Medication Utilization and Emergency Room Visits for Patients With Persistent Asthma

Asthma and ER utilization

Asthma

Asthma is a particularly debilitating condition. Asthma is characterized by a tightening in the chest with difficulty in breathing and wheezing. This difficulty in breathing can result, at best, in a decrease in quality of life and the inability of carry out normal function. At worst, the symptoms of asthma can lead to death. Incidences of asthma have increased significantly in the last twenty years. This is perhaps due to increase in urbanization, industrialization and the accompanying pollution. This pollution can also be due to the increase in dust and waste from automobiles. While the effects and symptoms of asthma are well-known and studied, the causes of asthma are not known. They are, at best, unclear. This is because indicators vary from person to person. It is important to understand the basic mechanism of an asthma attack. A discussion of the triggers of asthma will come later. During normal breathing, air enters through the nose and its hair filters. The air is piped through the trachea and then into the tracheal branches called bronchii. The bronchii, as they enter the lungs further subdivide into bronchioles. When an asthma triggering even occurs, the tissues inside the bronchioles get inflamed. At the same time, the muscles on the outside of these tubules contract. These two actions cause air pathways to constrict severely reducing the flow of air into the lungs. The body's defense mechanism is to protect the tissue by creating thick mucus in the airways. This further restricts the flow of air. Breathing becomes a problem. If the breathing is restricted for a long enough time, the oxygen supply to the blood is restricted and this can lead to heart failure and death. (Drugdigest.org, 2003)

The reason why asthma is difficult to manage is because triggers are different for different people. In some cases, hereditary factors play an important role. No specific gene has been identified for all causes of asthma. While consider heredity however, certain genes are identified in the passing down of susceptibility to allergens. There is no consistency in the allergens. Pollen allergies are far too common, but so are dust mite allergies; and for others, fruits or shellfish might cause allergic reactions. The susceptibility to allergens is called atopy. Atopic patients are said to produce certain undesirable proteins called immunoglobulin E (IgE) antibodies. Antibodies are produced by the immune system when the body is invaded by a pathogen. There is a possible relation between an inherited variant in the IL (interleukin) 4 promoter gene which gives hypersentivity to allergens that are harmless to others. (Burchard et al., 1999)

Tobacco smoke is a major risk factor for asthma in children, especially secondary smoke. Smoke is also a critical trigger for adults. For many exercise induced asthma is a major concern. Just a few minutes of sustained exercising can bring on an attack. Emotional factors also play an important role in acute attacks. Crying, laughing and even hyperventilating can bring about an attack. Cold air, wind, rain, changes in weather, and irritants like sprays, certain spices and preservatives, fumes and smog also increase the chances of an asthma attack. Occasionally, some medications such as aspirins and beta blockers can also trigger an asthmatic episode. Hospital and emergency room statistics indicate that seasonal and climatic variations play an important role in asthma attacks. Cold temperatures and low humidity are primary causes. Bacterial and viral infections can also trigger episodes of asthma. Rhinovirus, corona virus, influenza and parainfluenza, syncytial virus, mycoplasma and Chlamydia infections are also known to cause asthma attacks. (Johnston et al., 1995) In addition, some allergens include pet hair and dander, and insect droppings.

The kinds of people that are susceptible to asthmatic attacks are those that are typically atopic; or, those that are susceptible to triggers or those that have weaker lungs and a predisposition to respiratory diseases. Asthmatic mothers often have stillborn or deformed babies if their asthma is not well controlled. This is because the oxygen supply to the fetus is often restricted.

Effects and Impacts

Children are particularly affected by asthma. The numbers have increased in the last two decades and in some instances have more than doubled. According to the American Lung Association, chronic asthma is the primary chronic illness in children. The ALA estimates that 6.3 million children under the age of eighteen years have asthma. While for most, the symptoms are mild to moderate, there are enough instances of hospitalization such that it is the third largest cause of hospitalization in children with close to three quarters of a million ER visits per year. The American Lung Association also reports that the costs of treating asthma runs into the billions with the added costs of several million cumulative school days lost in a year.

Above eighty percent of children with asthma develop symptoms in the first five years of life. Three different types of very young children with asthma have been identified. The first type suffers from transient wheezing. These children have asthma like problems due to viral infections at very young age. These symptoms eventually die out as children grow older. The second types are less fortunate. The ill-effects of early infections do not go away and plague them for many more years. The third types of children are atopic and tend to develop symptoms after the second and their years of their lives. In the last case, this atopy can continue into adulthood. (Martinez & Helms, 1998)

Later, it will be discussed that there is a potential drawback of overuse of certain medication in a child's normal growth. But asthma as a condition has a retarding influence on the growth of the child. The intellectual and emotional development is also typically retarded because the days lost from illness often hinder extracurricular and social activities. Fortunately, the current treatment modes when properly prescribed and used can allow a child to carry on normal day-to-day activities.

