Advances in Knowledge 1. First report from Oman describing the characteristics of patients with asthma and the management practices in a specialist centre. 2. Allergic comorbidities and a strong family history are common in patients with asthma in Oman. 3. Concepts of short term and long term control in asthma introduced. Application to Patient Care 1. Goals of asthma treatment can be achieved if the international guidelines are followed properly. 2. More time needs to be spent on asthma education especially in the training of inhaler techniques and explanation of the need for regular use of controller medications. Management and Control of Asthma in Patients Attending a Specialist Centre in Oman Omar A Al-Rawas,1 Jayakrishnan B,2 Fatma Ben Abid,2 Jojy George,2 Sawsan A Baddar,2 Bazdawi M Al-Riyami1 SQU Med J, August 2009, Vol. 9, Iss. 2, pp. 132-139, Epub 30th June 2009 Submitted - 2nd February 09 Revision Req. 4th May 09, Revision Recd. 17th May 09 Accepted - 19th May 09 1Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman; 2Department of Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman *To whom correspondence should be addresses. Email: orawas@squ.edu.om clinical & basic research عالج الربو والسيطرة عليه مبركز ختصصي يف عمان عمر الرواس، جايا كريشنان، فاطمه بن عابد، جوجي جورج، سوسن بدار، بزدوي الريامي امللخص: الهدف: تكون الطريقة التي يستخدمها االختصاصيون لعالج الربو أكثر استنادا على األدلة عادة. في هذه الدراسة قمنا بتحليل خواص املرضى املراجعني لعيادتنا التخصصية من النواحي الدميغرافية ونوع األدوية املستعملة ومدى السيطرة على املرض. الطريقة: أجريت هذه الدراسة مابني ديسمبر 2005 ونوفمبر 2006 وشملت كل املرضى البالغني املصابني بالربو في مستشفى جامعة السلطان قابوس وذلك باستخدام بروتوكول مكتوب للتقييم. النتائج: شملت الدراسة 207 مرضى متوسط أعمارهم )40.64 ±14.8( سنة، وكان معظمهم من النساء )%72(، كما كان غالبية املرضى )%83.1( يعاني من الربو متوسط الشدة. بلغت نسبة حدوث حساسية األنف واجللد بني املرضى )%58.0( و )%11.1( على التوالي، فيما بلغت نسبة اإلصابة باحلساسية عند العائلة )%50.7(. كان مستوى الغلوبيولني املناعي الكلي نوع )E( في املصل مرتفعا )%66.7.( بينما كان فحص حساسية اجللد ايجابيا ألكثر من مستضدين عند )%52.3( من املرضى ، وكان مستضد غبار البيت فعاال في )%49( . بلغت نسبة العالج بالستيرويدات املستنشقة )%94.2( وموسعات الشعب الهوائية طويلة املفعول )ناهضات بيتا( )%85( ومضادات الهستامني )54.5%( ومضادات مستقبالت ليوكوترين)%11.6(. الغالبية )%40.1( استعملت الستيرويدات املنشقة بجرع متوسطة . وعلى الرغم من السيطرة على الربو في الشهر السابق بنسبة )%78.3(؛ فإن )%31.9( من املرضى راجعوا قسم الطوارئ و )%15( مت إدخالهم املستشفيات على األقل مرة واحدة بدقة الطبية النصائح فقط )25.6%( اتبع بينما صحيحة بطريقة البخاخ يستعملون فقط املرضى من )30.4%( السابق. ظهران العام في عائلي تأريخ وجود في احلال هو كما االنتشار واسعة االرجي بالطابع املتميزة املرافقة املراضة كانت الستيرويدية. اخلالصة: املنشقات باستخدام موجب للربو . على بالرغم من أن نسبة السيطرة على الربو في الشهر السابق كانت عالية ، إال أنها أقل بكثير على املدى الطويل ، وهذا يستدعي إعادة النظر في أساليب قياس معدل السيطرة على الربو على املدى القصير والطويل. مفتاح الكلمات: ربو، عمان، رعاية متخصصة، السيطرة على الربو. abstract: Objectives: The management of asthma by specialists is likely to become more evidence-based. This study analysed the characteristics of patients reporting to a specialist clinic including demographics, dispensed medications and the level of asthma control. Methods: All consecutive stable asthmatics seen in the adult pulmonary clinics of Sultan Qaboos University Hospital, Oman, between December 2005 and November 2006 were prospectively evaluated using a structured assessment protocol. Results: Of the 207 patients, )mean age 40.64 ±14.8(, 72% were females. The majority, 83.1%, had moderate persistent asthma. A positive history of allergic rhinitis, eczema and a family history of asthma were obtained in 58.0%, 11.1%, and 50.7% of patients respectively. Total serum immunoglobulin E )IgE( was elevated in 66.7%. Skin testing was positive for more than 2 antigens in 52.3%, with the house dust antigen being reactive in 49%. Inhaled steroids, long-acting beta agonists )LABA(, antihistamines and leukotriene receptor antagonists were prescribed in 94.2%, 85%, 54.5% and 11.6% of cases respectively. The majority )40.1%( was receiving medium dose inhaled steroids. Although asthma was