#inhaled beta-agonists

[jamie12walker]

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Table 3 gives the mean European order of chronic treatment in adults and in children. It is based on a ranking of the mean scores of the different modalities of treatment. For the answers in children, responses of the pediatricians were added to those of the ± 63 percent of the adult specialists also responding for children. The order of treatment is quite different for the two age groups. Inhaled beta-agonists are the first choice in adults while inhaled cromoglycate is first in children. Four drugs in adults and three in children are on average used “often or always” as first line for maintenance by more than 45 percent of the responding specialists.

However, this mean European order represents an average of considerable differences in opinion between specialists of individual countries. As an example, there is a clear preference for oral theophylline above inhaled beta-agonists in adults in France and Portugal, and specialists of Great Britain and Scandinavia prefer inhaled beta-agonists above inhaled cromoglycate in children. Table 4, based on the answers of adult specialists only, attempts to illustrate some differences between countries for four drugs and also for desensitization in allergic asthma. In each column the four countries with the highest percentages and the four with the lowest percentages for using the treatment “often or always” are listed above and below the MEA.

From this wide spectrum of percentages some clear regional trends can be identified. In Great Britain, inhaled beta-agonists and steroids are highly rated, whereas oral theophylline and desensitization have a particularly low use. In Scandinavia there is also frequent use of inhaled beta-agonists and steroids, but inhaled cromoglycate is rather poorly rated. In France, Belgium, and the Netherlands, the only clear pattern is the lower use of inhaled beta-agonists. Germany, Austria and Switzerland have in common a rather high use of theophylline and desensitization, whereas in southern Europe, there is a trend for frequent use of desensitization (Greece excepted) and a low use of inhaled beta-agonists and steroids. To start asthma treatment you may with the help of asthma ventolin inhaler which may be bought via the Internet as well as in the ordinary drug stores.

Recommended Metered Dose and Alternatives

Specialists of countries with a less frequent use of inhaled beta-agonists or steroids are generally also more reluctant to recommend adequate usual and maximal metered-doses of these aerosols. This is brought out in Table 5, showing that in several countries half of the physicians do not exceed 5 puffs as a usual dose and 10 puffs as a maximal tolerated dose of beta-agonists; the scatter of percentages is smaller for inhaled steroids and ventolin inhalers.

If a metered-dose aerosol of beta-agonists cannot be used satisfactorily, the oral formulation is on average the first choice for an alternative, followed by, respectively, the use of powdered inhaler, the addition of a spacer to the metered-dose, and the nebulization of the drug in soluble form. There was again a wide scatter of opinions, however, without clear regional patterns; this probably results from differences in availability of the alternatives in different countries.

Table 3—Chronic Treatment of Stable Asthma

Mean European Order of Treatment Adults (n = 735) Children in = 674) inhaled beta-agonist inhaled cromoglycate oral theophylline inhaled beta-agonist inhaled steroids oral theophylline inhaled cromoglycate oral beta-agonsst inhaled anticholinergic oral ketotifen oral beta-agonists inhaled steroids oral steroids inhaled anticholinergic oral ketotifen oral steroids

Table 4—Chronic Treatment of Stable Asthma by Adult Specialists

Rank (% using OFTEN and ALWAYS) Use as First Line for Maintenance Desensitization for Allergic Asthma InhaledBeta-Agonists* Adults OralTheophyllineAdults InhaledSteroidsAdults Inhaled Cromoglycate Adults Children Adults Children 1 S 94 A 100 GB 92 NL 81 GB 93 A 73 F 88 2 SF 93 B 96 S 90 B 67 NL 93 P 71 I 87 3 N 74 F 94 SF 89 P 64 B 91 K 61 A 83 4 GB 74 D 93 NL 87 I 59 I 90 D 45 P 79 MEA 52 79 67 48 86 34 58 13 B 33 NL 70 E 62 SF 30 D 77 NL 4 GR 13 14 F 29 CH 70 P 57 N 13 E 69 GB 1 N 7 15 NL 19 DK 61 B 42 DK 6 N 60 IRL 0 NL 5 16 P 14 GB 26 F 32 S 0 DK 53 N 0 GB 0