Adult asthma is also an important concern. Most adults who have asthma have experienced symptoms in one form or another during childhood. There are also many reasons why adult onset asthma is also a cause for concern. If an adult takes up smoking not realizing that it is one of the triggering mechanisms, then previously hidden symptoms might come to the fore. Occupational asthma is another reason for onset in adulthood. Workers in work environments and settings with which they are not familiar may develop occupational asthma because of exposure to chemicals, materials and dust levels with which they are not accustomed. Sometimes occupational asthma takes several years to develop. Triggering materials may range from chemicals such as plastics and polymers, chemicals that aerosolize, metal dust, organic dusts such as flour, grains, coffee, cotton, flax and hemp. A worker susceptible to these might experience occupational asthma. In addition to other symptoms, adult asthma can also be characterized by intolerance to smells of chemicals and chronic nighttime coughing. (Marabini, Siracusa, Stopponi, Tacconi, & Abbritti, 2003)

Older people also develop asthma with age. One of the reason is chronic exposure to a triggering agent over a long period of time can eventually result in asthma, especially when the body's defenses are weak. It is important to recognize that asthma can affect a person for the first time at any age. Weakened lungs can cause bouts of wheezing, especially with the weather. With older people, it is important to distinguish dyspnea from fatigue, bronchitis and emphysema from an actual asthmatic attack. Despite these confusing factors that come with age in making an accurate diagnoses, asthma does affect the older generation. Of the greater than twenty million people diagnosed with asthma in America, ten percent are over sixty-five years of age. The elderly also are prone to taking medications for more than one other condition. Sometimes, a medication for one condition might be a previously unknown asthma trigger. (Lungusa.org, 2003)

We have identified that no particular race, sex or age demographic is spared from asthma. With effective short- and long-term treatment options, asthma can be treated. There are asthma management plans that allow individuals to effectively treat their condition and live normal lives. Impact is an important consideration. Impact is based on several demographics: socio economic factors, geographical location, and productivity. We already know that asthma sufferers put a strain on the health care economy sometimes burdening the system. Nearly five thousand people die every year from asthma and more than fourteen billion dollars are spent in medical and indirect expenses. Several million people are diagnosed with asthma in one year. And a significant percentage of that number has at least one asthma attack in a year. (ALA, 2002)

Asthma in children increased more than seventy-four percent between 1980 and 1996. Childhood asthma persists beyond childhood in eighty-five percent women and seventy-two percent men. Women are more susceptible to asthma than men by almost thirty percent are. Urban sprawl exposure to pollution and other typical pollution due to cramped housing means that poorer urbanites, and this category includes a large percentage of minorities, are more negatively impacted. Asthma is more prevalent among African-Americans. The incidences were almost twenty two percent higher than Caucasians. On average, in every state in American, blacks suffered from asthmatic attacks almost eight percent more than whites did. The Hispanic population also suffered a greater number of attacks. (CDC, 2001)

Geographic disparities play an important role in the negative impact of asthmatic attacks. In poorer states, where more residents have difficulties in accessing health care have a greater incidences of asthma. Climatic conditions and states with greater polluting industries pose a greater risk for complaints with asthma. The states of Arizona, District of Columbia, Illinois, Indiana, Maine, Massachusetts, Montana, Nevada, New Hampshire, Ohio, Oregon, Rhode Island, Washington, West Virginia and Wyoming have higher percentages of asthma complainants than other states. The importance of occupational asthma, especially in adults has already been discussed. (CDC, 2002a)

Besides these broad demographics, personal impact is very important. Quality of life from symptoms and chronic bouts of asthma will be discussed in the following subsection. Deaths from asthma are more likely to affect African-American. In some cases, almost three times as much. Visits to emergency rooms number in the millions, annually. African-Americans visit ERs almost four times as whites. Children visited ERs about twice as many times as adults and women were also affected more than men were.

The unfortunate feature of this negative impact is simple preventive measures, to be discussed in a subsequent subsection, can prevent excess recourse to ERs and hospitalization.

Absenteeism from work results in drops in productivity which has long-term and indirect economic impacts. This amount easily runs into the billions of dollars. Several million work days are lost as a result of asthma. Besides loss in productivity in dollar amounts, there is also a loss of income and earnings, which is in the billions of dollars, from illness and death. Direct medical costs also range in the billions of dollars. They strain ERs where free treatment is mandated. The health care system, which is already stressed, is burdened further.

