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The New Asthma Guidelines: What Were They Thinking? · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  Music.
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  I'm your host, Holly Wayman. I work for UT Health San Antonio's Department of Pediatrics.
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  In this podcast, we explore how we can provide the best, most cutting-edge,
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  compassionate care for children.
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  We hope to give you a unique and behind-the-scenes edge from our expert guests.
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  After listening, click on the link on this podcast for free credit that may
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  include CME, MOC, or ethics credit, depending on the topic.
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  Joining me back on the show today is dr
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  ed brooks he's division chief of allergy immunology and infectious disease at
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  the university of texas health science center at san antonio he also has 30
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  years of experience in this field and dr brooks you were on a national panel
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  that set set these type of guidelines.
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  That's correct. Yeah, it went on for several years.
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  Thank you so much for being back here on the show. First off,
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  I'm getting questions from pediatricians. What are these guidelines?
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  What is the most important thing to know first?
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  Well, it's an update to the national guidelines, so it's not a total revision of the guidelines.
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  So the previous guidelines that most people have been following are perfectly
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  fine. There's nothing inherently wrong.
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  The big change is that we've instituted use of inhaled corticosteroids as needed,
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  as opposed to on a standard schedule, which again is perfectly fine.
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  But it appears that if you use inhaled steroids as needed during certain situations,
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  it's a superior way to control asthma.
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  And the specific circumstances that the guidelines addressed were in children
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  with intermittent but severe episodes of asthma, particularly with viral infections,
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  it's now been studied and appears to be superior to using inhaled bronchodilators
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  such as albuterol alone to add inhaled steroids along with it.
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  And those studies used a liquid inhaled steroid called it budesonide,
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  and they used it twice a day during the exacerbation, and it showed some improvement
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  in those severe exacerbations.
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  And these are, again, children with mild intermittent, meaning they don't have
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  symptoms other than during viral infections.
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  So that's a big change. The other is something called SMART therapy, in which.
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  And a combination inhaler, and most of the studies were done with the inhaled
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  steroid budesonide plus formaterol, which is long-acting bronchodilator.
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  However, the difference with salmeterol, which is in the product Advair,
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  which has a longer onset,
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  the formaterol has a very short onset of action, therefore can be used as needed
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  in place of albuterol or a short-acting bronchodilator.
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  The guidelines now recommend that someone with moderate persistent asthma can
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  use the combination once or twice a day, but then in addition,
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  when they have symptoms, instead of using albuterol, it was shown to be very
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  superior to use the combination inhaler as needed.
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  And in children under 12, the guidelines would recommend up to a total of eight
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  inhalations a day or eight puffs a day, and for older than 12 years old, up to 12 puffs a day.
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  And the outcomes were extremely significant for reduction of exacerbations requiring
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  hospitalizations or oral corticosteroids.
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  Now, one of the things that people were concerned about, well,
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  they get a lot more of that medication and therefore use a lot more inhaled steroid.
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  It turns out in the comparative trials, people did not use excess inhaler and
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  actually used a lot less of the inhaled steroid in addition to not requiring oral steroids.
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  So the overall exposure to corticosteroids was less using what we call SMART
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  therapy, which stands for single maintenance and reliever therapy.
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  That's probably the biggest sort of, I'll say, psychological change.
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  Why that is, is because we, for years, have used inhaled steroids on a schedule,
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  once or twice a day, and then as-needed bronchodilators.
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  Using as-needed inhaled steroids has not been FDA-approved in this country. However.
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  The Guidelines Committee and NHLBR are working with the FDA to allow people
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  to get, sometimes you may have a bad month, you may run out of that inhaler,
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  that's another concern.
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  And so they're working with that, as well as working with school districts in
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  which children have always had a rescue inhaler, albuterol.
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  And convincing everyone that if they use their combination inhaler.
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  So the two inhalers that are marketed in this country that would fit this therapy,
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  one is called, it's a Budesonide and Formaterol, and that's marketed under the
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  name Simbacort, and there's generic.
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  And there's also Mometasone Formaterol, which is marketed under the name Delera,
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  and again, there's generics of that.
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  And so getting a child two inhalers is still a bit tricky.
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  Tricky it's tricky in terms of insurance coverage
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  to make sure all the insurers will actually cover an
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  additional inhaler if they need it again the
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  the research suggests that they'll actually
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  end up using less and so a general approach would be prescribing and when the
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  way they did the study is prescribing inhaler one puff once a day for mild asthma
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  mild persistent asthma or up to two puffs twice a day on a regular schedule,
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  and in addition, using, again, up to eight puffs total in children under 12 or up to 12 puffs extra,
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  excuse me, 12 puffs total in older children and adults during exacerbations of their asthma.