Table 5—Recommended Metered-Dose in Adults (% Recommending)

rank Inhaled usual >5 P* 3-Agonists maximal >10 P* Inhaled usual >5 P* Steroids maximal >10 P* 1 GB 96 S 100 N 96 SF 88 2 S 94 DK 94 GB 94 S 83 3 SF 93 GB 93 SF 93 DK 82 4 IRL 92 SF 93 IKL 92 N 80 MEA 63 59 80 61 13 I 52 B 50 D 71 B 52 14 GR 43 NL 46 NL 70 NL 52 15 F 35 F 31 F 68 I 48 16 P 31 I 16 A 63 F 46

[apind1950]

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Possible Causes for Differences

There are many factors which could explain the large differences in the views on chronic treatment between European specialists:

1. Uneven sampling of physicians for the survey and different response rates.

This factor cannot be ruled out, but it is rather unlikely to greatly influence the responses because patterns within countries are consistent and they are for seven countries at least, nearly identical to those of the 1983 pilot survey.

2. Differences in the clinical features of asthma. Although there are no large scale comparative data, minor differences are quite likely. The prevalence of allergy may also be different, eg, in northern versus southern Europe, and this could affect the use of anti-allergic treatments. It is hard to believe that this could account for the differences in answers because divergent attitudes may be found between neighboring countries where asthma should have similar clinical features.

3. Differences in definition and diagnosis of asthma. No doubt this could be an important factor. What is called asthma in some countries may be called chronic (asthmatic) bronchitis in other countries and therefore may be treated somewhat differently. Furthermore, there may be a variable emphasis on allergic features of asthma. It is hard to believe this could account for all the differences. The asthma ventolin inhalers are the best ways of asthma treatment and arrest your attacks.

4. Differences in drug availability, dosage and promotion.

National health and drug registration policies could have serious effects on this factor and it surely influences responses. There are many examples of this within Europe, eg, oral ketotifen is hardly available in Scandinavia, metered-dose inhalers were until recently not reimbursed by Social Security in the Netherlands, and powdered inhalers and spacers are virtually not available in Belgium and several other countries.

5. Different impact of clinical pharmacology.

The standards and the impact of clinical pharmacology seem higher in Great Britain and Scandinavia. Chest physicians there could be expected to rely more heavily on high quality studies showing that apprehension towards instituting a properly dosed preventive therapy with inhaled broncho-dilators and steroids are unjustified.

6. Language of teaching and medical reading.

This may be the most important factor accounting for the differences within Europe. It is clear that French specialists have little contact with the English literature and vice versa: the largest differences were found between British and French specialists! Portuguese physicians are usually geared to French medicine and have indeed given comparable answers. In a similar survey conducted among 23 Tunisian chest specialists, their answers were also in the same line as those of their French colleagues. We are now also able to add some evidence from a survey among 325 Belgian general practitioners. Their answers, as well as those of 39 Belgian adult specialists, have been separated according to their language, and they were compared with those of Dutch and French specialists. Table 6 illustrates, for two important issues, the impact of the language factor in Belgium. Except for desensitization in children, all differences between both language groups of specialists and general practitioners are significant and their respective answers are much closer to those of their language colleagues of the neighboring countries. Language indeed seems the only factor which could explain such differences in a small country like Belgium.

Conclusions

The 1984 European Audit on Asthma Diagnosis and Treatment has confirmed that adult specialists (and probably all groups of physicians involved) on our continent have large and interesting differences in their views on how to treat the chronic stage of this disease. The main contrast is between Britain and Scandinavia favoring inhaled beta-agonists and corticosteroids and, on the other hand, France, Portugal and some other countries of central and southern Europe emphasizing the use of oral theophylline as well as desensitization for allergic asthma. The reliance on preventive inhaled therapy also leads to the use of high usual and maximal doses of metered-dose aerosols. All other countries take intermediate positions. An attempt to confirm these trends could be made by evaluating objective data on drug sales in all involved countries.

We estimate that the impact of clinical pharmacology and the influence of language on medical reading and teaching seem unsuspectedly important factors explaining these contrasts. This is further illustrated by additional surveys in Tunisia and Belgium, We feel that such audits are stimulating and that they have teaching value regarding this disease, especially when used on an intercontinental scale. Finally, they should be repeated at regular intervals in order to add a more time-related view on asthma management with the help of ventolin inhalers.

