Male: We have guidelines to go by in private practice and everything in it. They have come up with guidelines – to the kids that wheezes have asthma, like coughing, make a little less complicated guides, what are these new guidelines are about?
Dr. Marcus: The NHLBI the National Heart Lung Blood Institute from the National Institute of Health has recently, just one month ago in August of 2007 released the newest guidelines for the treatment of asthma. And these guidelines are a step beyond what the previous guidelines that five years ago taught us. Asthma has two pieces of its problem. It has, how severe the problem is and then it has how well controlled the symptoms are. And the guidelines really help us take a look at both parts of this problem. In looking at how severe the problem is, we break this down into how sick the child is now as well as what the risk is for them having problems in the future, so called the impairment domain and the risk domain. In taking a look at how sick they now, we look at how often they are wheezing everyday or every week, how often they are using their medicine specifically, their reliever medications, if they are waking up at night, if they are able to exercise and play with their friends properly, if they are able to attend school and work. We also look at their lung function tests to get a sense of how well the lungs are working. But sometimes children seem well when you do the lung function test but shows that they are actually sicker than what they appeared on the surface. Once you start with how severe they are, that will give you your starting point in which medications should be used. And the medications would include, inhaled corticosteroids, leukotriene modifiers, long-acting beta-agonists, as well as a group of other medications that we occasionally use in specific situations. Once that patient severity and starting medication has been instituted, you then need to re-evaluate that patient on a regular basis. Re-evaluation should occur anywhere from one month to maybe as long as every six months. But the usual recommendations are roughly every two to three months, at least once every season. So that we can judge whether our first round of medications are successfully controlling the symptoms. If the patient is using their reliever medicine more than twice a week, if they are waking up at night twice a month, if they are having difficulty with exercise, when they are coughing, or getting out of breath easily, if their lung function tests are not normal, these are all signs that the patient is not well controlled and if they are not well-controlled, we then would need to step up in their medication either to increase the dose or add a new medication. If they are very well controlled for anywhere from three to six month period that would also signal that we maybe able to lower their medications safely trying to minimize how much medicine the child is on while not increasing their risk of developing more serious symptoms in the future.
Male: One of the reasons some people don’t get well controlled is when they use inhalers, they think they have managed it, and that it has gas and no medicine, is that true?
Dr. Marcus: It is true. Inhalers have the advantage of being able to deliver medicine in a simple fashion but they have a disadvantage and that we don’t always know whether medicine remains in the inhaler. A very nice study was done a number of years ago where patients brought their inhalers in and the actual amount of medication was measured and it was found out that roughly 20% of the patients who thought they still have medicine left in their inhaler actually have inhalers that had no medicine left merely the gas propellant. This is why newer medications include counters so that we know how many doses are left in the device and as we get down to the end of the device, we can then know to refill our prescription. We should also keep track of when a canister was started because we know that there is roughly one-month supply in an average canister and if we count backwards on the starting day, we will know when it is time to refill our prescription. When in doubt, it is better to get a new canister of medication and to be pumping on a canister that is empty.
Male: So one month is a pretty good route, what is the time, it’s a month, get a new one.
Dr. Marcus: If you are using the medicine in the way that is recommended by the physician, then one month per canister would be the average.
Male: In fact the Albuterol inhaler, when it has 200 metered doses and we give two puffs four times a day, you are out in 25 days.
Dr. Marcus: Exactly, it does not even last a month. Now, ideally we shouldn’t be needing the Albuterol two puffs, four times a day. In fact if you are taking it that often then you really need to adjust your control on medications since Albuterol is a reliever and should be used more on an as needed basis. Therefore, once a month refill is the optimal and one of the guides that a physician can use that you are not under good control is if you are renewing your prescription more often than a monthly basis.
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