Episode transcript
Time stamps
0:36 - Introducing today’s episode.
2:27 - What is asthma peak week?
6:13 - Contributing factors and preventative measures for the asthma peak.
8:55 - Studies on the importance of reducing allergic triggers.
12:06 - Patient management tools and recommendations.
Announcer:
ImmunoCAST is brought to you by Thermo Fisher Scientific creators of ImmunoCAP™ Specific IgE diagnostics and Phadia™ Laboratory Systems.
Gary Falcetano:
I'm Gary Falcetano, a licensed and board-certified PA with over 12 years experience in allergy and immunology.
Luke Lemons:
And I'm Luke Lemons with over six years experience writing for healthcare providers and educating on allergies. You're listening to ImmunoCAST, your source for medically and scientifically-backed allergy insights. So Asthma Peak Week is almost a month away in September. And Gary and I had figured that we wanted to do an episode before that to really help inform healthcare providers on best practices in managing asthma patients, as well as talk a little bit about Peak Week and why it is a big deal for patients who do have asthma.
Gary Falcetano:
So we talk about anticipatory guidance all the time for patients. We're going to talk about that today. But this is a little anticipatory guidance for our clinicians, right, our providers. With Asthma Peak Week being about a month away, this is a perfect time to prepare.
Luke Lemons:
Yeah. And be proactive about it. And so why don't we start with what is Asthma Peak Week? So there are technically two weeks throughout the whole year where we see a peak in hospitalizations, exacerbations in patients with asthma. It's the third week in September, which is the closest one, and then the last week in December.
Gary Falcetano:
Yeah. And the third week in September is really the largest, which is why we're talking about this now. It's especially important for children, but we see the peak for adults as well.
Luke Lemons:
And so it is the 18 days after Labor Day, is where we see a heightened peak in hospitalization in asthma patients. And actually, one quarter of all children's hospital visits for asthma occur just in September, which is a lot.
Gary Falcetano:
And it's not just hospitalizations, right, but it's exacerbations of all forms, including unscheduled visits, urgent care visits. So this is a time ... It's pretty much, if we think about it, what's causing this peak, right. It's really a tsunami of inflammatory triggers that are occurring at this time of the year.
Luke Lemons:
And this is because children are returning to school and they're encountering maybe more respiratory viruses. And colds and flus are becoming more common and transmittable between different people, family members. It's also ragweed season for ragweed pollen, which is the most common fall allergen or pollen allergen. So that can lead to some difficulty breathing as well.
Gary Falcetano:
And we've seen this in multiple studies, lower levels of prescriptions being refilled during the summer. So especially among children, but even among adults, we're seeing less controller medications being refilled as well as rescue medications.
Luke Lemons:
Yeah. And that's really interesting to me because they're breathing easy during the summer, people who have asthma, and they're not filling their prescription. And then all of a sudden, September comes and all these things that can cause difficulty breathing hits them, and then they go and reactively get their prescription renewed. And so the goal here is to be, again, proactive so that they're not in a position where they feel like they need to rush to get their prescription filled, but making sure that they're prepared going into the season.
Gary Falcetano:
Absolutely. And there's a couple of other reasons, right. We talked about those returning to school and the viral illnesses, ragweed season. But there's other allergens potentially involved here too, right. Children are going back to schools, which may be in aging buildings. They may have poor air quality. They're spending more time inside. So increased exposure to indoor allergenic triggers, things like dust mites and pets and molds. As well as this time of year, there's a bit of stress and anxiety throughout the family, right, both in children going back to school, parents with changes in schedules returning from vacation. It can be a fairly stressful time.
Luke Lemons:
And you had called this a tsunami of different factors, and it really is because the combination of all of them is why we have Peak Week and why it's so important to be sure that patients are prepared. We actually see that if a patient has a viral illness, is exposed to an allergen that they're allergic to, and have asthma, we see a twenty-fold increase of hospitalization.
Gary Falcetano:
Yeah. So this was a study done by Murray and it's published in Thorax. And what they actually looked at was patients, especially this was children presenting to emergency departments. And they saw that if they had allergic sensitization, they were exposed to their allergic triggers, and developed a viral illness, so all three, that tsunami, if you will, that's where we saw the twenty-fold increase in hospitalizations.
