Two Steps Back on Asthma Control


Date: 06.03.2018

For all the headlines garnered by food allergies, asthma remains the larger threat to public health. While we like to think we know enough about this set of symptoms and how to treat it with the limited tools we have, current research shows otherwise. For example, an upcoming article from In Practice tells us that the guideline recommending a spacer for use with pressurized extra-fine-particle (QVAR) or fine-particle (Flixotide) inhaled corticosteroids (ICS) is not only ineffective but perhaps counterproductive.

This is an important article for me because while it deals only with patients 12 and up, I prescribe small-particle steroids for children. The small particles navigate the tiny airways of children better than those with larger particles. I need to know that I am doing the right thing.

Key results as reported by Univadis include:

  • No difference in rates of severe exacerbations between spacer and no-spacer groups in both ICS cohorts.
  • Rates of acute respiratory events and odds of risk-domain asthma control were similar with spacer and no-spacer.
  • Unadjusted results showed no significant difference in hospitalizations with spacers.
  • In unadjusted analysis, patients prescribed spacers had significantly lower odds of achieving overall asthma control, meeting treatment stability criteria.
  • Treatment changes were more common in patients prescribed spacers.

So, are spacers a good thing or not?

Let me describe what a spacer does. A pressurized metered-dose inhalers (pMDI) releases the gas at about 60 miles per hour. A spacer captures the dispersed gas so that the patient can inhale at something approaching his own speed instead of inhaling precisely at the time it is being jetted out. I’ve tried that and it’s not easy. Fail to coordinate and the active ingredients stay in your mouth where most patients just rinse them out. It’s difficult for kids but adults often get it wrong, too. Allergists and pulmonologists should take pains to instruct them, but I’m guessing that in the current assembly line medical environment we have today, it doesn’t get done. With internists doing a good deal of the prescribing, I’m betting it happens even less.

I am looking forward to the full article, but for the moment I am curious about the specific language of the above bullet points. Namely, the use of the word “prescribed.” Inadequate compliance is an issue plastered all over chronic disease management. We know that large numbers of patients never fill their first prescriptions and many more fail to renew them. Are these subjects using the spacers as prescribed? Do they purchase them but not bother to use them? Just as no medicine is effective if you don’t take it, no apparatus is effective if you don’t use it, or don’t use it right.

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