There is hope if the right efforts are made in creating Asthma Management. Short-term costs can realize long-term benefits since research through clinical trials has shown that most of the negative impacts can be easily removed through a simple system of education with efforts made to establish asthma specific clinics. The education and effective medication disbursement plans can actually help patients and positively impact the bottom lines of pharmaceuticals and the health care. (CDC, 2002b) It is imperative in terms of morbidity and mortality that more efforts are made in inner cities where lack of education and lack of preventive maintenance cause most of the problems that can be otherwise easily managed.

Quality of Life Issues

Every attack of asthma produces in the patient the fear that man's most basic involuntary function of breathing is compromised. The inability to take in a breath or expirate with normal force causes significant problems in how a person goes about his daily life. In the previous subsection, we have seen how asthma affects the inability to go to school and learn; or, in the case of adults, the inability to work, especially in the case of occupational asthma. The impacts that we have seen however, reveal only a small part of the problems that a patient faces. Most of the quality of life issues are personal. These problems are exacerbated if the asthma is not managed properly or if the person is clinically or environmentally more vulnerable to the problems. (USDHHS, 2000)

Some of the problems have to do with difficulty in sleeping, disturbed nights, stress and emotional problems. Not only is the patient's life affected, the lives of those around him are impacted negatively almost equally. The patient might be faced with the loss of job. The primary caregivers' jobs are also jeopardized. The loss of jobs if is often accompanied by a loss in benefits such as a higher standard of health care. Cost considerations in obtaining appropriate medication will result in the patient being caught in a vicious cycle, where medication that would treat the condition cannot be acquired.

Extracurricular activities are affected, as is the social life. Physical exercise is significantly hampered. One study showed that forty eight percent of the people reported that asthma affected their recreational activities. Thirty-six percent of the people believed that they could not carry out normal physical activities and twenty five percent reported a problem with social activities. Thirty percent people reported that they could not get a good night's sleep and often awoke from sleep due to breathing problems. (AsthmaInAmerica, 1998) In another study, the results were even worse. Eighty-four percent of the respondents believed that their lives had been negatively impacted. And a large percentage also believed that their asthma affected the quality of lives of their children. The patients were not able to visit friends' home for fear of an attack; or as the previous study, the subjects also reported problems with conducting normal routine or recreational activities. As has been described previously, studies have shown that social and family events have to be cut short and are severely restricted. (ALA, 1998)

Juniper and co-workers have developed a questionnaire to measure the quality of life for asthmatic patients. This is not only important from the standpoint of knowing more about the patients. This questionnaire, used all over the world is an important starting point in choosing patients for clinical trials. Knowing more about the patient is a first step in the beginning of a diagnosis and establishing a treatment method or even a more global asthma management program. (Juniper et al., 1992) The questionnaire consists of thirty two questions. It takes less than ten minutes to complete and is evolutionary. The questionnaire can also be used to measure the changes in quality of life, perhaps after a clinical trial or after a treatment regimen. The questionnaire addresses four basic areas: symptoms, emotions, exposure to environmental stimuli and activity limitation. The questionnaire can be self administered or it can be a part of an interview process.

Socio-Economic Factors in Asthma

The negative impact features and some of the causative asthma triggers have shown that socially and economically disadvantaged patients are more susceptible to asthma than the general population. Factor such as poverty result in inaccessibility to effective medication, which has been proven to be efficacious, is not available to these patients. The lack of education and awareness among the poor is one of the reasons why they cannot access the health facilities that are available. Race is not a consideration in incidences of asthma, per se. All races are equally susceptible. But since the minority races of African-Americans and Hispanic-American overwhelmingly represent the poor in this country. They are more likely to present at ERs or clinics with asthma. The subsection on Effects and Impact shows that minorities and children, and in some cases, women, are also particularly susceptible.

There is a strong variability in asthma presentation and the specific reasons are not known. It is possible that there are several factors that cause asthma. For instance, children in Papua New Guinea have no asthma, though the neighboring Caroline Islands have a 50% incidence among children. We have seen how asthma has risen by sixty percent in children in the United States. Interestingly, asthma has doubled in children in Western Europe during the same time period.

A study of hospitalization of asthma patients that represented specific inner city zip code in New York showed that family income, minorities in the population and children under the age of eighteen were overwhelmingly represented. (Suarez-Varela, Gonzalez, & Martinez Selva, 1999) A 1999 Chicago study found that almost a third of inner city kindergarten children had symptoms of asthma and only ten percent had been diagnosed because their condition was particularly severe.

