A maternal diet with plenty of vegetables and limited fried, low-fiber and sugary foods may prevent asthma and allergies in offspring, according to a speaker at the American Academy of Allergy, Asthma & Immunology Annual Meeting.
Carina Venter, PhD, RD, associate professor of pediatrics in the section of allergy/immunology at Children’s Hospital Colorado and University of Colorado Denver School of Medicine, provided the latest data on the role the maternal diet during pregnancy may have on the infant microbiome and subsequent development of allergies and asthma, including research she has led on the topic.
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Currently, it is recommended that a prenatal supplement with vitamin D be taken to reduce the risk for asthma and wheeze in offspring, Venter told Healio. Also, all allergy and pediatric medical societies recommend against avoiding food allergens during pregnancy to prevent food allergies in offspring, Venter said, although she added that the impact of maternal diet on other allergic diseases has so far been less conclusive.
Carina Venter
In a study published last year in Allergy, Venter and colleagues developed a maternal diet index during pregnancy — which included weighted measures of increased intake of vegetables and yogurt, and reduced intake of fried potatoes, rice/grains, red meats, pure fruit juice and cold cereals — to better assess the impact of maternal diet on offspring allergy outcomes.
Overall, greater intake of vegetables and yogurt appeared protective against development of offspring allergic disease, whereas the other food items were associated with greater risk in offspring.
Using these findings to inform the maternal diet index, researchers found that a one-unit increase in the index significantly reduced the likelihood of offspring allergic rhinitis (OR = 0.82; 95% CI, 0.72-0.94), atopic dermatitis (OR = 0.77; 95% CI, 0.69-0.86), asthma (OR = 0.84; 95% CI, 0.74-0.96) and wheeze (OR = 0.8; 95% CI, 0.71-0.9), but not food allergy (0.84; 85% CI, 0.66-1.08).
The researchers called their study the first to show a relationship between a maternal diet index and prevention of multiple allergic diseases in offspring but cautioned that more research is needed.
“Our data show that a diet with increased intake of vegetables and reduced intake of fried, low fiber and sugary foods is associated with reduced asthma, wheeze, allergic rhinitis and eczema by 4 years, and all allergies by 2 years of age,” Venter told Healio. “This needs to be confirmed in other cohorts and in randomized controlled trials.”
The researchers acknowledged that many of the foods in the index are known to impact the diversity and function of the gut microbiome, but how that affects the offspring microbiome, which in turn affects their allergy risk, remains to be elucidated.
“We have some preliminary data on how the maternal diet may affect the child’s microbiome and epigenetic profile, but many more studies are needed,” Venter said.
Despite these unknowns, maternal diet “is likely to play a role,” she added.
“Recent data indicate that the maternal diet can manipulate the maternal microbiome and subsequently the infant microbiome, but the exact effect in relation to allergy is still unclear,” she said.
Specifically, a study by Selma-Royo and colleagues, published in 2020 in European Journal of Nutrition, showed that maternal intake of saturated fats and monosaturated fatty acids appeared linked to intestinal markers and therefore likely indicates microbial transmission to the neonate.
Despite these data, a generalized diet that mothers can assume to reduce their offspring risk remains elusive.
It is clear that a diet filled with a variety of allergens in the infant’s first year of life has been shown to reduce their risk for later development of food allergies.
But pairing individual pregnant mothers with their optimal dietary intervention to prevent offspring allergic diseases remains a lofty goal.
“This statement is a ‘blue sky’ view of where we would like to be in the future, but more research data are required and we are not anywhere near clinical implementation yet,” Venter told Healio.
Vocal cord dysfunction (VCD), or inducible laryngeal obstruction, is the abnormal adduction of the vocal cords that leads to stridor, upper airway wheezing, cough, and dyspnea. It can be misdiagnosed as asthma, but it also occurs concomitantly in as many as half of patients with asthma. It is triggered by exercise, irritants, emotional stress, and, possibly, sleep apnea and gastroesophageal reflux disease. Definitive diagnosis involves laryngoscopic examination showing paradoxical vocal-fold movement, but such examination often is not available in primary care settings.
