers now, as well as most private insurers. If one does not, it might be a good idea to approach your American Lung Association chapter or the Asthma and Allergy Network/Mothers of Asthmatics. The company needs to catch up with 2020. If any little benefit is coming from COVID-19, it’s that most insurers are covering spacers to avoid nebulizers.
However, if you’re dealing with a really recalcitrant insurer, you can Google "asthma spacers" to find low cost and good quality spacers like Aerochamber, Philips, Optichamber, and Vortex. These can now be purchased for as little as $10.
Can Breo Ellipta and Anoro Ellipta be interchanged for cost-saving purposes?
I would not consider them interchangeable.
- Breo Ellipta is a combination of a beta-2 agonist (vilanterol) and a corticosteroid (fluticasone furoate).
- Anoro Ellipta is a combination of an anticholinergic (umeclidinium) and a beta-2 agonist (vilanterol).
Anoro Ellipta does not contain an anti-inflammatory medication, so I would use it and Breo Ellipta for separate indications. Because of this and the price, it would be wise to get pulmonary consultation when considering these two products.