A cross sectional demographic study based on mortality (from asthma records) showed that blacks were five times as likely to die from complications from asthma. The study also showed that the less educated had mortality levels almost two and a half times that of educated individuals. Also, low income patients were twice as likely to die as those from a higher income level. Even when factors of education and income were taken out of the equation, the study showed that the genetic proclivity for African-Americans to suffer (and/or die) from asthma was higher than Caucasians. (Haan, Kaplan, & Camacho, 1987)

As has been mentioned before, specific studies related to hygiene from inner city living conditions played a critical role in incidences of asthma. Cockroach and dust mite allergens are present in overwhelmingly large amounts in inner city homes. An Atlanta study showed that cockroach allergens were present in the dust of most urban homes, but were not found in twenty six suburban homes. (Ernst, Demissie, Joseph, Locher, & Becklake, 2004)

Preventive Measures for Asthma

Besides the effective treatment methods already established that seek to help patients get rid of immediate symptoms and also long terms effects, it is relatively easy to manage asthma such that normal life can continue with a combination of medication and simple preventive measures. The preventive measures can be established through effective educational programs. Removal of causative triggers is the first step. Cessation of smoking or restriction of smoking to well ventilated areas is important, especially with the awareness of the harmful effects of second-hand smoke. Often identifying the trigger can be painstaking and it involves limited exposure to potential triggers until the causative one has been identified. Hygiene is very important. Regular cleaning of homes to decrease the collection of dust, washing of linen in hot water at least once a week and taping cushions and mattresses that contain fiber or foam before covering them in cloth cases might be important to prevent the allergens from affecting the patient.

If cold and low humidity are triggers than moving to warm and humid climes might help. Failing that maintenance of comfortable temperatures in the household and higher humidity through a humidifier is very important. If the allergen is as pollen, then travel during fall and spring season where pollen is in the air should be avoided. Children and adults might have to do without pets if pet hair and pet dander are the triggers. The help of an allergist might be necessary to identify the asthma triggering allergen for some patients.

Regular checkups and proper use of prescribed medication is very useful. Equally useful are follow-up checkups. In subsequent sections, the importance of preferably using a primary care physician rather than an emergency room will be discussed as a means to prevent recurring attacks. Education is very important. Literature should be available to the patient and the primary care giver. Both parties can then be on the same page. Whenever possible, patients should, through their doctors avail themselves of international guidelines and recent research and clinical trials on treatment modalities for asthma. Intelligent discussions with physicians will only help the patient in the long run. Knowledge of side effects and medications that are likely to result in adverse reactions when taken with asthma medication is also important.

The same efforts should be utilized by adults that suffer from occupational asthma. They involve identifying the allergen and taking steps to prevent exposure. Groups that are genetically prone to suffer from asthma attacks should be aggressive in adopting preventive measures more. Any asthma management program should target social and economic groups that have been identified through clinical trials and other research to be more susceptible to asthma.

Medications

Asthma attacks manifest in two ways. The immediate symptoms involve difficulty in breathing. This means that medication should be made available that almost instantly dilates the bronchioles to allow the passage of air; or, anti-inflammatory agents to prevent inflammation of the tissue; or, muscle relaxants that prevent the constriction of the muscles of the bronchii can also help. The other care involves long-term medication that will either prevent or decrease the severity and frequency of asthma attacks. The next few subsections of this work will show clinical trials where the efficacy of long-term, quick relief and combination therapy.

Quick relief medications are those that act almost immediately. These are available in Metered Dose Inhalers and Nebulizers. They are also available in pills but the fastest action is available through aerosols.

Short acting beta 2 agonists are bronchodilators that aiding the easier flow of air by decreasing the constriction of the surface muscles of the bronchial tubes and tubules. These are fast acting. Some of them do have side effects. Examples of these with varying side effects are albuterol, pirbuterol and levalbuterol. Other examples are terbutaline sulfate, bitolterol mesylate and metaproterenol. The side effects range from irritability, abnormal heart rhythms, headache and insomnia. Beta 2-agnosists to not control inflammation and are best used for exercise induced asthma or when quick relief is desired. Levalbuterol, available as a nebulizer, is known to have fewer side effects that its short-acting beta-2 agonist counterparts.

For those that have an adverse affect with beta-2 agonists, anti-cholinergic drugs are often prescribed. These are also bronchodilators. The chemical name for this drug is ipratropium bromide and they are available as the brand names Combivent, Atrovent and Duoneb. Anti-cholinergic drugs are often used in combination with beta agonists. The draw backs are that they do not work as fast as the beta-2 agonists do; but they have fewer side effects. They are also no as effective as controlling exercise induced or cold air induced asthma.