An Australian clinic specializing in VCD and asthma reported outcomes of 212 patients who were referred for evaluation. Using spirometry with bronchodilator and direct vocal cord visualization before and after mannitol or irritant exposure, evaluators determined that 29% of patients had both VCD and asthma, 26% had VCD alone, 24% had asthma alone, and 21% had neither. Expert clinician evaluation predicted VCD in roughly 70% of patients with laryngoscopy-confirmed VCD. De-escalation or discontinuation of asthma therapy was successful in 63% of patients without variable airflow obstruction and in 81% of patients with laryngoscopy-confirmed VCD. Almost three quarters of patients who attended speech therapy reported improvement.
COMMENT
When patients have “severe asthma” without reversible obstruction, or if they report sudden onset of dyspnea and noisy upper airway breathing with exercise, stress, or strong odors or irritants, VCD should be suspected. Ideally, such patients should be evaluated by an expert who can perform laryngoscopy, but I often send patients straight to speech pathology. Such referral can lead to successful reductions of asthma medications and symptoms.
Factors considered high risk for penicillin allergy should not preclude children from undergoing reevaluation, according to a study presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.
“Children with penicillin allergy labels should be referred to and evaluated by an allergist for potential delabeling, even if they had traditionally ‘high-risk’ histories of anaphylaxis, serum sickness-like reactions or prior positive penicillin allergy testing,” lead study author Susan S. Xie, MD, clinical fellow in the division of allergy and immunology at Cincinnati Children’s Hospital, told Healio.
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Xie and colleagues reevaluated 1,553 risk-stratified children (median age at reaction, 1.8 years) listed in the penicillin allergy registry at Cincinnati Children’s Hospital Medical Center to characterize higher risk vs. lower risk and determine which children should be eligible for drug provocation challenges and allergy delabeling.
Susan S. Xie
“Large studies from multiple countries have already established tolerance rates of greater than 90% in children with penicillin-associated rashes when they are re-challenged to the culprit penicillin,” Xie said. “Our study found similar tolerance rates in children with higher-risk histories such as anaphylaxis and serum sickness-like reactions, who traditionally may have been excluded from referral or routine allergy testing.”
In all, 66.3% of children were categorized as having no risk, indicating they had an unknown family allergy history and had experienced a rash or hives more than 1 year before registry or other mild somatic symptoms; 27.3% were categorized as low risk, which included those who experienced a rash or hives within 1 year of registry, as well as swelling, difficulty breathing and reactions to all penicillins or cephalosporins; and 6.4% were categorized as high risk, indicating they had experienced serum sickness-like reactions, anaphylaxis, severe cutaneous reaction and prior positive penicillin skin testing or drug provocation challenges.
“We found that while only 31% of children classified as high-risk underwent challenges, 94% were tolerant. These nonallergic high-risk patients included 22 who originally had serum sickness-like reactions, three with anaphylaxis, four with prior positive skin testing and one with a prior allergic challenge. The two high-risk patients with allergic outcomes had histories of serum sickness-like reaction and possible anaphylaxis, but solely developed delayed-onset hives after their challenges,” Xie said.
“In comparison, patients classified as low risk and no risk in our registry were challenged at higher rates, 59% in both groups, and had similar tolerance rates of 92% in the low-risk group and 96% in the no-risk group,” Xie added.
Certain systemic symptoms likely deterred patients or providers from proceeding with challenges, Xie said. Specifically, patients with hand or foot swelling, vomiting or diarrhea, joint symptoms or fever were less likely to undergo drug challenges.
“However, children who experienced any systemic symptom still had a tolerance rate of 89% overall,” Xie said.
Future research will be aimed at guiding appropriate risk stratification of penicillin-allergic children, with the goal of being more inclusive with safely delabeling pediatric patients and preventing unnecessary avoidance of penicillin, Xie said.
“Given the small number of allergic outcomes even in reaction phenotypes deemed ‘high risk’ in children, we will continue to collect data in this population, and multicenter collaborations would be helpful,” Xie said.
This study was interesting because it sought to investigate a group of children with history of “high-risk” penicillin reactions; these are patients who are often not assessed. It was a retrospective study with the goal of identifying the characteristics of patients who underwent a direct oral challenge to penicillin (DPC) without a preceding skin test.
It was interesting to note that 32 “high-risk” patients did undergo DPC. However, as expected, fewer high-risk patients underwent DPC than those who had low-risk history.
