Introdução à Medicina II Control of the Disease in Patients with Asthma and Rhinitis Class 3 May...

Introdução à Medicina IIControl of the Disease in Patients with Asthma and Rhinitis

Class 3May 25th

Introdução à Medicina II

Control of the Disease in Patients with Asthma and Rhinitis

Title of Article

* Control of Allergic Rhinitis and Asthma Test2

Introduction



Introdution

3

Introduction Methods Results Discussion References

Asthma

•Respiratory tract disease;

•Inflammatory state;

•Narrowing of the bronchi;

•Allergic or non-allergic;

•Airways’ narrowing is reversible;

•Asthma’s prevalence ranges from 0,7 to 18,4%;

Rhinitis

•Respiratory tract disease;

•Occurs by the expositions to allergens;

•Nasal obstruction;

•High proliferation of mucus;

•Sneezing;

•Widely spreaded problem (affecting 10% to 20% of

global population);

Asthma and Rhinitis



Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2010 4




Control

Control of the disease

•Control is the degree to which the manifestations are minimized by therapeutic intervention and

the goals of therapy are met.

•Asthma is highly variable, therefore the level of control must be monitored on a periodic basis to

determine whether therapy should be maintained or adjusted.

•The specific measures used to assess control are: symptoms, limitations to normal activities

because of asthma, pulmonary function, need for reliever/rescue treatment and exacerbations.

(2007). "Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007." Journal of Allergy and Clinical Immunology 120(5, Supplement): S94-S138.J. Bousquet, T. J. H. Clark, S. Hurd,N. Khaltaev, C. Lenfant, P. O'Byrne, A. Sheffer. (2007). “GINA guidelines on asthma and beyond”. Allergy 2007: 62: 102–112

5


According to INCA …

43% hasn’t controlled asthma;

95% of those patients could have had the disease better controlled and consequently a better

life quality.

Inquérito Nacional de prevalência de AsmaInquérito Nacional de Controlo de Asma (National Survey of Asthma’s Control)RCM Pharma: Inquérito nacional: os asmáticos portugueses são controlados. Available from: http://www.rcmpharma.com/actualidade/saude/03-10

11/inquerito-nacional-os-asmaticos-portugueses-sao-controlados (29/20/2011)

Results from INPA showed:

• 700.000 Portuguese citizens were affected by asthma

• 1.8 million had lifetime asthma.

• 80% of the asthmatic people have had allergic rhinitis

• 40% of the patients with rhinitis also had asthma.

Population and Statistical Data



6


http://www.rcmpharma.com/actualidade/saude/03-10

CARAT* – Control of Allergic Rhinitis and Asthma Test



• It’s the first to assess the control of asthma and rhinitis together;

• It was already validated;

• Short and easy to complete;

• Self-administered questionnaire to quantify the degree of control in adult patients with a

previous diagnosis of ARA;

• It’s applicable both in clinical practice and research settings;

• It allows to assess both individual variations and discriminate between groups of patients

with different levels of control.

Nogueira-Silva, L., S. V. Martins, et al. (2009). "Control of allergic rhinitis and asthma test - a formal approach to the development of a measuring tool." Respiratory Research 10. Validation of a questionnaire (CARAT10) to assess rhinitis and asthma in patients with asthma [available from: http://www.caratnetwork.org/images/carat/pdf/carat2.pdf on 12/11/2011]

7


From: http://www.caratnetwork.org/

CARAT* – Control of Allergic Rhinitis and Asthma Test



8


Leynaert B, Neukirch C, Liard R, Bousquet J, Neukirch F. Quality of life in allergic rhinitis and asthma. A population-based study of young adults. Am J Respir Crit Care Med 2000;1:1391–1396Schatz M. A survey of the burden of allergic rhinitis in the USA. Allergy 2007;62(Suppl. 85):9–16Canonica GW, Bousquet J, Mullol J, Scadding GK, Virchow JC. A survey of the burden of allergic rhinitis in Europe. Allergy2007;62 (Suppl. 85): 17– 25



There’s no evidence about that control, concerning the comparison asthma with asthma and

rhinitis or rhinitis with asthma and rhinitis.