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  Which it might, with children under 12 especially, it might be hard to keep
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  track of during the school day how many puffs he or she has had.
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  Right, right. And toxicities were very low. And there's been some concern about
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  using that plus additional albuterol.
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  But again, there really were no concerns in the multiple studies that were reviewed of toxicity.
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  And in general, as I said, they end up using less of the medication.
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  And the theoretical background to why that is is because the combination,
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  the two inhaler, the two medications delivered together have a synergistic effect.
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  So it has an amplified benefit and it's borne out in the data,
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  particularly with regard to frequency of exacerbations and severity of exacerbation.
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  Again, they're together in the same inhaler. Okay.
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  Already. So you don't have to take two different inhalers. Okay.
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  Now, this issue, this topic has come up as well, where patients have been on
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  an inhaled steroid and a bronchodilator,
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  and additional research has come out since the guidelines that have shown that also is effective.
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  In other words, if they're taking fluticasone, let's say two puffs once or twice
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  a day, and And then they need the extra albuterol.
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  It seems to be effective to use albuterol plus additional fluticasone.
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  So you're adding additional inhaled steroid to the regimen.
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  And so one easy way to train your patients is every time you use albuterol,
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  use your Flovent. Just match it puff for puff.
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  And that seems to give, again, a similar synergy of the effect.
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  And again, obviating, hopefully, the need for oral steroids or emergency room
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  visits or hospitalizations.
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  Well, you know, the saying less is more and taking two at once so there's more
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  in there, but then it turns out to be less because you need less because it's more effective.
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  Correct. Correct. Children are staying under better control and their episodes
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  are shortened and where they don't need to continue taking high doses of the
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  medication for a prolonged period of time.
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  What would be some symptoms pediatric practitioners can tell the parents,
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  you know, that their children and tell the children this is if you're feeling
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  this, this and this, it's time for another puff?
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  If they're having cough, it seems to be relieved by the albuterol.
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  Many reasons for cough, one of which is asthma.
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  But many children, their primary symptom is coughing.
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  If they're coughing when they're running and playing, exercising is a common
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  trigger for asthma, then they need to increase the inhaler frequency.
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  And, of course, coughing at nighttime. time, in the middle of the night,
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  children with asthma will wake up in, you know, middle of the night,
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  one or two o'clock in the morning and have, as I say, a cough,
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  cough, cough, as opposed to simply clearing their throat.
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  And that's, those are the early warning signs of asthma.
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  And so there's two ways we classify the severity of asthma. One is how the chronicity of it.
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  And that, in other words, how often are they having symptoms during the week
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  with, with exercise, exercise at nighttime.
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  And the other is what we call the risk domain, in which they're at risk for
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  having severe exacerbations.
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  So I'll go back to the example I mentioned about children with viral infections
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  that have severe exacerbations that end up in the hospital.
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  And in between, they're perfectly fine. They have no symptoms,
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  no warning signs of asthma at all.
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  And so this is a a classic phenotype of very young children who are very sensitive
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  to some viruses that trigger asthma.
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  And so using, again, the inhaled steroids during the periods where they have
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  their viral episodes is very effective at reducing the severity of those episodes.
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  In the past, we might have reclassified them as persistent asthma and recommended
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  they take inhaled steroids all the the time.
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  And one of the parameters, we used to use the rules of two. If you have.
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  More than two episodes per week of cough or wheeze.
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  If you have more than two episodes at nighttime with coughing or wheezing,
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  or if you have more than two episodes of exacerbations in a year that require oral steroids,
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  we might, even though in between they're perfectly fine, we would reclassify
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  them as, quote, quote, persistent asthma, and then treat them with daily inhaled steroids.
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  Well, with the new guidelines, basically, regardless of how we end up classifying them,
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  if they beat the rules of two by the two severe exacerbations a year requiring
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  steroids, but the rest of the year they don't require anything.
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  Then it makes sense to treat them with inhaled steroids during those episodes
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  to avoid the use of systemic steroids or oral steroids, which we know have long-term side effects.
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  What are some of those long-term side effects? Well, you know,
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  when a child's on a course of oral steroids, they don't grow.
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  So, the growth inhibition is the biggest concern.
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  And inhaled steroids in higher doses can also have a similar effect.
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  So, the least amount of corticosteroids, we expose them to, the better.
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  The other is risk of fractures and osteoporosis.
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  They have an effect on that, and some studies have shown with five or more courses
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  of oral steroids in a year, a child is at higher risk of having fractures.
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  There are some more what we call idiosyncratic or rare side effects of cataracts.
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  Obviously, elevated blood glucose in children who are pre-diabetic is also a concern.