Corticosteroids are generally long-term control medications but can be used for short-term gain especially when presented with gradually deteriorating exacerbation. Corticosteroids are anti-inflammatory agents. These are mostly effective over the long-term. The examples are Methulprednisolone, Prednisolone and Prednisone. They are administered as pills over time or in short bursts using an inhaler. There are steroidal effects that can be assuaged by combination therapies as will be discussed later. It is recommended that corticosteroids needed to be taken exactly as prescribed because of short- and long-term side effects. It is also known that the dosage or method of administration can cause a shock to the system causing death. For example, when the use of corticosteroids changes abruptly from a pill form to an inhaler.

Membrane Stabilizers or Mast Cell inhibitors prevent the release of histamines that trigger allergic reactions that cause asthma. These prevent the allergic reaction. They are sold under the brand names Cromolun and Nedocromil. Both these medications are administered through MDI and are relative safe. These medications can produce side effects that range from sneezing to wheezing and heartburn, oral irritation and in extreme and rare cases, anaphylaxis.

For long terms treatment, long-acting beta-2 agonists can be used. These are bronchodilators that work differently from their short-acting counterparts. They can also be used to treat exercise induced asthma over the long-term. They can even control nocturnal asthma. They allow the bronchial tubes to remain open longer. They are not meant for acute attacks and take up to thirty minutes to work and last for up to four hours. These medications are sold under the brand names: Serevent (salmeterol xinafoate), Foradil Aerolizer (formoterol), Advair Diskus (fluticasone propionate and salmeterol -- combination therapy) and Symbicort Turbuhaler (budesondie with formoteraol -- comibnation therapy). They cause the side effects of oral irritation, headaches and nausea.

Methylxanthines are long-term bronchodilators. They relax the constriction in the bronchial muscles and blood vessels in the lungs. They improve air flow and also blood flow through the lungs. This drug also works as an anti-inflammatory agent. There is only one such drug called theophylline and it is sold under dour separate brand names: Theo-Dur, Slo-bid, Uniphyl and Uni-Dur. Methylxanthines often cause sleeplessness, nausea, headaches and vomiting, rapid heartrates and occasionally seizures. They are known to cause over-activity in children.

Leukotrine pathway modifiers are for people that need daily medication to control bronchial inflammation. They are known to replace short acting beta2 agonists. Though they are not known to be as effective as corticosteroids, they can also be used in combination with corticosteroids and reduce dosage of the latter without any adverse effects. These are sold under the brand names Singulair (montelukast sodium), Accolate (zafirlukast) and Zyflo (zileuton).

Expected Outcomes

There isn't enough literature that justifies a reasonable review of how medications (long-term vs. quick relief) are prescribed, administered or taken for patients that pay for the treatment through Medicaid or though other health plan means. For children and adults suffering from asthma, one of the problems with having Medicaid is finding a managed-care or a prescription- drug program that will pay for asthma medications quick relief versus.

Even when it is not a question of the availability of drug in deciding whether to take quick relief vs. long-term drugs, the lack of education or awareness plays an important role. Most Medicaid recipients come from low income families. These families are more likely to live in low income inner city urban areas. The pollution in these areas, as well the lack of awareness of secondary smoke as a primary asthmatic trigger makes people more likely to recourse to Medicaid. The lack of finding HMOs that take Medicaid also means that prescriptions drugs are not available to the patients on demand. A study at the University of Michigan on 19,000 children with asthma found that the lack of awareness was the primary problem. Inhalers were not available to most of the patients. Even if they were available were empty. Public schools do not allow the use of inhalers but the school nurse did have inhalers in case of an asthma attack. It will be shown later in this work why Medicaid recipients utilize ERs more than those that can pay for medication. Most Medicaid recipients therefore, are not in a position to follow guidelines that quick relief is made available.

Long-term medication is not a huge concern because many programs such as Asthma Care and SCHIP (for children) under the auspices of Medicaid which teaches asthma management techniques.

With children and adults enrolled in presscription-plans also generally, live in environments where awareness and health education is greater. Interestingly, the incidence of asthma does not depend on race; children of both races are susceptible to asthma. But primary managed care and the ability to buy medications plays an important role. Later in this work, the emergency room utilization will be discussed. The studies indicated there are a small number of the studies that have reported that almost overwhelmingly, inner city poor patients and Medicaid recipients have a tendency to recourse to ERs. This basically means that because quick relief medication is not available. Just like for any demographic of the population, managed care helps in the long-term.