That comparison is important because:

• patients with both asthma and allergic rhinitis experience more physical limitations than patients

with allergic rhinitis or asthma alone.

• no one has ever compared the CARAT scores between rhinitics, asthmatics and healthy

individuals what can lead to new approaches in the use of CARAT.

9


Assess the control of Asthma and Rhinitis comparing

CARAT scores between healthy individuals,

asthmatics and rhinitics.



AIM

10


AIM



In a more specific way, we want to compare the CARAT scores between the following groups:

• healthy individuals with asthma;

• healthy individuals with rhinitis;

• healthy individuals with asthma and rhinitis;

• asthma with rhinitis;

• asthma with asthma and rhinitis;

• rhinitis with asthma and rhinitis.

11


Methods



12


Study Design



Observational study (we are going to analyze INCA’s database without making

any kind of intervention);

Unit of analysis: individual;

Retrospective study (we’ll focus on past events, the questionnaire´s database);

Transversal study (there is no following period).

13


Statistical Analysis



• We will use SPSS (Statistical Package for the Social Sciences ) as a predictive

analytic software;

• We used error bars with confidence interval at 95% and t-test. Results of t-test under

0,05 are statistically significant results, above 0,05 the results are statistically

insignificant.

14


Variables



Analysis Variables (individuals with asthma, rhinitis, asthma and rhinitis and with no disease)

- Asthmatic individuals – answered positively to the following question: 1) “Have you ever had asthma?” and at least one of the following: a)“Have you ever had wheezing in the chest or “kittens” in the

last 12 months?”; b)“Have you ever been awakened due to lack of air in recent

months?”; c)“Have you ever had an asthma attack on the last 12

months?” and d)“Currently are you taking medication for asthma or

shortness of breath?”

- Rhinitic individuals – answered positively the question:“Had you rhinitis including hay fever or allergies of the nose?”

- Healthy individuals –answered all of the previous questions negatively

15


Flow Chart



16


Variables



• Age a)

• Gender b)

• Socio demographic and socioeconomic variables c)

• Impact of the environment d), e)

• Smoking habits f)

• BMI g)

• Concomitant Diseases h), i), j)

a) Loureiro C. C., Age as influence in the adrenergic/cholinergic bronchomotor response, Acta Med Port. 2011;24(2):231-40, Serviço de Pneumologia, Hospitais da Universidade de Coimbra, Portugal

b) Guoda Pilkauskaitė, Kęstutis Malakauskas, Raimundas Sakalauskas, Assessment of disease control in patients with asthma, Medicina (Kaunas) 2009; 45 (12): 943-951, Department of Pulmonology and Immunology, Institute for Biomedical Research, Kaunas University of Medicine, Lithuania

c) Watson J P, Cowen P, Lewis R A, The relationship between asthma admission rates, routes of admission, and socioeconomic deprivation. Eur Respir J. 1996; 9(10):2087-9

d) Comhair SA, Gaston BM, Ricci KS et al (2011), Detrimental effects of environmental tobacco smoke in relation to asthma severity, PLoS One 4;6(5):e18574, Departments of Pathobiology, Cleveland Clinic, Cleveland, Ohio, United States of America

e) Mukherjee AB, Zhang Z. Allergic asthma: Influence of genetic and environmental factors. Journal of Biological Chemistry. 2011;286(38):32883-9 f) Sarinho S. C., Sarinho S., Ferrira O. S. et al (1995), Risk factors for childhood asthma in Fernando de Noronha: A case control study, Jornal de Pediatria - Vol. 71,

Sociedade Brasileira de Pediatria g) Sutherland ER, Camargo CA Jr, Busse WW, et al (2010), Comparative effect of body mass index on response to asthma controller therapy, Allergy Asthma Proc.

