Intranasal steroids and the risk of emergency department visits for asthma

doi:10.1067/mai.2002.123237

Journal of Allergy and Clinical Immunology

Volume 109, Issue 4, April 2002, Pages 636-642

https://doi.org/10.1067/mai.2002.123237 Get rights and content

Abstract

Background: In patients with asthma, treatment for associated conditions, such as rhinitis, is recommended. It is unknown whether this treatment can reduce the risk for emergency department (ED) visits for asthma. Objectives: We sought to determine whether treatment with intranasal steroids or prescription antihistamines in persons with asthma is associated with a reduced risk for ED visits caused by asthma. Methods: We performed a retrospective cohort study of members of a managed care organization aged greater than 5 years who were identified during the period of October 1991 to September 1994 as having a diagnosis of asthma by using a computerized medical record system. The main outcome measure was an ED visit for asthma. Results: Of the 13,844 eligible persons, 1031 (7.4%) had an ED visit for asthma. The overall relative risk (RR) for an ED visit among those who received intranasal corticosteroids, adjusted for age, sex, frequency of orally inhaled corticosteroid and β-agonist dispensing, amount and type of ambulatory care for asthma, and diagnosis of an upper airways condition (rhinitis, sinusitis, or otitis media), was 0.7 (95% confidence interval [CI], 0.59-0.94). For those receiving prescription antihistamines, the risk was indeterminate (RR, 0.9; 95% CI, 0.78-1.11). When different rates of dispensing for intranasal steroids were examined, a reduced risk was seen in ED visits in those with greater than 0 to 1 (RR, 0.7; 95% CI, 0.57-0.99) and greater than 3 (RR, 0.5; 95% CI, 0.23-1.05) dispensed prescriptions per year. Conclusions: Treatment of nasal conditions, particularly with intranasal steroids, confers significant protection against exacerbations of asthma leading to ED visits for asthma. These results support the use of intranasal steroids by individuals with asthma and upper airways conditions. (J Allergy Clin Immunol 2002;109:636-42.)

Section snippets

Methods

All subjects were members of Harvard Pilgrim Health Care and received care at any one of 14 staff-model centers (now Harvard Vanguard Medical Associates) located in eastern Massachusetts. The MCO maintains computerized information systems that capture basic demographic data, medical records that include coded diagnoses, tests and procedures from each ambulatory encounter, and claims files for all hospitalizations and ED visits. Automated pharmacy records maintained by or available at all sites

Results

During the 3-year study period, 13,844 persons satisfied the eligibility criteria for asthma. The overall observation time was 40,402 person-years. The median duration of observation time was 3 years, and 75% of the study population were members of the MCO for at least 2.3 years. The mean age of the population was 26 years (SD, 17 years). The majority were adults, with 3888 aged between 6 and 17 years, 5134 aged between 18 and 34 years, and 4822 aged 35 years and older. Female patients

Discussion

These data suggest that treatment for upper airways diseases with nasal steroids and oral antihistamines is associated with a reduced frequency of asthma-related ED visits. The effect of treatment for the nose in reducing asthma-related ED visits was seen in persons who were also being treated with orally inhaled corticosteroids for asthma, as well as in those not using inhaled steroids. After controlling for asthma treatment and indicators of asthma care (routine and urgent ambulatory visits),

References (49)

SL. Spector
Overview of comorbid associations of allergic rhinitis
J Allergy Clin Immunol
(1997)
MF Mullarkey et al.
Allergic and non-allergic rhinitis: their characterisation with attention to the meaning of nasal eosinophilia
J Allergy Clin Immunol
(1980)
B Leynaert et al.
Perennial rhinitis: an independent risk factor for asthma in non-atopic subjects
J Allergy Clin Immunol
(1999)
C Bucca et al.
Extrathoracic and intrathoracic airway responsiveness in sinusitis
J Allergy Clin Immunol
(1995)
P. Fireman
The role of antihistamines in otitis
J Allergy Clin Immunol
(1990)
JM. Bernstein
The role of IgE-mediated hypersensitivity in the development of otitis media with effusion
Otolaryngol Clin North Am
(1992)
DP Skoner et al.
Eustachian tube dysfunction after histamine nasal provocation
J Allergy Clin Immunol
(1987)
FER. Simons
Allergic rhinobronchitis: the asthma-allergic rhinitis link
J Allergy Clin Immunol
(1999)
BP Yawn et al.
Allergic rhinitis in Rochester, Minnesota residents with asthma: frequency and impact on healthcare charges
J Allergy Clin Immunol
(1999)
PW Welsh et al.
Efficacy of beclomethasone nasal solution, flunisolide and cromolyn in relieving symptoms of ragweed
Mayo Clin Proc
(1987)

J Corren et al.