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  And again, it's worse with oral steroids than with inhaled steroids.
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  And is it because the inhaled steroids are going right to where the irritation is happening?
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  I think that's part of the explanation. the synergy
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  between the two the beta agonist
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  and the corticosteroid seems to have a more
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  beneficial effect on relieving bronchospasm and
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  airway inflammation so and i
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  know you mentioned toxicity so it's got to be stressful having a child who has
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  asthma and then on top of it with everything else you're trying to keep track
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  of work and home and kids and then if you can't remember if your child has already
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  had eight puffs and he or she's under 12.
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  Is it a big deal if they have a ninth one and you can't remember?
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  Or do you want to say anything there?
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  Again, the data in all the studies didn't show any toxicities.
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  They chose these numbers to do their clinical trials.
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  So they didn't go higher.
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  But that's why the recommendations come down on these. So I personally don't
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  think it's a big deal to go extra.
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  But guidelines are guidelines. It sounds like it's pretty complicated,
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  but then kind of when you put it, as you're saying, bottom line,
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  then it isn't that much to keep track of.
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  It's actually much easier. It's actually much easier, in my opinion.
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  I've been doing this approach for many years.
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  And basically, the concept is if you have two inhalers, a rescue and a controller inhaler.
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  Again, we've had it beat into our brain that controllers you use regularly and
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  the rescue medicine you use as needed.
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  So I think we're just unlearning what we've been learning for the last decade or two.
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  So with a combination inhaler, you have one inhaler, single inhaler.
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  You don't have to worry about a second inhaler. That in and of itself is simple.
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  And you tell them, okay, you're going to take this inhaler once a day or twice a day.
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  And then when you have a flare-up just
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  use the same inhaler as often as
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  you need it and you know try to keep track of the number of total numbers of
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  puffs you know if they're doing a single puff at a time then you know 12 puffs
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  a day you'd have to be doing it you know pretty often without any benefit and
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  in that situation you probably need to go to the nursery room anyway and that
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  those Those are the guidelines.
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  If you reach that 12, then or eight and the younger kids, then you probably
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  ought to be seeing your physician anyway.
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  Because it's not 100 percent. Some exacerbations are severe and that you need
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  to seek medical care. But for the most part.
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  Again, just using that and again, I just sort of say, well, before sports, use your inhaler.
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  You have one inhaler to remember that's it and so in that respect it is simpler and again it's,
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  up to eight puffs recommended 12 and under and up
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  to 12 puffs if you're over 12 right so and do you recommend always before athletics
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  say if a child's going into pe taking a dose even if they're not he or she isn't
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  coughing no i don't okay in fact that's one of the questions i ask ask the patients that say,
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  well, when you go out and play or do something,
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  do you cough or have trouble every single time?
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  Because there's a good feedback for me. And if the answer is no,
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  then no, you don't have to use it pre-exercise.
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  One of our pediatric listeners for Pediatrics Now was asking,
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  what about when there are medication shortages?
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  What do you do then? Dr. Anneke Vandenbroek.
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  All inhaled steroids are about equal.
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  So if a child is on an inhaled steroid, it doesn't matter. Same with the bronchodilator products.
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  They're all equal. And so if you're on one of these combination inhalers and
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  there's a shortage, you just revert back to the two inhaler system.
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  And again, you can use it the same way. use your controller inhaler you know
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  once or twice a day and then use the combination as many as much as you need
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  it again follow the same guidelines about eight and twelve,
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  puffs and that's been shown to be more effective than only using albuterol alone
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  that's the only change the only change is instead of albuterol alone you're
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  using two inhalers each time you you need rescue inhalation.
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  And is it fewer doses a day though, or that has not changed?
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  It has been as needed, a couple of doses?
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  Yeah, that hasn't changed because you base that on how chronic their symptoms are.
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  And if a child is having daily symptoms, well, you're going to dose the daily
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  regimen higher and you're going to increase the constant, you know,
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  so that many of these come in different concentrations of inhaled steroid.
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  So you're going to increase the inhaled steroid based on their chronicity to
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  try to get their asthma under control.
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  Okay. This question is from Acorn Pediatrics.
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  The doctors there are saying, please clarify management of asthma exacerbation
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  for children on controller therapy, especially if on LABA, LABA?
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  Yeah, the LABA.
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  Is that bronchodilator that's long-acting, long-acting bronchodilator agents.
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  So there's two classes of them, and this is the tricky part,
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  because one of the original combination inhaler was fluticasone and salmeterol.
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  Now, salmeterol you cannot use in SMART therapy because it takes two to three
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  hours before the full benefit of the bronchodilator.
