1. State of asthma and allergies in Canada from the reference point of a family practitioner Alan Kaplan MD CCFP(EM) FCFP Chair, FPAGC Family Physician, Richmond Hill, Ontario

2. Objectives What are the asthma statistics? What do we aim for in Asthma management? Why don’t we get it? Adherence! Primary prevention, does it exist?

3. Where are we (Ontario data)?

4. Is Asthma getting better?

5. Incidence rates falling in the very young

6. Hospitalizations falling

7. But ER visits seem to continue

8. And there are still hospitalizations!

9. But, less claims for Physician visits

10. In Primary Care People with asthma present to a variety of places: – Primary care physicians – Pharmacists – Nurse practitioners – Pediatricians – Respiratory specialists – Allergists – Alternative care practitioners

11. There are guidelines for management MD Lougheed, C Lemiere, FM Ducharme, et al; Canadian Thoracic Society Asthma Clinical Assembly. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012;19(2):127-164.

12. Management of Asthma in Canada Manfreda J, et al: CMAJ 2001; 164(7):995-1001.

13. Are you in Asthma control?

14. Actual vs. perceived asthma control Fitzgerald 2005 N=893N=386N=77 47 97 88 90 Actual control by patients PatientsGPsSpecialists

15. Patient expectation can be raised “That can’t be right. My treatment doesn’t do that” Before After 020%50%40%60%30%10% Percentage of respondents who said that they were very satisfied with the standard of their asthma management, before and after being shown international guidelines Haughney J, Barnes G, Partridge M, Cleland J. The living and breathing study: a study of patients views of asthma and its treatment. Primary Care Respiratory J. 2004; 13: 28-35.

16. What can we (family docs) do? Ask about asthma control every visit Ensure you are using your inhaler device properly Ensure that you have an asthma action plan Review comorbid conditions that can affect asthma (rhinitis, sinusitis, GERD, obesity) Review any fears/concerns you have regarding your asthma medications

17. Can you see why this patient has uncontrolled Asthma?

18. What can you do? Go and see your doctor about your asthma Make it a priority, not one of a dozen things you go to talk to them about It is not about just getting a blue rescue inhaler that you ran out of! Understand that you need to have good asthma control! Take your preventative medications regularly Deal with your environmental triggers Ensure that you have had at least one breathing test (spirometry) Have an Asthma Action Plan

19. Asthma treatment plan is easy to follow? Patients Fitzgerald 2005

20. Stop smoking, really!!

21. The problem of nonadherence in healthcare WHO report 2003: Estimated that between 30 -50% medicines prescribed for long term illnesses are not taken as directed If prescription was appropriate then this represents a loss for patients, and healthcare providers Effective interventions are elusive (Haynes et al 1996, 2003)

22. Low adherence Doubts about NECESSITY CONCERNS about potential adverse effects The necessity-concerns framework and adherence asthma (Horne & Weinman, 2002), renal disease (Horne, et al 2001), renal transplantation (Butler et al 2004) cancer and coronary heart disease (Horne & Weinman, 1999), hypertension (Ross et al 2004), HIV/Aids (Horne et al., 2001), haemophilia (Llewellyn, et al, 2003), depression (Aikens et al 2005)& rheumatoid arthritis (Neame & Hammond, 2005)

23. Profile of concerns about ICS Patients (%) endorsing individual concerns R Horne University of Brighton 2004

24. How can you prevent asthma in your kids? Controversial stuff!

25. Smoking – primary prevention All pregnant women should be advised not to smoke Exposure to ETS independent risk factor for allergic sensitization In occupational health cigarette smoking may increase risk of asthma Image http://vienna-doctor.com/ENG/Articles_ENG/smoking_in_pregnancy.htmlhttp://vienna-doctor.com/ENG/Articles_ENG/smoking_in_pregnancy.html

26. Breast feeding – primary prevention Halken (2004) concludes breast feeding should be encouraged for at least 4-6 months Conflicting evidence – Probably protective against asthma risk overall, and in children with a family history of atopy (Goalevich 2001) – Protective effect against wheezing strongest in non-atopic children, and this effect mainly due to prevention of wheezing during viral respiratory infections. (Burr 1993, Wright 1995) – Breastfeeding may be associated with an increased risk of asthma development in older children and in adult life (Wright 1995, Sears 2002) Image http://mirror-au-wa1.gallery.hd.org/_c/baby/_more2005/_more12/breastfeeding-breast-feeding-suckling-newborn-baby- girl-three-3-days-old-closeup-2-DHD.jpg.htmlhttp://mirror-au-wa1.gallery.hd.org/_c/baby/_more2005/_more12/breastfeeding-breast-feeding-suckling-newborn-baby- girl-three-3-days-old-closeup-2-DHD.jpg.html

27. House dust mite Multifaceted environmental interventions that include dietary and house dust mite avoidance components reduced asthma symptoms and atopic sensitization at 8 years (Arshad 2003) House dust mite avoidance measures comprise part of the management of HDM allergic children (Halken 2004) Techniques: washing bedding in very hot water, ‘freeze of fry them’, Image http://www.topsleep.co.uk/images/images/images_hdm.jpghttp://www.topsleep.co.uk/images/images/images_hdm.jpg

28. Pets Not able to make a clear recommendation Is dose of allergen important? A lot of cat early may be protective, but a little bit of cat may be causative

29. The CHILD Study has recruited over 3500 families ! Expectant mothers, most of whom in their second trimester, have been recruited from the general population in several areas in Canada including: Vancouver, British Columbia; Edmonton, Alberta; Manitoba (Winnipeg and 2 rural sites); and Toronto, Ontario. The children and their mothers are monitored throughout the remainder of pregnancy and until the babies reach 5 years of age. All children will be clinically assessed at: – delivery, – at a 3-month home visit, and – at ages 1, 3, and 5 years. Home assessment with dust sample collection at 3 months is complemented by repeated detailed environmental questionnaires from pregnancy to age 5. Anthropometric measures, pulmonary function and viral infections are assessed longitudinally.

30. Summary See your physician or educator Aim for proper control Vaccinate..new indication for pneumonia vaccination in all asthmatics (as well as flushot!) Have someone watch your technique Control your environment, where possible