Luke Lemons:
And this is part of the reason why the NIH recommends that patients with asthma get the influenza vaccine. So that's category B evidence from the NIH that patients should get the influenza vaccine if they have asthma. But Gary, there is actually category A evidence that many providers may not know is more recommended, "more", quote, unquote, than that.
Gary Falcetano:
Well, at least better supported, right.
Luke Lemons:
Yes.
Gary Falcetano:
With the evidence. Yeah. We wouldn't think of not recommending an influenza vaccine, right. But I think where, and we've talked about this on previous episodes, where we see a gap, right, is actually testing patients with asthma for their allergic triggers. And that in the NIH asthma guidelines is actually considered category A evidence. So a high level of evidence.
Luke Lemons:
It's not just the NIH. The CDC also says that any patient with persistent asthma should be tested, whether it's controlled or uncontrolled. So you have the CDC and the NIH saying, "Hey, patients with asthma need to be evaluated for allergic triggers." And this is because about 90% of children and 60% of adults have allergies that drive their asthma.
Gary Falcetano:
Yeah. And we also know that we can't just assume, right, what those allergic triggers are. And we've spoken about the symptom threshold before, but we know that up to 90% of people that are allergic and sensitized are allergic to more than one thing. So it's ragweed season. We're assuming that it's ragweed allergy that's driving this increase in symptoms, but it's probably not, right. 90% of the time, it's a ragweed allergy and maybe something else as well. So dust mite or pet or a cockroach or a mouse allergy, right, any one of these things. And they're all cumulative to cause symptoms.
Luke Lemons:
Yeah. You had said 90% of allergic patients are sensitized to more than ... I just want to reiterate that because the chances that you have a patient who comes in and says, "Oh. Well, I'm just allergic to ragweed," is really, really low. 90% of patients will be allergic to another allergen. And I'm glad you mentioned that it's something that stacks in a way. So we talk about the symptom threshold all the time. And that is that if you can reduce exposure to one of the allergens that is causing some symptoms, you may be below that threshold and you won't have as severe symptoms as you normally would.
Gary Falcetano:
Exactly. So you've got things like ... Let's say you are sensitized and allergic to dust mites, to a pet, and then also to the seasonal ragweed pollen, right, they're all adding up to push you past that symptom threshold. We can't put people in a bubble, but if we can control their exposures, especially in the bedroom, right, where they spend eight, nine, 10 hours a day, it has a dramatic effect on symptoms. And there was actually a study that looked at this and really proved that telling people and identifying their triggers and addressing those triggers can have a dramatic impact.
Luke Lemons:
Yeah. And so the study you're referencing is from The New England Journal of Medicine where they looked at inner city asthma patients. And they looked at all over the country. They looked at about a thousand patients over a course of two years. And they randomized an active and control group where the active group received recommendations on interventions in the bedroom that they could do to reduce allergic triggers. The control group still had conversations around the correct way to use your asthma inhaler and having an asthma action plan, but they didn't talk about allergens in the control group.
Gary Falcetano:
The only difference in the active group was identifying their allergic triggers, right, and modifying them or reducing them in the bedroom.
Luke Lemons:
So Gary, why don't you share what they found? Because it's really interesting.
Gary Falcetano:
Yeah. So pretty dramatic results. Was a two-year study. In the first year of the study, they started to see, as I said, some pretty dramatic results. In the second year of the study, they weren't as prescriptive about reminding people, right, exactly what they had to do. And what they found was people actually internalized the advice and kept doing it. And the results that they saw were, as we said, dramatic. So 21 less days of symptoms per year. So three weeks less symptoms per year, right. Almost a week's less missed school days. I think it was 4.1 less missed school. And finally, two less unscheduled ER visits or office visits. So again, the only independent variable or the only variable here was identifying their sensitizations and reducing the exposure in the bedroom.
Luke Lemons:
I like how you mentioned that during the second year, they weren't as intense about reminding them because I think oftentimes when you do have patient [inaudible 00:09:03] conversations and management conversations, it may feel like, oh, they're not actually going home and doing this. But the study says they were educated, they kept doing the things that were recommended, and it showed. And these asthma patients were able to keep themselves out of the ER, less days experiencing symptoms of their asthma and missing school.
Gary Falcetano:
Yeah. One of the other call-outs, Luke, was they saw similar change in symptoms as a steroid naive asthma patient would see with starting an inhaled corticosteroid. So this preventative measure with no side effects, right, had a similar efficacy as actually starting someone on an inhaled corticosteroid.