31(1):20-5, Department of Medicine, National Jewish Health, Denver, Colorado, USA h) Wijnhoven HAH, Kriegsman DMW, Hesselink AE, Penninx BWJH, De Haan M. Determinants of diferente dimensions of disease severity in asthma and COPD:

pulmonary function and health-related quality of life. Chest. 2001; 119: 1034-42 i) Sherman CB, Hubert M, Fogel BS. Unrecognized respiratory disease in the elderly. Am Respir Dis 1992;145:763 j) Serman CB, Late-onset asthma: making the diagnosis, choosing the drug therapy, Geriatrics 1995; 50:24-33

18


http://www.ncbi.nlm.nih.gov/pubmed/21572527

Study Participants



Our criteria must be the same they followed:

Inclusion Criteria

• all the participants of the study must be resident in Portugal

•have landline telephone

•be identified as belonging to one of the groups (asthmatic, rhinitis and healthy ones)

Exclusion Criteria

• participants who are unable to fill in the CARAT questionnaire and those who reject to be called again

were excluded.

19


Inquérito Nacional de Controlo de Asma, 2010 [available from:

http://www.arsalgarve.min-saude.pt/site/images/centrodocs/inquerito_dgs_asma_dez_2010.pdf on 21/10/2011]

Control of allergic rhinitis and asthma test – a formal approach to the development of a measuring tool [available from:

http://www.caratnetwork.org/images/carat/pdf/carat1.pdf on 10/11/2011 on 12/11/2011]

Study Participants



20


Study Participants



Introduction Research Question

Aims Participants Methods Expected Results

ReferencesIntroduction Methods Results References



Carat Score

The value of the score varies between 0 and 30Concerning CARAT global score, the disease is controlled for a score higher than 24

Upper airways Score varies between 0 and 12

- upper airway’s disease controlled (score>8)- upper airway’s disease uncontrolled (score≤8)

Lower airwaysScore varies between 0 and 18

- lower airway’s disease controlled (score≥16)- lower airway’s disease uncontrolled (score<16)

Introduction Research Question

Aims Participants Methods Expected Results

ReferencesIntroduction Methods Results References

22


Results



23




24* Measures expressed in terms of means.


Introdução à Medicina I


Fig.1: Error bar plot made in order to assess the differences between each group’s global score.


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Significance

(p)

Mean

difference

Stand Error

Difference

Asmathics and Rhinitics

(n=671)0,000 -3,695 0,696

Rhinitics and individuals with asthma and

rhinitis

(n=690)

0,000 3,973 0,637

Asmathics and individuals with asthma and

rhinitis

(n=227)

0,756 0,279 0,895

Individuals with asthma and rhinitis and

healthy individuals

(n=1090)

0,000 -7,612 0,604

Asmathics and healthy individuals

(n=1071)0,000 -7,334 0,666

Rhinitics with healthy individuals

(n=1534)0,000 -3,639 0,216

Table 2: Results of the independent-sample t-tests – comparison between means of the global scores.


26



Fig. 2 Error bar plot made in order to assess the differences between each group’s score of upper airways.


27



Significance

(p)

Mean

difference

Stand Error

Difference

Asmathics and Rhinitics

(n=721)0,244 -0,402 0,345

Rhinitics and individuals with asthma and

rhinitis

(n=751)

0,000 1,139 0,316

Asmathics and individuals with asthma and

rhinitis

(n=254)

0,074 0,737 0,411

Individuals with asthma and rhinitis and

healthy individuals

(n=1137)

0,000 -3,861 0,285

Asmathics and healthy individuals

(n=1107)0,000 -3,125 0,295

Rhinitics with healthy individuals

(n=1604)0,000 -2,733 0,143

Table 3: Results of the independent-sample t-tests – comparison between means of the upper airways scores.


28




Fig. 3 Error bar plot made in order to assess the differences between each group’s score of lower airways.