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  And so it's not a rescue medicine in the least bit. It is only for daily chronic management.
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  And so people who are on Advair or the fluticasone salmeterol combination would
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  take it one or two puffs, one or two times a day.
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  And if they have exacerbation, they use as needed albuterol.
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  Now, the other two products, the Budesonide, Firmatorol, mainly it's the difference
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  between the Firmatorol and Salmeterol, have a rapid onset of action.
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  So you can use it as if it was your rescue inhaler. And that's where smart therapy is really beneficial.
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  We walk us through what would be important not to miss saying to a family.
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  Okay, the biggest danger is if they're on Advair. They cannot use Advair beyond
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  what the physician's prescribed.
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  And one of the dangers is they use the Advair or the salmeterol-fluticasone
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  combination regularly, and then they try to use it as needed, and it doesn't work.
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  So they turn around and give them albuterol because it does work rapidly.
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  Well, after two to three hours, that Advair kicks in and you can get combined
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  toxicities of the beta agonist.
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  It's usually not as big a problem in children who have healthy hearts,
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  but in adults with heart disease, that can be a real risk.
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  The beta agonist can have some effects on the heart, tachycardia, etc.
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  Okay, so bottom line with Advair, only use that if that's the only way?
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  And only as prescribed? Yeah, only as prescribed. It should be one or two puffs once or twice a day.
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  And not as needed? Right. You cannot use it as needed. The other products you can use as needed.
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  A 12-and-a-half-year-old boy, Benjamin, is seeing his pediatrician.
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  The mom is in the clinic with them. The asthma seems to be getting worse.
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  And walk us through what we should say based on the new guidelines. lines?
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  Well, it depends on what's getting worse.
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  If they're having higher frequency of symptoms throughout the week,
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  then one would increase their baseline therapy.
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  So they might increase the dose of the inhaled steroid. That would be the most effective approach.
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  Or the numbers of inhalations.
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  Let's say he was on one puff a day of Flovent, vent and then pure in albuterol,
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  but he's having a lot of symptoms.
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  One approach would be, well, increase the flow vent to two puffs twice a day
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  or increase the dose from flow vent 44 to flow vent 110.
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  There's three different doses of flow vent. Those would all be appropriate.
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  If, on the other hand, he was doing mostly fine, but every month or so he was
• 22:02
  having a severe exacerbation that It ended up in the ER and they ended up on oral steroids.
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  In that case, I would institute smart therapy and I would use one of the other products.
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  You can either have them on Flovent and just say, just use Flovent each time you use your albuterol.
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  And I, for simplicity, say just match it puff for puff.
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  In other words, if you give him two puffs of albuterol, give him two puffs of
• 22:28
  the extra aflovent every time he needs it.
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  And that's particularly important in children who are using albuterol or short-acting
• 22:36
  beta agonist very frequently.
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  If they're using it very frequently, that's a risk because there's a risk of
• 22:44
  something called tachyphylaxis. In other words, the beta agonist receptor will
• 22:49
  downregulate and the albuterol become less and less effective.
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  And that's the advantage, again, of the combination with inhaled steroid is
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  it protects you from that downregulation.
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  So again, that's part of the physiologic synergy between the two medications.
• 23:05
  The other approach would say, okay, stop taking that. We're going to put you
• 23:09
  on budesonide and formaterol combination.
• 23:11
  Use that inhaler, you know, one puff twice a day, and then as needed in between
• 23:19
  for the exacerbations or for your worsening symptoms.
• 23:24
  So say Benjamin's cousin who's eight, Sarah, her asthma is not getting worse,
• 23:32
  but does she need to come in and the pediatrician should talk to that family
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  about the new guidelines?
• 23:38
  Guidelines like call that family and schedule a time for them to come in?
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  If they're doing well on the current regimen, there's really no reason to rock the boat.
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  I would say if they're doing well on their current regimen, there's really no reason to change it.
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  And so when talking to patients, is it more saying, you know,
• 23:59
  we have these new guidelines.
• 24:00
  If would you like to hear them. It's not like we need to talk to every patient
• 24:05
  who has asthma about these new guidelines.
• 24:08
  Yeah, I don't do that. And of course, it depends on how much people want to hear.
• 24:15
  Sometimes, you know, keeping it simple is the best approach.
• 24:20
  And if a child's doing well on it, let's say they're on Fluvent,
• 24:22
  you know, two puffs twice a day, and they're doing great.
• 24:25
  They occasionally use albuterol with sports, you know, maybe once a week or
• 24:31
  every other week, They need a little albuterol to get a virus and need albuterol for a day or two.
• 24:36
  I'm not sure I would change much at that point.
• 24:40
  It's primarily focused on those. And a more typical scenario is the teenagers
• 24:46
  who never take medication regularly.