Medication: Quick Relief and Long-Term

We have previously looked at the mechanism of an asthma attack following hypersensitivity to a specific trigger. In this, the inflammation of the bronchioles is the primary cause of asthma. The difficulty in breathing can be assuaged by using anti-inflammatory agents. These are inhaled corticosteriods, which when taken in measured and prescribed doses provide almost instantaneous relief without aide effects. A study by Solidoro et al. (Martin, 2003)

Unavailability of drugs is an important consideration, especially with quick relief medication. The researchers studied prescription receipts of asthma medication recipients from a health plan. Of more than eleven and a half thousand patients that met the cohort requirements, most of the prescriptions were for a combination of asthma management and quick relief medication. While some were for only quick relief medication, most of quick relief-necessitating symptoms were treated with long-term medication. The outcomes were unsatisfactory especially when quick relief drugs were clearly prescribed. This is a study that can almost parallel the Medicaid situation in the United States. The study was conducted for subjects in Northern Italy where the prescription information was obtained from reimbursement receipts from a Universal Health coverage plan. (Poluzzi et al., 2002)

In addition to practices by physicians that prescribe asthma medication that do not comply with international asthma guidelines, some of the problems are due to the lack of education. This results in a long-term medication being used for an acute condition, resulting in instances of morbidity if not worse. A study of western European patients with asthma conducted by researchers at Glaxo-Smith Kline indicated that very few patients had the means or the awareness of proper asthma control. One of these instances was that they were not aware of what caused the difficulty in breathing; the second was that they did not know that using ICS would help with the symptoms of an acute attack. (Soriano, Rabe, & Vermeire, 2003)

One of the fears of continued use of long-term ICS is that they cause stunted growth among children. This outcome was studied by researchers in Athens, Greece who divided a cohort of 436 asthmatic children ranging in three groups, the oldest being fifteen and a half years old. The groups height and weight (adjusted and normalized) were measured following use of long-term ICS. The heights and weights were measured against a control group. The study showed that there were no statistically significant differences between the asthmatics group and the control group. The only stunting in growth was observed in pubescent girls. The researchers caution that other factors may be at play, including the fact that ICS might have an impact of "pubertal maturation." (Moudiou, Theophilatou, Priftis, & Papadimitriou, 2003)

In recognizing adverse effects due to long-term use, the concept of therapeutic margin is an important consideration. The therapeutic margin is defined as the difference in dosage between an optimally effective dosage and dosage at which the drugs produced an adverse reaction in the patient. This therapeutic margin when traced over short- and long-term studies becomes a good measure of long-term efficacy and also safety. These scales were measured for the long-term drug budesonide and it was compared to other ICS. By comparing the graphical scales for the relationship of the drugs efficacy with severity of asthma and the frequency of attacks as a measure of acuteness or chronicness, the outcomes of long-term medication can be predicted. (Skoner, 2003)

The role of anti-allergic medication is important when long-term inflammation control is indicated. This medication affects the cause of the asthmatic attack and not the effect symptoms. Nasal lavages with leukotrienes receptor agonists such as montelukast have helped in decreasing the levels of cytokines such as IL3 and IL4 (interleukins) and IFN gamma. These medication modulate the levels of these cytokines, effectively making the system less sensitive to allergens (Ciprandi et al., 2003)

The Advantage of Combination Therapy

The summary of quick relief and short-term medications indicate that complete success cannot be achieved with one without the other. With quick relief medication, there is a fear of addiction and perceived (or otherwise) fear of steroidal side-effects. Long-term medication is largely preventative that might help in chronic situation. It does not help with asthmatic attacks that are acute and typically characterized by an inability to breathe.

Combination therapy drugs offer the advantage of short- and long-term relief. With a combination of medications, the dosage of each also does not have to be high. Thus, the fear of over dosing or side effects is largely assuaged. The National Asthma Education and Prevention Program (NAEPP) has recommended that inhaled corticosteriods are safe and effective as quick relief medications; also, ICSs in conjunction with long-term bronco-dilators often work well for people with chronic, persistent problems with asthma. Combining ICSs with other long-term medication has helped in side effects such as skin bruising, cataracts and osteoporosis in all, and stunted growth (debatable) among children and youth. For instance, the drug Advair combines both medication types in a single inhaler. Other combinations combine ICSs and either anti-inflammatory agents (leukotrines) or broncodilators (theophylline), both of the long-term medications taken in the form of pills. This treatment modality was supported by a study conducted at Brown University Medical School (Simon, 2003) There is yet another school of thought that suggests combining the quick relief corticosteroid inhaler with an anti-inflammatory agent and a bronchodilator.