controlled in 162 )78.3%(, during the previous month 66 )31.9%( patients had visited the emergency department and 31 )15.0%( patients were hospitalised at least once during the previous year. Only 63 )30.4%( patients were using their inhalers correctly. Good compliance with inhaled steroids was observed in only 53 )25.6%( patients. Conclusion: Allergic comorbidities and a strong family history of asthma were common. Although the level of asthma control in the previous month was high, it was much lower in the long term. The concepts of short term, long term and total control of asthma need to be explored. Keywords: Asthma; Oman; Specialist care; Asthma control. Omar A Al-Rawas, Jayakrishnan B, Fatma Ben Abid, Jojy George, Sawsan A Baddar and Bazdawi M Al-Riyami Clinical and Basic Research | 133 Current asthma management is focused on asthma control.1 The management of asthma in a tertiary care centre by specialists is expected to be more scientific, following international or local guidelines more strictly. However, Gaga et al. 2 reported that the goals of asthma treatment were not achieved, even under specialist care, as some patients were found not to follow prescriptions despite the distressing nature of their symptoms. In Oman, no published data are available on the magnitude of asthma in adults, but the prevalence of allergic conditions in children, including asthma, was found to be higher than in neighbouring countries and that too with significant morbidity.3 A study among private practitioners in Oman, undertaken a decade ago, showed that the treatment of both acute and stable asthma was sub-optimal.4 Interestingly, a more recent survey among asthma specialists in the Chicago area revealed that the care is consistent with national guidelines with certain differences and that the asthma care differed between the two subspecialty groups of allergists and pulmonologists.5 In this context of a higher prevalence of asthma and the reports of differences in the care rendered, it is important to study patients under the care of specialists in our area in order to plan optimal asthma control. The aim of this study was to document the characteristics of adult patients reporting to the specialists at Sultan Qaboos University Hospital (SQUH) including demographics, dispensed anti-asthma medications and the level of asthma control. Methods All consecutive patients referred to or followed up in the adult pulmonary clinics of SQUH between December 2005 and November 2006 with a diagnosis of asthma, were considered for enrolment in the study and were prospectively evaluated using a structured assessment protocol. SQUH is a teaching tertiary care hospital which receives referrals from all over Oman. The diagnosis of asthma was made by the physician on the basis of typical history of wheezing, breathlessness, recurrent exacerbations, a previous response to asthma medications, spirometry results and peak expiratory flow rate (PEFR) variability. A positive family history, elevated total serum immunoglobulin E (IgE) and positive skin tests were also factors confirming the diagnosis. At the time of the evaluation, the patients were in their usual state of health, stable and with no evidence of asthma exacerbations. During assessment in the clinic, the following information was obtained: duration of asthma, smoking and family history, the degree of asthma control based on asthma symptoms, frequency of exacerbations, hospital admissions, emergency visits, and use of asthma medications. Patients’ compliance with the medications and inhaler technique were also assessed and documented. Current and ex-smokers were excluded from the study. Patients with a history or evidence of co-existing chronic lung disease, heart disease or any other illness were not included. Asthma severity was assessed by a composite score based on Global Initiative for Asthma (GINA) guidelines.6 Plain chest radiographs were performed for all patients, and only those with normal or minor changes consistent with asthma like hyperinflation and increased lung markings were included. The forced vital capacity (FVC), the forced expiratory volume in the first second (FEV1) and the response to bronchodilator administration were measured using a spirometer according to the European