• 24:50
  Right? Right. Can you have a teenager?
• 24:54
  And you say, take your nasal spray every day. Well, they just don't do it.
• 24:59
  Most people don't do that. out. They use medication when they need it.
• 25:04
  And that's where I think the underlying advantage of smart therapy is.
• 25:09
  I put every teenager on it because they don't take medicine unless they need it. With the,
• 25:17
  the bronchodilator mixed in with the inhaled steroid, they use it.
• 25:21
  You never have to train a teenager to use albuterol.
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  They will use it and use it and use it and overuse it because it gives them relief immediately.
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  They get immediate benefit.
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  And so you're sneaking the steroid in on the side, which you don't feel it working.
• 25:38
  So that's one of the advantages is that probably Probably a lot of people back
• 25:43
  off or skip their medication.
• 25:45
  I know they do because I ask them if they do. And some of them haven't taken
• 25:49
  it in months and their parents think they're taking it regularly.
• 25:53
  So they know the answer on the test. They just, you know, it's hard to get an
• 25:56
  honest answer. But when they need it, they will use it.
• 25:59
  And whatever motivates them to use the inhaled steroid is a win because they
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  won't use it at all because they don't feel it working.
• 26:10
  Okay. And for kids under 12 or kids in school in general, should the nurse be
• 26:17
  informed that, you know, if the child asks to be excused from class to be able
• 26:21
  to take this medication, any time to be able to do it?
• 26:24
  I think so. I mean, I'm not sure where all the schools are.
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  There's a sort of a diversity of responses out there in the schools.
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  And they pretty much want to control in the younger kids, particularly in the
• 26:38
  elementary and middle schools and high schools, because it's a state law that
• 26:43
  they can carry their own inhaler.
• 26:44
  Some kids tell me, oh, I just carry it with me and nobody ever says anything. thing.
• 26:49
  So some always go to the school nurse and have to keep their inhaler with the
• 26:54
  school nurse and some carry it with them.
• 26:57
  So there's kind of a, it's all over the place.
• 27:01
  And I believe whatever works, I mean, I understand the schools want to keep
• 27:05
  control of medication use during school time, but at the same time,
• 27:11
  it's a state law that they can carry their inhaler with them.
• 27:14
  Okay, and it may vary from state to state, so check your state law for listeners
• 27:19
  out of state or in other countries.
• 27:22
  Correct. I don't know what all the laws are. I know in Texas,
• 27:25
  you know, they can carry their own inhaler.
• 27:29
  Any other advice about the new asthma guidelines you'd like to give to pediatricians?
• 27:33
  Well, there are a couple other areas that we address. You know,
• 27:36
  I mentioned what I think is the most dramatic change.
• 27:40
  One is with environmental controls and with people with allergic asthma.
• 27:45
  And the guy that studied a lot of investigations into doing things in the home
• 27:51
  that might make a difference in reducing allergen exposure.
• 27:55
  Exposure and so basically if
• 27:59
  you have allergies to molds
• 28:03
  and insects things like
• 28:06
  that you know like mites then just
• 28:10
  getting a dust cover for the bed is not enough you have to use what we call
• 28:15
  comprehensive allergy control and it goes from mold mitigation to insect mitigation
• 28:22
  to the covers on the beds and reducing the humidity in the home, comprehensive things.
• 28:29
  We don't recommend the air filters. I know those get still, I get a lot of questions
• 28:34
  about the air filters, and they
• 28:36
  basically have not shown any benefit for people with allergic disease.
• 28:40
  And the main reason is most of the allergens are very heavy and they're not floating in the air.
• 28:45
  It's only if you vacuum and kick it up in the air that you might notice that.
• 28:50
  I think there may be two Two situations in which air filters may be a benefit,
• 28:55
  and that's with cat dander, which has a very high buoyancy, and so it floats
• 29:00
  in the air quite a bit, and mold spores also.
• 29:04
  But the main mitigation for mold is get rid of the water, the dampness,
• 29:08
  because mold can't grow without water.
• 29:11
  And so you don't have to rip out walls and clean out air filters or clean out
• 29:16
  air ducts, things of that nature, and all these expensive solutions that just
• 29:20
  haven't been shown to be beneficial.
• 29:22
  Doing the simple things makes it.
• 29:26
  Insects, allergy, you know, cockroach allergy, things like that,
• 29:30
  just doing cockroach control, and again, comprehensive insect control and not,
• 29:36
  or what they call, what's the term? They use universal or comprehensive.
• 29:40
  Basically, don't use insecticides. Yeah, don't use insecticides.