Nasal beclomethasone prevents the seasonal increase in bronchial responsiveness in patients with allergic rhinitis and asthma

J Allergy Clin Immunol

(1992)

J Corren et al.

Efficacy and safety of loratidine plus pseudoephedrine in patients with seasonal allergic rhinitis and mild asthma

J Allergy Clin Immunol

(1997)

JA Grant et al.

Clinical aspects of disease. Cetrizine in patients with seasonal rhinitis and concomitant asthma: prospective, randomized, placebo-controlled trial

J Allergy Clin Immunol

(1995)

BL Strom et al.

Post-marketing studies of drug efficacy: why?

Am J Med

(1985)

BL Strom et al.

Post-marketing studies of drug efficacy: how?

Am J Med

(1984)

FT Leone et al.

Pharmaceutically-based severity stratification of an asthmatic population

Respir Med

(1999)

J. Corren

Allergic rhinitis and asthma: How important is the link?

J Allergy Clin Immunol

(1997)

WTA Watson et al.

Treatment of allergic rhinitis with intranasal corticosteroids in patients with mild asthma: effect on lower airway responsiveness

J Allergy Clin Immunol

(1993)

A Jen et al.

As-needed use of fluticasone propionate nasal sprays reduces symptoms of seasonal allergic rhinitis

J Allergy Clin Immunol

(2000)

WW Crawford et al.

Comparative efficacy of terfenadine, loratidine, and astemizole in perennial allergic rhinitis

Otolaryngol Head Neck Surg

(1998)

RP Harvey et al.

Model for outcome assessment of antihistamine use for seasonal allergic rhinitis

J Allergy Clin Immunol

(1996)

CA Wong et al.

Inhaled corticosteroid use and bone-mineral density in patients with asthma

Lancet

(2000)

B. Lundbäck

Epidemiology of rhinitis and asthma

Clin Exp Allergy

(1998)

T Kapsali et al.

Rhinitis is ubiquitous in allergic asthmatics

J Allergy Clin Immunol

(1997)

Cited by (218)