Respiratory Society guidelines.7 Skin prick tests were performed using the Bencard system with a panel of 25 allergens. Positive skin reactions were assessed as wheal and flare reactions greater than 3mm. Serum IgE was measured using a microparticle enzyme immunoassay (Abbot Laboratories, IL 60064, USA). Atopy was defined as having an elevated serum level of total IgE or having positive skin tests for more than two allergens. The body mass index (BMI) was calculated for each patient from their recorded height and weight. It was then classified as normal, overweight and obese as per the published criteria.8 A diagnosis of gastro-oesophageal reflux disease (GERD) was entertained by the presence of oesophageal symptoms such as heartburn and regurgitation and was confirmed after a gastroenterologist reviewed the patient. Compliance for the study was categorised as good, partial or poor. Good compliance was defined as self-reported meticulous adherence to the dose and frequency of the prescribed steroid inhalers. Partial compliance was recorded when they reported Management and Control of Asthma in Patients attending a Specialist Centre in Oman 134 | SQU Medical Journal, August 2009, Volume 9, Issue 2 regular usage as per their prescription, but with occasional irregularity (mainly forgetting doses). All other patients who were not using the prescribed inhaled steroid, using them as and when needed or using them with frequent or regular omissions (e.g. using one puff instead of the prescribed 2 puffs daily or once instead of twice daily) were labelled as having poor compliance. The inhaler technique was assessed by a qualified respiratory therapist by a uniform protocol as outlined by Hilton et al.9 Each step of adequate preparation, adequate expiration, adequate inspiration and holding the breath was given one point. The above steps were clearly defined for different devices separately. Though they used three categories, we defined only two groups: adequate and inadequate. Only beclomethasone and salbutamol were available as metered dose inhalers (MDI). Dry powder inhalers (DPI) were available as single dose dispensers for formoterol and multidose dispensers like turbohalers for budesonide and disk halers for fluticasone. For comparison, the doses of all inhaled steroids were converted to beclomethasone equivalent as given in the GINA guidelines.6 The data were tabulated and analysed using the Statistical Package for the Social Sciences software (SPSS, PC Version 11.0). The various variables were cross-tabulated and the Chi Square test or Fischer’s exact test were used to see if any association existed or proportions were significantly different. The non-parametric Mann-Whitney test was used in analysing the age difference between male and female patients. Results There were 207 patients with a diagnosis of asthma without any other illness or a smoking history during the study period. One hundred and forty- nine (72.0%) were females and 58 (28.0%) were males. The mean age of the study population was 40.64 ±14.8 years. The baseline characteristics of the patients are given in Table 1. A positive family history of asthma was obtained in 105 (50.7%). The mean FEV1 was 2.0 ±0.72 liters and the FEV1 percentage was 71.92 ±19.2. Minor changes like hyperinflation, increased lung markings and some linear shadows were found in 46 (22.2%) patients. Total serum IgE was elevated in 138 patients (66.7%) and skin prick tests were positive for more than two antigens in 78 of the 148 patient who did this test (52.3%), indicating an atopic status. Skin prick tests were positive for the house dust antigen in 76 (49%), grass antigen in 36 (23.2%), shrimp antigen in 41 (26.4%), cat fur antigen in 23 (14.8%) and feather antigens in 22 (14.2%). The details of asthma medications are given in Table 1. One hundred and ninety-five patients Table 1: Baseline characteristics of patients with asthma n % Asthma severity Mild intermittant 12 5.8 Mild persistant 23 11.1 Moderate persistant 172 83.1 Comorbidities Allergic rhinitis 120 58.0 Eczema 23 11.1 GERD 28 13.5 Investigations Abnormal chest radiograph n=207 46 22.2 SPT with > 2 allergens n=148 78 52.3 High IgE 138 66.7 Medications Inhaled steroids 195 94.2 LABA 176 85.0 Theophylline 42 20.3 Montelukast 