• 29:44
  Use roach motels and, you know, get rid of the food crumbs and things like that
• 29:49
  because the insecticides themselves
• 29:50
  have a toxic effect and can actually worsen allergies and asthma.
• 29:55
  So you want to avoid using, I always call them poisons. Don't put poison in your home.
• 30:01
  And are even outside of your home? Yeah, I'm not a big fan of poisons anywhere
• 30:07
  for pets and small children, you know, get into stuff like that.
• 30:11
  The other two areas that were addressed during the expert panel were the use
• 30:15
  of exhaled nitric oxide.
• 30:17
  And this really impacts mostly the a specialist, but basically you can't really
• 30:23
  use that as a criteria for diagnosing asthma,
• 30:26
  but it's helpful for monitoring asthma progress over time.
• 30:33
  But as a single modality, it's really not very specific for asthma.
• 30:39
  It's not good in that context.
• 30:42
  The other is the use of immunotherapy there were allergy shots for children
• 30:48
  with asthma or people with asthma.
• 30:50
  And it was a positive. The studies show that there's a positive effect of controlling
• 30:55
  allergic disease with allergy shots and controlling asthma.
• 31:00
  Okay. I have a short answer for those, but like I said, I think most of the
• 31:05
  changes people are affected by who are not a specialist are going to be the
• 31:09
  use of inhaled steroids as needed.
• 31:12
  And thank you so much. This has been so insightful. It helps so much.
• 31:16
  And it helps to really hear you talk about the asthma guidelines as opposed
• 31:20
  to reading it. It looks really complicated.
• 31:23
  Yeah. The wording of it is very detailed and scientific and specific.
• 31:29
  The guidelines process is shifted and we have to adhere to very strict statistical outcomes.
• 31:39
  And so only certain Certain clinical trials get included in the reviews.
• 31:45
  And like this information for smart therapy, that's been around for a couple
• 31:50
  of decades, you know, where people were doing some non-controlled clinical trials.
• 31:56
  But only a few of them that were done, quote, the right way got included in the reviews.
• 32:01
  So that's why the reviews are very kind of narrow in their scope,
• 32:05
  so to speak. And a lot of people were upset with that, but that's the process.
• 32:13
  In the NHLBI, National Heart, Lung, Blood Institute, they adhere to these very
• 32:20
  strict things because they don't want to have to backtrack.
• 32:23
  And there have been some mistakes in the past in the guidelines when they made
• 32:27
  recommendations and then had to backtrack because the evidence really wasn't there.
• 32:32
  And so I have to be very careful about that. but general
• 32:36
  principles are inhaled steroids work great
• 32:39
  and like here's something
• 32:43
  i tell my patients when your allergies are really bad you
• 32:46
  know the fda's you know people are going to prescribe flonase like
• 32:50
  once once or twice a day i say
• 32:53
  use it four or five times a day if it's really bad slam it
• 32:56
  and then back off and that works really well and a lot of people tell me oh
• 33:01
  that stuff stuff doesn't work well they're not using enough if you're snotty
• 33:04
  you put it in your nose then you blow your nose it's gone and i say you can't
• 33:10
  overdose i mean yes there's side effects of.
• 33:15
  Corticosteroids, but you can't even come near to what the side effects are of
• 33:18
  taking oral prednisone.
• 33:20
  So it's always, I think topical steroids are always safer than oral steroids.
• 33:25
  And the old guidelines lean heavily on oral steroids as a last resort,
• 33:31
  but it happened a lot because the, when you have an exacerbation,
• 33:36
  you need to ramp it up fast.
• 33:37
  And so again, going back to SMART, it gives patients the tools to treat those
• 33:42
  exacerbations and not have to end up in the ER and not end up on oral steroids.
• 33:48
  And I think getting high doses of topical steroids is as effective as taking prednisone.
• 33:55
  And so that information has been around for a long time.
• 34:00
  The committee did not address acute exacerbation of asthma with inhaled steroids,
• 34:05
  even though that That was one of the outcome measures.
• 34:08
  Because some studies have suggested that, well, if you just use tons of inhaled
• 34:13
  steroid and compare that to prednisone, it's about the same.
• 34:16
  And the side effects are much less.
• 34:19
  So I think people need to not be afraid of inhaled steroids or nasal steroids.
• 34:27
  And antihistamines just don't have any long-term prophylactic benefit.
• 34:32
  So, in general, what I see is everybody takes antihistamines all the time.
• 34:39
  Even for a cold, it could be opening the body up for a secondary infection, right?
• 34:45
  Indirectly, you're right. They've studied mostly otitis media and shown that,
• 34:52
  for one, antihistamines don't have any benefit. effect.
• 34:57
  And some of the studies actually show a risk of persistent what we call serosotitis.