Intranasal steroid use and COVID-19 mortality among patients with asthma and COPD: A retrospective cohort study
2023, Annals of Allergy, Asthma and Immunology
Systemic corticosteroids have been widely used for treating patients with severe acute respiratory distress syndrome. Inhaled corticosteroids may have a protective effect for treating acute coronavirus disease 2019 (COVID-19); however, little is known about the potential effect of intranasal corticosteroids (INCS) on COVID-19 outcomes and severity.
To assess the impact of prior long-term INCS exposure on COVID-19 mortality among patients with chronic respiratory disease and in the general population.
A retrospective cohort study was conducted. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between INCS exposure and all-cause and COVID-19 mortality, adjusted by age, sex, deprivation, exacerbations in the last year, and comorbidities.
Exposure to INCS did not have a significant association with COVID-19 mortality among the general population or cohorts with chronic obstructive pulmonary disease or asthma, with HRs of 0.8 (95% CI, 0.6-1.0, P = .06), 0.6 (95% CI, 0.3-1.1, P = .1), and 0.9 (95% CI, 0.2-3.9, P = .9), respectively. Exposure to INCS was, however, significantly associated with reduction in all-cause mortality in all groups, which was 40% lower (HR, 0.6 [95% CI, 0.5-0.6, P < .001]) among the general population, 30% lower (HR, 0.7; 95% CI, 0.6-0.8, P < .001) among patients with chronic obstructive pulmonary disease, and 50% lower (HR, 0.5; 95% CI, 0.3-0.7, P = .003) among patients with asthma.
The role of INCS in COVID-19 is still unclear, but exposure to INCS does not adversely affect COVID-19 mortality. Further studies are needed to explore the association between their use and inflammatory activation, viral load, angiotensin-converting enzyme 2 gene expression, and outcomes, exploring different types and doses of INCS.
The impact of specialized management on allergic asthma outcomes
2023, Revue des Maladies Respiratoires
L’asthme allergique a des caractéristiques variables en fonction de la région. Sa prise en charge est souvent réalisée sans accès facile à une évaluation pneumo-allergologique spécialisée.
Caractériser l’asthme allergique des patients suivis au CHRU de Nancy.
Estimer l’impact à 12 mois de la prise en charge spécialisée proposée.
Étude rétrospective incluant des adultes asthmatiques allergiques entre le 01/01/2016 et le 31/12/2018. Paramètres étudiés (en dehors des paramètres descriptifs) : score du contrôle de l’asthme ACQ-7 (Asthma Control Questionnaire) et fonction respiratoire à l’inclusion et à un an.
Cent-quinze patients inclus (âge 42 ± 16 ans, femmes 63 %, non-fumeurs 70 %). Les symptômes d’asthme débutaient à 19 ± 18 ans, mais la consultation spécialisée était réalisée 21 ± 17,5 ans après. Les sensibilisations fréquentes étaient : acariens (49 %), phanères de chat (43 %), graminées (43 %). Les patients sous-estimaient la fréquence de leurs allergies (acariens 36 % p = 0,011, pollens 36 % p = 0,001, phanères 42 % p = 0,003, moisissures 80 % p = 0,007). À 1 an de suivi il existait une amélioration du score ACQ-7 (1,3 ± 1,3 vs 0,8 ± 0,9 ; p = 0,007) et du volume expiratoire maximal par seconde (81,3 ± 20,8 % vs 86,2 ± 21,9 % ; p = 0,002).
les asthmatiques allergiques suivis à Nancy sont caractérisés par une âge de début de l’asthme et consultation spécialisée tardifs, une sensibilisation prédominante aux phanères de chat et aux pollens de bétulacées, une sous-estimation des allergies par le patient. La prise en charge spécialisée semble avoir une place importante dans la gestion de l’asthme allergique. Son accès, actuellement difficile, pourrait être facilité par la création de filières dédiées.
Allergic asthma has variable characteristics depending on the region of occurrence. Management is often organized without easy access to a specialized pneumo-allergological evaluation.
To characterize allergic asthma in patients followed at the Nancy University Hospital.
To estimate the impact at 12 months of the proposed specialized management.
Retrospective study including allergic asthmatic adults conducted between 01/01/2016 and 31/12/2018. Parameters studied (aside from descriptive parameters): asthma control score ACQ-7 (Asthma Control Questionnaire) and lung function at inclusion and at one year.
One hundred and fifteen patients were included (age 42 ± 16 years, women 63%, non-smokers 70%). Even though asthma symptoms arose at 19 ± 18 years, the specialized consultation was performed 21 ± 17.5 years later. Frequent sensitizations involved house dust mites (49%), cat dander (43%), grasses (43%). Patients tended to underestimate the frequency of their allergies (mites 36% P = 0.011, pollens 36% P = 0.001, pet dander 42% P = 0.003, molds 80% P = 0.007). At 1-year follow-up both the ACQ-7 score (1.3 ± 1.3 vs. 0.8 ± 0.9; P = 0.007) and the forced expiratory volume per second (81.3 ± 20.8% vs. 86.2 ± 21.9%; P = 0.002) had improved.
The specificities of allergic asthmatics followed up in Nancy: late age of asthma onset of asthma and specialized consultation; predominant sensitization to cat dander and Betulaceae pollens; underestimation of allergies by the patient. Specialized care seems to important in the management of allergic asthma. While access to specialized care remains problematic, it could be facilitated by the creation of dedicated networks.
Lantibiotics in antifungal therapy: a futuristic approach
2023, Lantibiotics as Alternative Therapeutics
Lantibiotics are a class of bacteriocin that are commonly used in preventing Gram-positive bacterial growth and has the potency to be used in antifungal therapy. Early lantibiotics were isolated exclusively from Gram-positive bacteria, nisin being the first to be discovered. Pinensin from Chitinophaga pinensis is the first lantibiotic isolated from a Gram-negative bacterium, which showed weak antibacterial activity and significant inhibition of yeast and fungi by degrading chitin. Antifungal therapy is currently limited to griseofulvin, polyenes, azoles, azole derivatives (triazoles, imidazole, and fluconazole), and echinocandins. Lantibiotics have the potential to be the future antifungal drug either in combination amongst themselves or in combination with steroids or traditional antifungal drugs (amphotericin B, liposomal amphotericin B, caspofungin, etc.). In recent years, several antifungal natural products from the cyanobacteria, Prochlorococcus, and the bacteroidetes, Pedobacter, have been reported, which also have the potential to be used in combination with lantibiotics. Combinatorial strategy will reduce the dose required for equivalent efficacy and thus mitigate associated toxicity. Lantibiotics can address the concerns of life-threatening disease mycosis in immunocompromised patients. This review will explore the possibility of using novel antifungal therapy against several progressive multidrug-resistant fungal strains.
Secondary asthma prevention measures are not adequately addressed prior to emergency department discharge!
2022, American Journal of Emergency Medicine
Exacerbations of acute asthma are frequent presentations to the Emergency Department (ED) and contribute to ED overcrowding and healthcare cost. The purpose of this study was to evaluate whether ED clinicians are implementing secondary asthma prevention measures prior to discharging patients after an acute asthma exacerbation and also to determine whether ED clinicians are able to correctly demonstrate how to use an asthma metered dose inhaler (MDI) device.
Consenting doctors employed at four EDs situated in the Gauteng province of South Africa were asked to complete a questionnaire and thereafter demonstrate the technique of using an MDI device. Collected data was presented using descriptive statistics.
Eighty-six doctors were included in the study. Of these, 18 (20.9%) routinely checked that inhaler technique was correct, 50 (58.1%) routinely enquired regarding adherence to their asthma treatment, 8 (9.3%) routinely informed patients of the side effects of asthma medication, 16 (18.6%) routinely provided patients with a written asthma action plan, 7 (8.1%) routinely evaluated for the presence of concurrent allergic rhinitis and 53 (61.6%) routinely counselled patients regarding smoking cessation. With regards to correctly demonstrating how to use an MDI device, only 23 (26.74%) physician participants performed all eight steps correctly.
This study indicates that secondary asthma prevention measures are not adequately addressed by clinicians prior to discharging patients from the ED after an acute asthma attack. It is recommended that ED clinicians are educated with regards to the importance of these measures.
Asthma-COPD Overlap and Chronic Airflow Obstruction: Definitions, Management, and Unanswered Questions
2020, Journal of Allergy and Clinical Immunology: In Practice
Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a common clinical presentation of chronic airways disease in which patients show some features usually associated with asthma, and some usually associated with COPD. There is ongoing debate over whether ACO is a discrete clinical entity, or if it is part of a continuum of airways disease. Furthermore, there is considerable variation among current definitions of ACO, which makes diagnosis potentially challenging for clinicians. Treating ACO may be equally challenging because ACO is an understudied population, and the evidence base for its management comes largely from asthma and COPD studies, the relevance of which deserves careful consideration. In this review, we synthesize the various approaches to ACO diagnosis and evaluate the role of currently available diagnostic tests. We describe the potential benefits of existing asthma and COPD therapies in treating patients with ACO, and the value of a “treatable traits” approach to ACO management. Throughout the review, we highlight some of the pressing, unanswered questions surrounding ACO that are relevant to the clinical community. Ultimately, addressing these questions is necessary if we are to improve clinical outcomes for this complex and heterogeneous patient population.
Treatment of allergic rhinitis reduces acute asthma exacerbation risk among asthmatic children aged 2–18 years
2019, Journal of Microbiology, Immunology and Infection
Asthma and allergic rhinitis (AR) frequently coexist in the same individuals in childhood and adolescence. We evaluated whether AR had an impact on acute exacerbation (AE) and whether intranasal corticosteroid (INCS) and second-generation antihistamines (SGH) for AR modified the association of AR with AE in asthmatics aged 2–6 years and 7–18 years.
Using the National Health Research Institutes (NHRI) Database 2005 of Taiwan, we investigated patients who had been diagnosed with asthma in the years 2000 through 2012 and who had then been followed-up with for at least one year. The risk factors of AE were evaluated using multiple Cox proportional hazards regression analysis.
The incidence of AE was higher in the preschool group than the older group (adj. HR: 1.68, 95% CI: 1.44–1.95). The AR with INCS and/or SGH group was found to have a lower risk of AE than the non-AR group (adj. HR: 0.32, 0.44 and 0.30), but the AR without treatment group did not have a significant difference with the non-AR group. After propensity score matching, the use of INCS and/or SGH was associated with a significant reduction in the occurrence of AE among AR patients aged 2–6 years old (adj. HR: 0.38, 0.57 and 0.45) and 7–18 years old (adj. HR: 0.50, 0.52 and 0.35).
The preschool patients had a higher incidence of AE than the older patients in general. Adequate treatment with INCS and/or SGH in asthma with AR patients is important for reducing the incidence of AE of asthma.