The researchers found that most of the “high-risk” children (94%) did tolerate the DPC, a similar tolerance rate as those with low-risk history.
These are promising initial data, but further investigation of these “high-risk” patients would better guide how we should manage these patients. For example, some high-risk reactions (such as serum sickness, Stevens-Johnson syndrome and DRESS, or drug rash with eosinophilia and systemic symptoms) require several days of antibiotic use before they manifest; therefore, one could consider several days of an oral challenge to really determine whether there is tolerance.
In addition, it is possible that the providers felt that the challenged high-risk patients were more likely to tolerate DPC than the nonchallenged high-risk patients. A future goal might be a prospective study that identifies specific high-risk categories of patients who will undergo DPC in order to determine outcome.
Overall, this study should encourage providers to not simply dismiss patients with “high-risk” histories, but rather to probe histories further and, if appropriate, administer DPC.
Jumy (Olajumoke) Fadugba, MD, FAAAAI
Associate professor of clinical medicine Chief, section of allergy & immunology Fellowship program director of allergy & immunology Perelman School of Medicine, University of Pennsylvania
Higher BMI linked to COPD, asthma for women during midlife
Obesity may put women at a higher risk for airway obstructive diseases, a Korean population-based cohort study suggested.
In an adjusted model, premenopausal women with severe obesity had a 67% higher risk for chronic obstructive pulmonary disease (COPD; HR 1.67, 95% CI 1.54-1.81), while postmenopausal women had a 57% elevated risk (HR 1.57, 95% CI 1.50-1.65), compared with women of normal weight, reported Do-Hoon Kim, MD, PhD, of Korea University Ansan Hospital, and colleagues in Menopause, the journal of the North American Menopause Society (NAMS).
Although not to the same extent, non-severe obesity and overweight also increased women’s risk of developing COPD — regardless of menopausal status — versus a reference BMI of 18.5 to 23:
Premenopause BMI 23-25: HR 1.11 (95% CI 1.07-1.16)
Postmenopause BMI 23-25: HR 1.05 (95% CI 1.02-1.07)
Premenopause BMI 25-30: HR 1.26 (95% CI 1.21-1.31)
Postmenopause BMI 25-30: HR 1.20 (95% CI 1.17-1.23)
This link wasn’t limited to just BMI, though, as Kim’s group found the same positive correlation between waist circumference and risk for COPD. Premenopausal women with a waist circumference of 95 cm (37 in) or higher saw the biggest increased risk for COPD (HR 1.74, 95% CI 1.57-1.93) compared with a reference waist circumference of 65 to 75 cm (26 to 30 in).
These patterns were similar when the researchers looked at the risk for asthma. Likewise, both pre- and postmenopausal women with higher BMI and waist circumference had significantly higher risks for developing asthma.
Looking at the other end of the spectrum, pre- and postmenopausal women who were underweight did not have a higher risk for these airway obstructive diseases, with the exception of postmenopausal women with a BMI under 18.5 or waist circumference under 65 cm who showed a modestly higher risk for COPD, but not asthma.
However, Kim’s group pointed out that several prior studies have suggested a relationship between underweight and incidence of COPD.
“This study highlights yet another detrimental effect of obesity and abdominal adiposity in women and specifically identified that women with a high BMI and/or waist circumference had a greater risk of developing COPD and asthma,” said Stephanie Faubion, MD, MBA, medical director of NAMS, in a statement. “In addition to avoiding tobacco use, maintaining a healthy body weight and composition may help reduce the incidence of COPD and asthma in women.”
Inflammation is one likely culprit behind this association, Kim and colleagues suggested. “Increased adiposity associated with obesity acts by increasing the levels of pro-inflammatory cytokines, such as tumor necrosis factor-alpha and interleukin-6, and decreasing the levels of adiponectin, thereby increasing systemic inflammation,” they wrote.
For the analysis, the researchers used national health insurance claims data for 1,644,635 women ages 30 and older enrolled in the Korean National Health Insurance Service, who had no prior diagnosis of COPD or asthma. Women who previously underwent a hysterectomy were excluded.
They categorized BMI according to the WHO Western Pacific Region’s categories: underweight (under 18.5), normal weight (18.5-23), overweight (23-25), obesity (25-30), and severe obesity (30+).
