In episode 105, James and Mike continue on with breathless abandon their discussion about the use of drugs in asthma. With chronic asthma the whole concept of low dose and shared-informed decision making comes right back into focus (thank goodness) and so both of us rest easy that the last 104 podcasts, at least from that perspective, have not been a waste of time.

Show notes

1) PRN versus chronic use of inhaled salbutamol

Lancet 2000;355:1675-9

2) Inhaled corticosteroids in patients with new-onset asthma

NEJM 1991;325:388-92

“all patients with mild persistent asthma deserve the opportunity to decide whether the benefit from their use is worth the effort of taking a very safe medication,  usually once daily”

Am J Res Crit Care Med 2005;172:410-2

3) Choice of inhaled corticosteroid – no difference

Ann Allergy Asthma Immunol 2003;91:326-34

Ann Pharmaco 2009;43:519-27

4) Doses of inhaled corticosteroid – low doses

“published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma”

Cochrane Library

5) Equipotent daily doses of inhaled corticosteroids in adults – the doses listed below are considered ‘low” doses, “moderate doses = doubling these doses; “high” doses = quadrupling these doses. In children the corresponding doses are usually about 2/3 of the adult doses

Triamcinolone/Flunisolide 400/500-1000 mcg

Beclomethasone 200-500 mcg

Budesonide /Mometasone 200-400 mcg

Fluticasone 100-250 mcg

Ciclesonide 80-160 mcg

Eur Respir J 2008;31:143–78

6) Doubling the dose of inhaled CS when symptoms get worse provides no benefit

Lancet 2004;363:271-5

Thorax 2004;59:550–6

Cochrane Library

7) Maybe quadrupling the dose will work????

Am J Respir Crit Care Med 2009;180:598–602

8) High dose inhaled corticosteroids can often be reduced without any change  in symptom control

NEJM 1994;331:700-5

9) After inhaled steroids what’s next – tiotropium or salmeterol?

NEJM 2010;Sept 19

10) LABA vs LTRA

“In asthmatic adults inadequately controlled on low doses of inhaled steroids, the addition of LABA is superior to LTRA for preventing exacerbations requiring systemic steroids, and for improving lung function, symptoms, and use of rescue ß2-agonists”

Cochrane Library

11) Peak flow measurements

Am J Respir Crit Care Med 2006;174:1077–87

In episode 104, Mike and James blow out a lot of hot air about the use of medications for acute asthma and they come to the quick realization that the concepts they have been evangelising for the past 2 years (low dose and shared-informed decision making) have no role in acute asthma. James, in an act of defiance gets a cat to sit on top of Mike’s head until becomes acutely short of breath and then gives Mike a 1/4 puff of salbutamol. Shockingly, the outcome was less than optimal.

Show notes

1) Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

Cochrane review

2) Continuous versus intermittent beta-agonists for acute asthma

Cochrane review

3) Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children

Cochrane review

4) Early emergency department treatment of acute asthma with systemic corticosteroids

Cochrane review

5) Magnesium for acute asthma

Cochrane review

6) Aminophylline for acute asthma

Cochrane review

In episode 103, James and Mike discuss the whole concept of discussion of side effects with patients. They rarely disagree but commonly get confused and at the end they both develop all the side effects discussed, which goes completely against the available literature.

Show notes

1) Important elements of outpatient care

Ann Intern Med 1996;125:640-5

2) The consent form that caused side effects

Clin Pharmacol Ther 1987;42:250-3

3) The evidence that telling patients about side effects doesn’t cause side effects

Br J Psych 1973;122:461-4

Br J Psych 1978;132:526-7

J Behav Med 1982;5:263-73

Br J Clin Pharmac 1984;17:21-5

Br J Clin Pharmac 1989;27:723-39

J Fam Pract 1990;31:62-4

Arch Int Med 1994;154:2753-6

4) If you are allergic you are allergic

N Engl J Med 2003;349:1628-35

5) Why you shouldn’t use words to describe the magnitude of side effects

Lancet 2002;359:853–54