• 35:05
  Now, and the way I think about it, antihistamines dry things up.
• 35:09
  So it makes it look good on the outside, but the natural healing process is
• 35:14
  to drain all that stuff out, the sinuses, the ears, the lungs,
• 35:17
  their natural mechanism for staying healthy is they produce mucus and you just
• 35:23
  wash wash all the gunk away and keep the bacteria washed out and the viruses, et cetera.
• 35:27
  And if you slow that process down, you're going to be more prone to getting
• 35:31
  sinus infections and ear infections.
• 35:33
  So I think overuse of the over-the-counter medications would tend to be even more drying.
• 35:39
  And the decongestants, you just need to get in bed and drink and get chicken
• 35:45
  soup, in my opinion. Right.
• 35:48
  And for a cold, distinguishing a cold from allergies is really,
• 35:54
  really difficult, but very important for pediatricians to know. So.
• 36:00
  One thing, if they have fever, it's not allergy. It's got to be an infection.
• 36:05
  Allergies do not cause fever.
• 36:08
  And a lot of people say, well, I have seasonal allergies. And I'll say, what season?
• 36:13
  Well, they can't tell me because it's off and on all year.
• 36:16
  And typically in the fall and winter when that's the cold and virus season,
• 36:20
  when the kids go back to school, that's when we get all the colds and viruses.
• 36:23
  And I'll say, how long do your allergies last? Oh, about a week.
• 36:28
  And they'll say with the weather change and something
• 36:31
  blew in and then it goes away completely i said that was probably a cold we
• 36:37
  are if you're around kids young kids you are showered with viruses all the time
• 36:43
  i can pull a virus out of a kid's nose all the time no matter what,
• 36:49
  they're healthy there's always a virus in there really even teenagers well we
• 36:55
  did a study with With kids with asthma, they were mostly younger children,
• 37:00
  sort of school-age kids and middle schoolers.
• 37:05
  I don't know if we had too many high schoolers.
• 37:07
  But every time we stuck a swab up their nose, there was a virus,
• 37:11
  no matter whether they're healthy or sick or otherwise.
• 37:14
  Really? There was a virus in there all the time.
• 37:17
  Whether we catch a cold is a function of the immune system.
• 37:21
  And, of course, we had to relearn this with COVID. it
• 37:25
  you know they were people were healthy and fine and
• 37:28
  yet they test positive for covet and could pass it on and that's the viruses
• 37:33
  being smart it's like well we don't want to really make people sick but we want
• 37:37
  to propagate we want to spread we want to reproduce and but how the immune system
• 37:42
  handles that virus and that's how the vaccine works people say well it doesn't prevent,
• 37:48
  and people get upset because it doesn't prevent covet it's like well no it just
• 37:51
  keep you from From dying from it.
• 37:53
  The more important thing is. You catch it. And so it's the same with all the viruses.
• 37:59
  Chickenpox. When I was young. We all got chickenpox. And we had immunity the rest of our life.
• 38:06
  That immunity has waned. Because.
• 38:09
  There's no more chickenpox out there.
• 38:12
  And that's why we have to worry about shingles? Shingles, exactly,
• 38:15
  because the immune system now has gone to sleep.
• 38:18
  And every year we would get hit with chickenpox as it spread everywhere.
• 38:22
  And that has a boosting effect. So natural immunity was always there.
• 38:27
  So the kids go through the first year of school, they're just sick as heck.
• 38:31
  And then after that, they, quote, don't catch the viruses. Well,
• 38:35
  they get the viruses. They just kill it.
• 38:37
  And occasionally we get a new strain, a strong one like COVID that comes along.
• 38:42
  And our immune system hadn't seen it before.
• 38:45
  But they did a recent study with COVID and found that some children who showed
• 38:51
  immunity to the common cold coronavirus had developed some immunity to COVID.
• 38:57
  And so the cross-reaction, so it's a coronavirus and so there's some components
• 39:03
  of it that are similar to the common cold.
• 39:05
  And so, but those antibodies helped, added some degree of protection against COVID. it.
• 39:11
  So bugs are, you know, they're, they're part of our life. We're,
• 39:15
  we're surrounded, we're swimming in bugs and prison viruses.
• 39:19
  And do adults have, do we all have that in our nasal passages or we just know that kids do?
• 39:25
  I think it's less so, you know, the least exposure you have to crowds and kids,
• 39:32
  you know, there's less exposure, which represents
• 39:35
  somewhat of a a risk because your immunity if you're
• 39:38
  not exposed at all once you do finally
• 39:41
  catch or get exposed to somebody then we're more likely to be sick with it if
• 39:48
  our immunity has waned but like you said about shingles that's probably true
• 39:52
  our immune systems have gone to sleep because we haven't been exposed to it
• 39:56
  in such a long time that the virus lives in our nerve roots if we had chicken chickenpox.