29



Significance

(p)Mean

differenceStand ErrorDifference

Asmathics and Rhinitics (n=692)

0,000 -3,203 0,478

Rhinitics and individuals with asthma and rhinitis (n=715)

0,000 2,894 0,400

Asmathics and individuals with asthma and rhinitis (n=231)

0,608 -0,308 0,601

Individuals with asthma and rhinitis and healthy individuals (n=1113)

0,000 -3,940 0,388

Asmathics and healthy individuals (n=1090)

0,000 -4,249 0,468

Rhinitics with healthy individuals (n=1574)

0,000 -1,046 0,105

Table 4: Results of the independent-sample t-tests – comparison between means of the lower airways scores.


30

Discussion



31




• Our main conclusion is that the comparison of patients with asthma and rhinitis and individuals

with asthma is not statistically significant (table 3), p=0,756.

• Healthy individuals, functioning as the control group, show the lowest CARAT scores,

comproving the aplicability of CARAT

• Although it was expected that patients with both asthma and allergic rhinitis would have a

worst control, people with both diseases showed a similar global CARAT score as only

asthmatic individuals (there are no statistically significant difference between asthmatic and

individuals with both asthma and rhinitis).

• Individuals with only rhinitis showed higher scores in CARAT global score, overpassing the

score of 24, which leads us to consider the global score not reliable for rhinitics

32


Leynaert B, Bousquet J, Neukirch C, Liard R, Neukirch F. Perennial rhinitis: An independent risk factor for asthma in nonatopic subjects: Results from the European Community Respiratory Health Survey. J Allergy Clin Immunol. 1999;104:301–4.Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema: ISAAC. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Lancet. 1998;351:1225–32.David Price, Asthma and allergic rhinitis: Linked in treatment and outcomes, Annals of Thoracic Medicine, 2010; 5(2): 63–64.



• CARAT scores are affected by the different groups of individuals

• Considering the scores for upper airways, we could observe that the comparison between

patients with only asthma and patients with only rhinitis was not statistically significant (p =

0,244).This way, we may speculate that the majority of asthmatics considered have probably

also rhinitis, and were wrongly classified by CARAT

33




• Recent studies have shown (Scichilone, Arrigo et al. 2011) that in subjects with allergic rhinitis with

mild asthma, nasal inflammation impacts on asthma control, proving that asthma control is more

prone to be affected by such factors, rather than rhinitis

• Errors on diagnostic and treatment of asthma are often, particularly on elderly people, because

there are concomitant diseases.

• The neediest and less instructed social classes are associated to severe grades of asthma,

which means fragile control of the disease.

34


Watson J P, Cowen P, Lewis R A, The relationship between asthma admission rates, routes of admission, and socioeconomic deprivation. Eur Respir J. 1996;

9(10):2087-9

Coelho R., Oliveira L., Martins A. Et al (1999), Factores psico-sociais e asma brônquica na adolescência, Revista Portuguesa de Psicossomática, vol. 1, pp.

131-143, Sociedade Portuguesa de Psicossomática, Porto, Portugal

Limitations



• Due to the fact that there are individuals that did not complete the questionnaire (some of them responded only to the upper airways part or only to the lower airways part of CARAT) the number of subjects (n) is different on each comparison (mean global score of CARAT, mean score of upper airways and mean score of lower airways).

• There were also variables that could have influenced our results:

• Sociodemografic and socioeconomics

• Physical Exercise

• Psychosocial factors

• Smoking Habits

• Although we identified the variables that could influence CARAT scores, we weren’t able to eliminate

these factors, as they are intrinsic to the individuals of our population study.

35


Clinical Benefits



36


• This study allowed to increase the assessement of the control of both important diseases,

and also reinforced the connection between asthma and rhinitis.

• There are some drugs, specially modern antihistaminic preparations of the second generation

having an advantage over other drugs for the treatment of allergic rhinitis in a way that it may

be prescribe to the patients with concomitant bronchial asthma.