24 11.6 Antihistamines 112 54.5 Nasal steroids 79 38.2 BMI Class Normal 63 30.4 Over weight 64 30.9 Obese 79 38.2 GERD = Gastro-oesophageal reflux disease; SPT = Skin prick test; IgE = Immunoglobulin E; LABA = Long-acting beta agonists; BMI = Body mass index Omar A Al-Rawas, Jayakrishnan B, Fatma Ben Abid, Jojy George, Sawsan A Baddar and Bazdawi M Al-Riyami Clinical and Basic Research | 135 (94.2%) were prescribed inhaled corticosteroids (ICS); 176 (85%) were receiving long acting beta agonists (LABA), and 112 (54.5%) were receiving oral antihistamines. Some of the patients were receiving ICS and LABA through the same device. In most of the patients, asthma was controlled as 162 (78.3%) were using salbutamol inhaler less than twice per week and only 26 (12.6%) were using it daily. The details of the steroid inhalers, the type of medication, the type of devices used and the dose converted to beclomethasone equivalent are given in Table 2. Most patients were on dry powder inhalers (DPI), and the majority was receiving medium dose inhaled steroids. Only one patient was using ipratropium bromide inhaler. Twenty eight (13.5%) were taking treatment for GERD. Sixty-six (31.9%) patients reported an exacerbation requiring a visit to the emergency department at least once during the previous year. Thirty-four (51.5%) had visited the emergency department three times or less, while 32 (48.5%) reported more than 3 visits. Thirty-one (15.0%) patients were hospitalised at least once in the past year. The mean age of the females (41.32 ±13.6 years) was slightly higher when compared to the males, 38.91 ±17.7 (p = 0.164). Patients with mild asthma were younger. The mean age of patients with mild intermittent, mild persistent and moderate persistent asthma were 31.92 ±11.5, 35.4 ±12.5 and 41.96 ±15.02 years respectively. Only 63 (30.4%) patients were using their inhalers correctly: 22 (37.9%) males and 41 (27.5%) females (p = 0.178) [Table 3]. In addition, only 53 (25.6%) were fully compliant with regular inhaler medications, whereas 82 (39.6%) were partially compliant and 72 (34.8%) showed poor compliance with no significant difference between the different types of inhalers (p = 0.906) [Table 2]. The compliance was good in 9 (22.5%), partial in 17 (42.5%) and poor in 14 (35.5%) patients using MDI compared to good in 38 (24.5%), partial in 60 (38.7%) and poor in 57 (36.8%) of the patients using DPI. The distribution of patients with high IgE was similar in patients with normal BMI, in overweight or in obese persons (p = 0.716). In the same way, the distribution of patients with different levels of asthma severity was also similar in the above groups Discussion This report presents the characteristics of asthma patients receiving specialist care in our centre. The majority was female and had moderate persistent asthma. Allergic comorbidities were common in our patients. The level of asthma control was relatively high, in spite of suboptimal compliance and inadequate inhaler technique. Only a few patients had mild intermittent asthma, the majority had moderate persistent asthma. This was expected as the study was performed in a tertiary centre and the patients’ access to the services was only through referral. Likewise mild intermittent asthma was seen in only 7.5% of patients reporting to large outpatient clinics of four teaching hospitals in Greece.2 A positive family history of asthma was obtained in virtually half of the patients. Asthma definitely has a heritable component the exact nature of which is Table 2: Details of prescribed inhalers and the compliance achieved n % Generic Beclomethasone 40 20.5 Budesonide 67 34.4 Fluticasone 88 45.1 Devices Metered dose inhaler 40 20.5 Dry powder devices 155 74.9 Dose Low dose 47 22.7 Medium dose 83 40.1 High dose 65 31.4 Compliance Good 53 25.6 Partial 82 39.6 Poor 72 34.8 Inhaler Technique Adequate 63 30.4 Management and Control of Asthma in Patients attending a Specialist Centre in Oman 136 | SQU Medical Journal, August 2009, Volume 9, Issue 2 not clearly defined. Bjerg et al.10 found that asthma in both parents conferred a multiplicative risk, whereas the effect of parental atopy was additive indicating that asthma and atopy, despite their causal relationship, may be separate entities and