• 40:01
  And once everybody gets exposed to chickenpox at some point,
• 40:06
  and it lives in our nerve roots, and then it can come out and cause shingles.
• 40:10
  And it's happening in kids.
• 40:14
  It never happened before. So it's a much higher rate of shingles than we used to ever see.
• 40:19
  Right now, there's a higher rate of shingles in children. I didn't know children
• 40:22
  got shingles. Yeah, Yeah, I didn't either until they started getting it.
• 40:27
  Wow. When did that happen? Again, this is in the last decade since the vaccine
• 40:32
  has cut down on the wild virus floating around.
• 40:36
  People don't get boosted. So now they're recommending a booster for the chickenpox vaccine.
• 40:42
  CDC and, you know, the health agencies, you know, put all their heads together
• 40:46
  and come up with these guidelines.
• 40:47
  And I think it's reasonable to, you know, protect against. And adults,
• 40:54
  of course, get the Shingrix, which is basically the adult chickenpox vaccine
• 40:58
  to help protect against shingles.
• 41:00
  And that's just, again, it's just boosting the immune system because we don't
• 41:05
  have any natural immunity to boost against anymore.
• 41:08
  There's very little chickenpox out there anymore.
• 41:11
  Does the shingles look different? Do you want to talk about that?
• 41:15
  Just one other thing just to add to our pediatrician listeners.
• 41:19
  Would that look different in a child? What do you look for? It's the same as an adult.
• 41:23
  You get in a particular dermatome and it comes out of the nerve roots and it's
• 41:28
  the blistering and it's extremely painful.
• 41:32
  It's very different from chickenpox because it's embedded in the nerve roots
• 41:36
  and it comes out in the nerves.
• 41:39
  And so it irritates the nerves. It's very painful.
• 41:41
  And it's only like that comes out around the back or around the chest and stops
• 41:46
  in midline because it's coming out of that particular nerve root and that dermatome.
• 41:51
  And then what would you recommend if one of our pediatric practitioner listeners,
• 41:55
  if they see a child who they think has shingles, what do you do next?
• 42:00
  Well, you treat it. There are some antivirals that may be beneficial,
• 42:04
  but most people, unfortunately, kind of suffer through it.
• 42:09
  So pain medication? Yeah.
• 42:13
  Some people use acyclovir, but that would be a question for the infectious disease expert.
• 42:19
  They would know that information a bit better than I do.
• 42:23
  Well, Dr. Brooks, and of course you see patients at University Hospital and
• 42:28
  at UT Health San Antonio.
• 42:30
  It's so insightful talking to you. I feel like the new asthma guidelines,
• 42:34
  they're kind of like reading Shakespeare as opposed to watching or listening
• 42:38
  to Shakespeare, it's much more, it makes a lot more sense listening to you say it.
• 42:44
  Yeah, I think there's some, you know, the way they're written,
• 42:47
  of course, is very pedantic, if you will,
• 42:50
  and very specific because it was guided by the very specific clinical trials
• 42:57
  that were conducted in the right way.
• 43:00
  And the way we practice it, though, is a little bit different.
• 43:05
  Yeah, it almost seems like more punchy writing where it's these are the top,
• 43:09
  you know, five things to do. This is the biggest change, you know.
• 43:13
  Yeah, I think I think that was sort of I was lucky because I was really passionate
• 43:19
  about this topic even before I was asked to be on the committee.
• 43:23
  Committee and so i got to be on the subcommittee on the smart therapy and helped
• 43:29
  write most of the guidelines or the the text then nobody probably will read but that's okay,
• 43:37
  reads like a scientific journal not quoting the
• 43:40
  the literature but i i think we it's you can simplify it and i think other papers
• 43:47
  have come out since with saying oh well you can just just use your regular steroid
• 43:52
  inhaler along with albuterol when you're having an exacerbation,
• 43:56
  you get the similar result.
• 43:57
  And that's what a lot of us have been doing for years.
• 44:00
  And continue that SMART therapy. Right, right.
• 44:04
  Well, Dr. Ed Brooks with the University of Texas Health Science Center,
• 44:08
  thank you so much for being here back on the show on Pediatrics Now. Thank you so much.
• 44:14
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• 44:18
  free credit if you're a practitioner.
• 44:20
  You can also email us with questions or episode ideas.
• 44:24
  That address is pediatricsnow at U-T-H-S-C-S-A dot E-D-U.
• 44:30
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• 44:33
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• 44:37
  Music.