• Our study reinforces the idea of other studies, that asthma has a higher impact than rhinitis,

and the contrary is not true.

Zaǐtseva OV. [The approaches to diagnostics and therapy of allergic rhinitis]. Vestnik otorinolaringologii. 2011(5):62-5Bousquet J, Van Cauwenberge P, Khaltaev N, Aria Workshop Group; World Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108(5 Suppl):S147-334.

Yorgancioglu, A., C. Ozdemir, et al. (2012). "[ARIA (Allergic rhinitis and its impact on asthma) Achievements in 10 years and future needs]." Tuberk Toraks 60(1): 92-97.

Future Studies



37


Based on our results, it wasn’t possibly to distinguish differences between

asthmatics and individuals with both asthma and rhinitis. It would be

interesting in the future to study if the CARAT questions related to

symptoms are more directed to asthma than to rhinitis, covering the

detection of individuals with both asthma and rhinitis.

Take Home Message



38


• The control of rhinitis in asthma patients can lead to a better control related to

the upper airways, while this phenomenon is not so evident in asthma.

• The impact of rhinitis on asthma seems to play a minor role in it’s control.

Braido F, Baiardini I, Balestracci S, Ghiglione V, Stagi E, Ridolo E, et al. Does asthma control correlate with quality of life related to upper and lower airways? A real life study. Allergy. 2009;64(6):937-43. Epub 2009/02/27.Kalpaklioglu AF, Baccioglu A. Evaluation of quality of life: impact of allergic rhinitis on asthma. Journal of investigational allergology & clinical immunology : official organ of the International Association of Asthmology (INTERASMA) and Sociedad Latinoamericana de Alergia e Inmunologia. 2008;18(3):168-73. Epub 2008/06/21.

References



39


•Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A et al. Allergic Rhinitis and its Impact on

Asthma (ARIA) 2010

•J. A. Fonseca, L. Nogueira-Silva, M. Morais-Almeida, L. Azevedo, A. Sa-Sousa, M. Branco-Ferreira, L.

Fernandes & J. Bousquet. Validation of a questionnaire (CARAT10) to assess rhinitis and asthma in patients with

asthma

•Inquérito Nacional de Controlo de Asma, 2010 [available from:

http://www.arsalgarve.min-saude.pt/site/images/centrodocs/inquerito_dgs_asma_dez_2010.pdf on 21/10/2011]

•Control of allergic rhinitis and asthma test – a formal approach to the development of a measuring tool

[available from: http://www.caratnetwork.org/images/carat/pdf/carat1.pdf on 10/11/2011 on 12/11/2011]

•Validation of a questionnaire (CARAT10) to assess rhinitis and asthma in patients with asthma [available

from: http://www.caratnetwork.org/images/carat/pdf/carat2.pdf on 12/11/2011]

•Alsamarai, A. M., A. M. Alwan, et al. (2009). "The relationship between asthma and allergic rhinitis in the

Iraqi population." Allergology International 58(4): 549-555



40




•Demoly, P. and P. J. Bousquet (2008). "Links between allergic rhinitis and asthma still reinforced." Allergy:

European Journal of Allergy and Clinical Immunology 63(3): 251-254

•Nogueira-Silva, L., S. V. Martins, et al. (2009). "Control of allergic rhinitis and asthma test - a formal

approach to the development of a measuring tool." Respiratory Research 10

•Walls RS, Heddle RJ, Tang MLK, Basger BJ, Solley GO, Yeo GT. Optimising the management of allergic

rhinitis: An Australian perspective. Medical Journal of Australia2005;182(1):28-33

• RCM Pharma: Asma e Rinite Alérgica: investigadores portugueses desenvolvem primeiro e único

inquérito mundial [cited 28/09/2011]. Available from

http://www.rcmpharma.com/actualidade/saude/28-09-11/asma-e-rinite-alergica-investigadores-portugueses-

desenvolvem-primeiro-e- (29/10/2011)

•Eriksson J, Bjerg A, LÃ¶tvall J, Wennergren G, RÃ¶nmark E, TorÃ©n K, et al. Rhinitis phenotypes correlate

with different symptom presentation and risk factor patterns of asthma. Respiratory Medicine;105(11):1611-21

•Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 Update (in collaboration with the World Health

Organization, GA2LEN* and AllerGen**)


41



•Wijnhoven HAH, Kriegsman DMW, Hesselink AE, Penninx BWJH, De Haan M. Determinants of diferente

dimensions of disease severity in asthma and COPD: pulmonary function and health-related quality of life.