could be inherited differently. In a study from Qatar, where consanguinity is as prevalent as in Oman, it was found that 21.6% of asthmatic children had mothers with asthma and 18.2% had fathers with asthma.11 Allergic rhinitis, but not eczema, was seen in a significant number of our patients. More than half had an atopic status with either a high total IgE or positive skin prick tests. Similar results were reported by Cengizlier et al.12 where 57.6% of their patients had a history of atopy. Farhoudi et al.13 noted that the most common risk factors were an elevated total IgE and a positive family history of atopy. We also noted a strong family history of allergy. The total IgE was elevated in more than 60% of our patients as well. Like elsewhere, house dust was the main allergen in majority of our cases. Minor non-specific chest radiographic abnormalities were recorded in 22.2%. Similarly, Hodson et al.14 reported that in nearly 81% of their patients with stable asthma the chest radiographs were normal. At the same time, in another study on acute asthma, only 50% of the chest radiographs were totally normal.15 Most of our patients were overweight or obese which was more evident among females. This is of particular importance as obesity is known to be associated with increased asthma severity and a decreased response to inhaled corticosteroids.16,17 However, there was no significant correlation between BMI and asthma severity and control in our patients. The majority of the patients was prescribed inhaled steroids and LABA. Prescriptions of antihistamines were high which probably reflects the presence of allergic co-morbidities. Additional controllers like montelukast or bronchodilators like theophylline were prescribed frequently which indirectly may suggest the severity of the disease. GERD was diagnosed in 13.5% and they were on regular treatment which is in keeping with previous reports.18,19 In the first multinational survey in Western Europe, the Asthma Insights and Reality in Europe (AIRE) study,20 only 5.3% of patients met all the GINA criteria for asthma control. Urgent care needs were reported by 27.9% and emergency visits by 11% of the adults. The most significant findings were the high levels of unscheduled emergency visits and hospitalisation by these patients and the major discrepancy between the patients’ perceived control and reported symptom severity. Using the presence of symptoms and the frequency of salbutamol use during the previous month in our patients, asthma appeared to be controlled as the majority (78.3%) was using rescue doses of salbutamol less than twice a week. However, when we consider the hospital admissions (15%) or emergency visits (31.9%) over the previous one year this was not the case. This may be due to the fact that these patients referred to specialists had a moderate or severe spectrum of the Table 3: Gender differences in asthma severity, body mass index (BMI) class, steroid inhaler technique and the compliance Characteristics Males n=58 Females n=149 p value Asthma severity Mild intermittant 6 (10.3) 6 (4.0) 0.142 Mild persistant 8 (13.8) 15 (10.1) Moderate persistant 44 (75.9) 128 (85.9) BMI Class Normal 28 (48.3) 35 (23.6) 0.001 Over weight 17 (29.3) 47 (31.8) Obese 13 (22.4) 66 (44.6) Compliance Good 17 (29.3) 36 (24.2) 0.746Partial 22 (37.9) 60 (40.3) Poor 19 (32.8) 53 (35.6) Inhaler Technique Adequate 22 (37.9) 41 (27.5) 0.178 Omar A Al-Rawas, Jayakrishnan B, Fatma Ben Abid, Jojy George, Sawsan A Baddar and Bazdawi M Al-Riyami Clinical and Basic Research | 137 disease. It is also possible that there was reluctance on the part of the patients to use rescue doses of inhaled salbutamol frequently in spite of having symptoms. The difference between the measures of control using symptoms or rescue medication use in the past month and the emergency visits or admissions in the same year brings up a need for recording short term and long term control of asthma separately. Adherence with controller therapy poses a major challenge to the effective management of persistent asthma. The data from the European Community Respiratory Health Survey documents that compliance to the treatment of asthma is poor worldwide and that there are large variations between countries.21 The compliance rates