View all citing articles on Scopus

^☆: Supported by Harvard Pilgrim Health Care Research Foundation. Dr Adams is a recipient of the Thoracic Society of Australia and New Zealand/Allen and Hanbury's Respiratory Research Fellowship. Dr Fuhlbrigge is supported by a Mentored Clinical Scientist Development Award (1 KO8 HL03919-01) from the National Heart, Lung, and Blood Institute.

^☆☆: Reprint requests: Anne L. Fuhlbrigge, MD, MS, Channing Laboratory, Brigham and Women's Hospital, 181 Longwood Ave, Boston, MA 02115.

View full text

Asthma, Rhinitis, Other Respiratory DiseasesIntranasal steroids and the risk of emergency department visits for asthma☆,☆☆

Abstract

Section snippets

Methods

Results

Discussion

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Otolaryngol Clin North Am

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Mayo Clin Proc

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Am J Med

Am J Med

Respir Med

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Otolaryngol Head Neck Surg

J Allergy Clin Immunol

Lancet

Epidemiology of rhinitis and asthma

Clin Exp Allergy

Rhinitis is ubiquitous in allergic asthmatics

J Allergy Clin Immunol

Asthma, Rhinitis, Other Respiratory Diseases
Intranasal steroids and the risk of emergency department visits for asthma☆,☆☆