In considering the use of combination therapy, there is no one size fits all solution.

Serious consideration should be given to medication depending on the asthma triggers and what one's asthma management goals are. There are several studies that identify the advantages of combination therapy in treating. These studies have to do with clinical trials identifying effective treatments results with commercially available medications when taken in combinations. A study out of the Mayo clinic identified as beta agonists as useful in treating asthma. Beta agonists are of two types: short- and long-term. The researchers aver that beta agonists are useful in treating asthma especially exercise induced asthma. Long acting beta agonists are useful especially when combined with ICSs. The researchers Dutta and Li indicate the beta agonists when administered properly have very few side effects. (Dutta & Li, 2002)

Other studies showed the results of the efficaciousness of one combination over the other. The salmeterol/fluticasone propionate combination product was shown to work more effectively than the fluticasone propionate (FP) plus oral montelukast combination in a randomized double blind study of patients aged fifteen years or greater. The efficacy of the combinations were measured based on expiration rates during and following twelve week treatment period. (Hughes et al., 2003)

Two separately conducted studies by the same research group showed the improvements in asthma management. These studies also highlighted the decrease of steroid dosage as an advantage of combination therapy. These two studies also went a long way in establishing asthma as an inflammatory disease. The studies used the long-term corticosteroid triamcinolone acetonide and the bronchodilator Salmeterol xinafoate. Even though the asthmatic condition was well maintained using only the corticosteroid, concerns of side effects forced many patients to switch to salmeterol. The study, a random trial, involving one hundred and sixty four patients showed that patients whose asthma was under control using triamcinolone during the first part of the clinical trial were then divided in groups that continued the use of triamcinolone, switched to salmeterol or were given a placebo. (Holt et al., 2001)

Combination therapy is used not only for a combination of quick rescue and long-term benefits but also even for quick relief. A study by Lanes and co-workers showed that for more than a thousand patients involved in a study a combination of ipratropium bromide and salbutamol in treating acute attacks of asthma proved better (in terms of measured expiratory rates) than using salbutamol nebulizers alone. (Lanes, Garrett, Wentworth, Fitzgerald, & Karpel, 1998) The expiratory rates were measured forty five and ninety minutes after treatment was administered. Since this study was in the treatment of acute and severe attacks, no follow up was required. The advantages of combination therapy in asthma management are that as asthma management progresses for each patient, the doses can be modified to account for the change in severity and frequency of attacks. There are certain dangers in the long terms use of certain combinations, of which physicians need to be aware. The points to ponder are the fact the increased use does not mask deterioration in lungs or the decreased response to quick response bronchodilators should the need for rescue arise. Another factor that needs to be taken into account is a cause-and-effect one. This is the treatment against the allergen rather than treatment of the symptoms of the effects of allergens. A study showed that a "combination therapy" of anti-IgE therapy that reduces the hypersensitivity to IgE serum and allergy immunotherapy at the hands of an allergist is also an important factor in treating asthma -- acute and chronic. A comprehensive study of health care and emergency care utilization by asthmatics that used single unit combination therapy showed that the combination therapy did not decrease ER utilization. This study was sponsored by the pharmaceutical companies Genentech and Novartis.

Emergency Room Utilization of Asthma Patients

One of the important factors to consider about asthma is that though, by and large, the condition is relatively temporary, and the difficulty in drawing a breath can lead to serious consequences. Therefore, emergency room utilization is frequent and quite commonplace among asthma patients, especially children. It is possible that emergency room utilization can be decreased irrespective of age if a well-defined system of asthma management in the individual, no matter what the age, can be designed. Such success was observed in a comprehensive study conducted at the Kaiser Permanente Los Angeles Medical Center. The researchers Branin and Cochran studied 2459 asthma patients. Each complained of moderate to severe attacks that often required either long-term hospitalization or outpatient emergency room visits. The researchers designed an asthma management program that enrolled these patients. The oldest of this sample space was 56 years old. Though not mention, it is conceivable that a significant number of these patients were children and adolescents. The management program provided the patients with asthma education materials. The patients were taught to avoid the typical asthma triggers. They were taught how to monitor their peak flow meter usage. Certain hygienic factors such as maintaining dust-controlled environments were also taught. The patients also received one-on-one help; and, stringent follow-ups were conducted. The study showed that such asthma management programs were useful because not only did they reduce hospitalizations, they also reduced emergency room utilizations. (Branin & Cochran, 2002)

These results were supported by a study that compared morbidity results in children with asthma in ERs vs. allergy clinics. The results were better in clinics irrespective of socioeconomic factors. (Moore et al., 1997)