[josephfarmer-blog]

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In Europe, as on other continents, bronchial asthma is a common disorder with widely variable clinical features. It is frequently not diagnosed and, if diagnosed, its severity is often underestimated by the medical profession as well as by patients and their families. Failure to diagnose or to correctly estimate the severity leads to considerable undertreatment. Moreover, in few other chronic conditions have more divergent opinions been noted concerning the correct type and order of treatment to be applied to the chronic state of the disease, as well as to its acute exacerbations. This was also brought out by a pilot survey conducted on the basis of a questionnaire among 68 chest physicians from seven European countries during the summer of 1983; although clear patterns of responses emerged among the physicians of each country, there was considerable disagreement among countries on the proper choice and dosage of drugs and ventolin inhalers for asthma therapy. Because of the interest generated by the presentation and the discussion of this survey at the Second Annual Meeting of the European Society of Pneumology in Edinburgh, it was decided to enlarge the scope into a complete European Audit on Diagnosis and Treatment of Asthma, covering all major countries of western Europe and using an improved and extended questionnaire.

Methodology of the 1984 European Audit

The questionnaire now also included questions on diagnosis and management of asthma, as well as on patient information and education. However, the emphasis was on treatment of chronic (stable) asthma, both in adults and in children. The main questions were the following:

1. In patients whose asthma is stable and not acutely deteriorating:

a. what is the considered order (sequence) of treatment for maintenance (8 choices to be numbered 1 to 8);

b. how often are a number of drugs used as “first line” therapy for regular maintenance (never, sometimes, often, always)?

2. For allergic asthma, how often is desensitisation used (same gradations as for lb)?

3. If they are used, what is the recommended metered-dose of inhaled beta-agonists and steroids (in number of puffs daily: 0-5, 5-10, 10-15,15-20, more than 20)?

4. If patients with mild/moderate asthma are unable to satisfactorily use a metered-dose inhaler, what is the order of preference (1 to 4) for an alternative delivery system?

A total of 3,305 questionnaires were mailed in June 1984 (1,075 to members of the European Society of Pneumology and 2,230 to other physicians in 16 countries). The latter were either non-pediatric (adult) specialists, pediatricians, or general practitioners and they were randomly selected within their country by the Glaxo Company. The time comes to purchase ventolin inhaler for asthma treatment via buy-asthma-inhalers-online.com.

French questionnaires were used in France and Portugal, German in western Germany and Austria, and the Spanish version was distributed in Spain. Physicians in the other countries received the English version. In a covering letter, responding physicians were encouraged to express in their answers their average attitude in their average asthma patient.

The present analysis for 16 countries (Table 1) is based on 735 answers from adult specialists (88 percent of whom were chest specialists) and 209 responses from pediatricians. Response rates were 40 percent and 27 percent respectively. Only for seven countries did the number of responses from pediatricians exceed 10, which was considered a minimum for meaningful analysis.

For all possible answers, the percentage of the total picking that answer was calculated. For questions about frequency of use or the order of treatment, a mean score was also calculated (Table 2). Furthermore, for all percentages and scores (provided that the number of responses of all countries exceeded 10), a mean European answer (MEA) was calculated in which the answers of each country were weighted for the population supposedly served by the specialists in that country.

A brief account of the results will be given here. Two preliminary reports have already been published, and a more complete report is in preparation.

Table 1—Responses from 16 Countries

Regions Countries AdultSpecialists Pediatricians British Great Britain (GB) 132 60 Isles Ireland (IRL) 13 (10) Northern Denmark (DK) 39 27 Norway (N) 28 24 Sweden (S) 32 11 Finland (SF) 27 (0) Western France (F) 128 28 Belgium (B) 50 (5) Netherlands (NL) 48 (3) Central Germany (D) 79 11 Switzerland (CH) 53 (7) Austria (A) 27 12 Southern Italy (I) 28 (2) Greece (GR) 14 (4) Spain (E) 23 (2) Portugal (P) 14 (3) Total 735 209

Table 2—Analysis