often are below 50%, the reasons for noncompliance being multiple and complex and not always clearly understood.22 Only 25% of our patients were fully compliant with regular use of the prescribed steroid inhalers. Nearly 40% were not using the steroid inhalers in the prescribed doses all the time. The rest of the patients (35%) were using them only when they had symptoms, or were not using them at all. This may reflect the lower perceived need for ICS therapy in our patients or the patients own cultural beliefs preventing them from using medications, especially inhalers, regularly. Non-adherence is usually associated with lower baseline rescue medication use, younger age, female sex, lack of symptoms, physical and psychological comorbidities or difficult social and economic circumstances.23-25 Adding to this may be the fact that patients often underestimate the severity of their asthma.26 Interestingly, a recent report from Italy concludes that most people in the general population do not use drugs, in spite of reported respiratory disorders, though to a certain extent asthma was an exception.27 A more regional study documents that the most common fears hindering regular ICS use were their potential to lead to addiction and the worry about steroid side effects.28 Hilton et al.9 report that only 25% of their patients had inadequate technique, the turbohaler being the easiest inhaler to use and metered dose inhalers being the most difficult. The relatively low level of performance was unexpected in our patients as they were instructed in the proper technique more than once. It is also important that the prescriber is fully aware of the characteristics of the different types of DPI, so that the most appropriate one is suggested.29 This is often not the case as a review of 20 studies highlighted the lack of skill among healthcare professionals in using different inhalation devices.30 This was also documented from Oman earlier where only 15% of the health care providers who participated in the study performed all the steps correctly.31 Boys are consistently reported to have more prevalent wheeze, but after childhood it is more common and more severe in females.32-34 Females also have significantly more asthma control problems and a lower asthma-related quality of life. The sex hormones are major determinants of these biological gender differences.35 However, despite their overall worse health outcomes, in another study, female subjects demonstrated better lung function, had similar treatment patterns, and showed no differences in physician approach.36 In our study, there were more females and they were older and heavier than the males. However, neither the asthma control nor the compliance were different between the sexes. Though the inhaler techniques in females were inferior, the difference was not statistically significant. The limitations in our study are probably few, the first being the strict inclusion criteria. A large number of patients with other even minor associated illness were not included. Asthmatics who smoke also were not included. The second limitation may be the fact that the some of the information, like compliance and the frequency of health care visits, were self-reported. In conclusion, most of the patients seen in our centre had moderately severe asthma with a high prevalence of atopy. Although the majority appeared to be controlled on standard forms of treatment, we have identified areas where considerable improvement is needed. More effort is needed to teach the correct inhaler technique and more time needs be spent on educating the patients and ensuring proper compliance. We also would like to suggest that there should be separate indicators to assess long term and short term control of asthma which in turn would contribute to assessing total control. Acknowledgement The authors would like to thank Sultan Qaboos University Hospital for supporting this study. Management and Control of Asthma in Patients attending a Specialist Centre in Oman 138 | SQU Medical Journal, August 2009, Volume 9, Issue 2 conflict of Interest The authors report no conflict of interest. References 1. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, Fitzgerald M, et al. 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