Luke Lemons:
And some of the recommendations that they had, because we're talking about all the intervention, but some of the things that they had recommended was closing the window in their bedroom if they had a pollen allergy, having a HEPA filter, dust mite covers on the bed and pillows if they had a sensitization to dust mites, as well as if they had a family pet, keeping it out of the bedroom. Alone. Remember, this isn't just the whole house. This is just the bedroom. Imagine the whole house if everyone was on the same page. But it really shows the power of telling patients what they can do to reduce their allergic triggers if they know what they are. So I think that that goes into what can providers do gearing up for Asthma Peak Week that's about to happen, Gary.
Gary Falcetano:
Yeah. And you know what? Before we talk about that, let's also just remind the listeners that we do have resources, right, that help with these targeted exposure reduction recommendations. Short, to the point patient education instructions that they can download from the show notes. So this time of year, again, being proactive, right, it's important, number one. We mentioned that a lot of patients are not refilling their prescriptions over the summer, so making sure they have up-to-date prescriptions for their current meds, especially their controller medications, and that they've filled them, right, in anticipation of Peak Week coming in September. Also, common sense, right. They have an asthma action plan in place and they know what to do if they experience an increase in symptoms. Making sure we're doing an asthma control test at every visit, right, to assess their level of control. And that's whether they're here for a ... Whether they're presenting for an asthma visit or an unrelated visit, right, we should assess control at every visit.
Luke Lemons:
That's a great call out. Asthma patients need to be flagged this time of year. They may come in with a sprained ankle and you see on their chart, oh, they have asthma. Okay. Is their prescription up to date? Have they been allergy tested too? Because that's another, again, NIH, CDC recommendations, that a patient with asthma should know what their allergic triggers are. And then coaching the patients to reduce exposure to those triggers. And we have actually, in the description of this episode, there's a link. And it'll bring you to this episode's specific webpage where we have some patient management tools that can help you have those conversations about reducing exposure to specific allergens as well as an asthma action plan template if you would like that as well.
Gary Falcetano:
Yeah. And let's not forget making sure their vaccines are up to date, right. Their influenza vaccine. Any other respiratory vaccines that are indicated. It's always important to remind them about ways to prevent viral illnesses, right. Washing hands. Not going to school or work if they're sick. All of the standard things that we think about for preventing illness.
Luke Lemons:
Yeah. And even though it's extremely important to be having these conversations and doing this sort of testing now, in general, this should be standard practice for asthma patients because 10 people die a day from asthma. And that's across whether it's controlled or uncontrolled, right, Gary. It's a problem. And we need to be better about managing these patients.
Gary Falcetano:
Exactly. 25 million people in the US have asthma. The majority of them are being managed in primary care. So it's really incumbent upon primary care providers to really provide the best possible evidence-based management and care that they can for these patients to be sure they're living their best lives and they're especially prepared for the upcoming Asthma Peak Week.
Luke Lemons:
So again, that's the third week in September is Asthma Peak Week. And we have about a month to prepare patients. But remember, there's also December Peak Week coming up as well. So we need to make sure that right now, asthma patients are prepared to go into these colder months and they can stay safe and lower their risks. On this episode's webpage, which you can find via the link in the description of this episode, we will have an asthma action plan example you can download as well as a sheet that explains how to reduce exposure to certain allergens that patients can take home with them and do that intervention themselves. We'll also have the two studies we mentioned here around the twenty-fold increase in hospitalizations and the inner city asthma study, along with our lab ordering guide, which has all the local test codes for allergen panels in your area through labs that you use. So thanks for listening, again. And until next time.
Gary Falcetano:
Thanks so much. We'll see you next time.
Announcer:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP Specific IgE Diagnostics and Phadia laboratory systems. For more information on allergies and specific IgE testing, please visit thermofisher.com/immunocast. Specific IgE testing is an aid to healthcare providers in the diagnosis of allergy and cannot alone diagnose a clinical allergy. Clinical history alongside specific IgE testing is needed to diagnose a clinical allergy. The content of this podcast is not intended to be and should not be interpreted as or substitute professional medical advice, diagnosis or treatment. Any medical questions pertaining to one's own health should be discussed with a healthcare provider.