We have previously looked at demographics and socioeconomic factors that contributed to asthma. The urban poor, especially inner city youth are most susceptible because of poor hygienic condition and greater urban pollution, besides factors like second hand smoke. An asthma management program similar to the Kaiser Permanente medical center was established at the Bronx Lebanon Health Center in New York. The management program involved close monitoring of its three hundred test subjects whose ages ranged from three to seventeen. The staff at this program clinic was also available twenty-four hours. Follow up studies indicated that the emergency room visits reduced significantly by almost seventy percent. (Harish et al., 2001)

Another study in the Bronx, at the Albert Einstein Medical College of three hundred and seventy eight inner city children with asthma indicated that children with primary care needed less visits to the emergency rooms since prescribed medication was available. About half the children identified the emergency room as the only source of primary care for asthma. There is a significant discrepancy between children treated by a primary care physician and those that receive instant care at the emergency rooms. However, the symptoms of asthma do not change no matter what the source of care. This indicates that there are other factors at play such as asthma triggers. Though one would surmise, that children are better of in the care of a primary care physician. (Dinkevich, Cunningham, & Crain, 1998)

Such programs reduced the strain on emergency rooms personnel and will result in improved care. Such a management program also has important consequences in the health of the patient. More than twenty six percent of the patients in the Kaiser Permanente showed improvement in the severity and acuity of their asthma attacks. Another study conducted at the University of Florida Health Science Center showed that a management program that involved the pharmacists' input also reduced emergency room visits by patients by almost fifty percent. In this study, the patients had complete access to the pharmacist by way of telephone. In addition to preventive measures, quick access to a qualified opinion on the choice and dosage of medication also helps to prevent the preponderance of emergency rooms visits. (Pauley, Magee, & Cury, 1995)

Emergency room visits can also be reduced by routine visits to the primary care physician. The finances of a patient and his or her family are important, especially in the case of patients who have health insurance and are therefore not hesitant to visit their primary care physicians. These routine visits might help the physician evaluate the patient's state of health and the chances of the next asthma attack. This visit also helps the physician keep tabs on how the family of the patient is maintaining conditions that might minimize an asthma attack. A two-year study of four hundred and eleven children with asthma aged five to fourteen years that visited a pediatrician and also had an HMO insured coverage showed that they're emergency room visits decreased. If the insurance entitled the child to visit an allergist, the prognosis for not using the ER was even higher. This is an important consideration for elderly patients with Medicare. Routine visits might preclude the frequency ER visits. (Lafata, Xi, & Divine, 2002)

Establishing an effective program of asthma management provides all around benefits. There are other demographic factors that affect how and why asthma patients visit emergency rooms after an attack. One issue is gender. Any study has to take into account the fact of how perceptions of the necessity of emergency room utilization differ from gender to gender. A study by Awadh and co-workers at the University of British Columbia, in Vancouver, BC, Canada showed that perceptions do matter. They measured the expiration flow rates and flow volumes per second for one hundred and thirty seven patients who made one hundred and ninety six visits over a six-month period. The results showed that the number of females visiting emergency rooms were almost twice as much as males. Females were more than two and a half times as likely to make repeat utilizations. Interestingly, the parameters measured for both females and males as expiration rates and heart rates did not differ statistically. While this is an interesting result, the authors rightly mention that follow up studies were necessary to ascertain the results. It would be also important to determine what conditions caused women to present more than men at emergency rooms. (Awadh, Chu, Grunfeld, Simpson, & FitzGerald, 1996) more comprehensive study at the Ponce School of Medicine in Puerto Rico studied the female to male ER utilization ratios. This study supports the study by Awadh et al. It however, adds a different twist to the study by also including ratios based on age. The Puerto Rico study also shows that seasonal variations are an important consideration in emergency room utilization. The coldest month of December see the highest utilization; whereas, the warmer temperatures of June see the lowest numbers. The researchers studied more than fifty-five thousand patients. They averred that, probably due to the poverty, ED is the only recourse to most patients. They also aver that asthma should be declared as a national health problem and that efforts should be made to treat asthma as more than just an emergency-necessitating condition. This study showed that of the respondents in the study, which was conducted over five years, the average age was between seventeen and eighteen. A large number of the subjects were between the ages of one and nine. The ratios are interesting. The youngest section of the demographic had more male patients than female. In adolescent and teenage years, the ratios were identical. Among young adults, the ratios switched -- "females being the larger of the two groups presenting at ERs with asthma. The last part supports the results of the study by Awadh and co-workers, though both studies do not report the reasons for this discrepancy in asthma presentation. (Montealegre, Bayona, Chardon, & Trevino, 2002)