Chest. 2001; 119: 1034-42

•Mukherjee AB, Zhang Z. Allergic asthma: Influence of genetic and environmental factors. Journal of

Biological Chemistry. 2011;286(38):32883-9

•Loureiro C. C., Age as influence in the adrenergic/cholinergic bronchomotor response, Acta Med Port.

2011;24(2):231-40, Serviço de Pneumologia, Hospitais da Universidade de Coimbra, Portugal.

•Guoda Pilkauskaitė, Kęstutis Malakauskas, Raimundas Sakalauskas, Assessment of disease control in

patients with asthma, Medicina (Kaunas) 2009; 45 (12): 943-951, Department of Pulmonology and

Immunology, Institute for Biomedical Research, Kaunas University of Medicine, Lithuania

•Watson J P, Cowen P, Lewis R A, The relationship between asthma admission rates, routes of admission,

and socioeconomic deprivation. Eur Respir J. 1996; 9(10):2087-9

• J. Bousquet, T. J. H. Clark, S. Hurd,N. Khaltaev, C. Lenfant, P. O'Byrne, A. Sheffer. (2007). “GINA

guidelines on asthma and beyond”. Allergy 2007: 62: 102–112


42



•Sarinho S. C., Sarinho S., Ferrira O. S. et al (1995), Risk factors for childhood asthma in Fernando de

Noronha: A case control study, Jornal de Pediatria - Vol. 71, Sociedade Brasileira de Pediatria

•Sutherland ER, Camargo CA Jr, Busse WW, et al (2010), Comparative effect of body mass index on

response to asthma controller therapy, Allergy Asthma Proc. 31(1):20-5, Department of Medicine, National

Jewish Health, Denver, Colorado, USA.

•Sherman CB, Hubert M, Fogel BS. Unrecognized respiratory disease in the elderly. Am Respir Dis

1992;145:763

•Leynaert B, Bousquet J, Neukirch C, Liard R, Neukirch F. Perennial rhinitis: An independent risk factor for

asthma in nonatopic subjects: Results from the European Community Respiratory Health Survey. J Allergy Clin

Immunol. 1999;104:301–4.

• Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema:

ISAAC. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Lancet.

1998;351:1225–32.


43



• (2007). "Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–

Summary Report 2007." Journal of Allergy and Clinical Immunology 120(5, Supplement): S94-S138.

• David Price, Asthma and allergic rhinitis: Linked in treatment and outcomes, Annals of Thoracic Medicine,

2010; 5(2): 63–64.

• Comhair SA, Gaston BM, Ricci KS et al (2011), Detrimental effects of environmental tobacco smoke in

relation to asthma severity, PLoS One 4;6(5):e18574, Departments of Pathobiology, Cleveland Clinic,

Cleveland, Ohio, United States of America

• Wijnhoven HAH, Kriegsman DMW, Hesselink AE, Penninx BWJH, De Haan M. Determinants of diferente

dimensions of disease severity in asthma and COPD: pulmonary function and health-related quality of life.

Chest. 2001; 119: 1034-42


44

http://www.ncbi.nlm.nih.gov/pubmed/21572527

Acknowledgment

s



45

• Altamiro da Costa Pereira, MD, PhD

• João De Almeida Lopes Da Fonseca, MD, PhD

• Daniela Vilas Boas Rosa Linhares

• Ana Margarida Barbosa Ribeiro Pereira, MD



46

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