Kim and team adjusted their model for age, smoking status, alcohol intake, income level, exercise, hypertension, dyslipidemia, and hormone therapy usage.
The study was exclusive to South Korean women, which was a limitation, the researchers acknowledged. In addition, menopausal status was sometimes incorrectly self-reported.
Interventions that promote physical activity could improve symptoms and quality of life for people with asthma, although these interventions may face barriers to success, according to a review published in Journal of Health Psychology.
“Engaging in regular physical activity is associated with better measures of lung function, disease control, health status and use of health care services,” author Leanne Tyson, PhD, postgraduate researcher at Norwich Medical School at University of East Anglia in Norwich, England, told Healio.
Data were derived from Tyson L, et al. Journal of Health Psychology. 2021;doi:10.1177/13591053211059386.
Leanne Tyson
“Despite this, people with asthma engage in less physical activity and are more sedentary than people without asthma. Consequently, there is a need to develop interventions that promote physical activity within the asthma population, but no reviews to date have examined the effectiveness of interventions that have been developed and their components,” Tyson said.
The study’s methodology
The researchers examined 25 studies involving 1,840 participants with varying degrees of asthma. The 21 unique physical activity interventions reported in these studies primarily included aerobics, strength or resistance training, yoga and walking. High-intensity interval training, indoor circuit training and aquatic training also were used.
Participants typically were asked to engage in these activities two or three times a week for 30 to 60 minutes. Most of these interventions were delivered by a combination of providers face-to-face individually and within groups.
Ten of the 25 studies involving eight unique interventions showed significant improvements in relevant behavioral and/or health outcomes, the researchers wrote.
Of the 10 studies that assessed physical activity as an outcome, four found significant positive between-group effects, and four found significant positive within-group effects. Also, participants in one study increased daily step count by approximately 2,000 steps.
Two of the three studies examining sedentary behavior indicated a significant within-group decrease in time spent sedentary. Five of the 16 studies examining quality of life found evidence of a significant positive within-group effect, and five found significant positive between-group effects.
Four of the 12 studies exploring asthma control reported significant positive within-group effects, and two reported significant between-group effects. In the 11 studies including asthma symptoms, four found significant positive within-group effects, and four reported a significant positive between-group effect.
Finally, two of the eight studies that assessed medication usage as an outcome found within-group evidence of a significant reduction in the use of rescue inhalers among its intervention group.
The ways these interventions are presented can have a significant impact on their success, the researchers wrote, involving specific behavior change techniques. The researchers identified 25 of such techniques, with an average of nine per intervention.
The unique effective interventions included 20 of these behavior change techniques. The most common interventions included “action planning” (100%), “goal setting (behavior)” (100%), “instructions on how to plan the behavior” (89%) and “demonstration of behavior” (89%).
Recommendations for interventions
Setting a specific and detailed plan on when, where and how to perform a behavior and providing instructions increases self-efficacy and physical activity, the researchers wrote, as low self-efficacy and negative beliefs about capabilities are major barriers.
“We showed that interventions aimed at promoting physical activity in adults diagnosed with asthma were successful and improved quality of life and asthma symptoms in the short term,” Tyson said.
“However, they would not have overcome patient-reported barriers to physical activity, as they still required patients to travel and were not suitable for those with additional health conditions,” she continued.
The researchers determined which evidence-based behavior change techniques were not extracted from the interventions and recommend techniques to include in future interventions to improve outcomes as well, Tyson said.
Also, Tyson continued, health care providers can be crucial in encouraging patients to be physically active in providing information on how they can do so safely, as such support facilitates physical activity.
“In terms of developing future interventions, incorporating behavior change techniques that promote self-regulation and sustained motivation, as well as considering patient-reported barriers, could improve outcomes in the long term,” Tyson said.
The researchers highlighted the potential use of digital interventions such as video conferencing and fitness trackers, which Tyson called “notably absent” from the studies that were reviewed.
“This is important now more than ever, as patients have not been able to attend face-to-face support during the COVID-19 pandemic, and services will likely become overwhelmed,” she said. “Therefore, alternative interventions and methods of delivery need to be considered.”
The researchers continue to study how these interventions can be improved.
“We have been conducting interviews and focus groups with adults diagnosed with asthma to understand more about the barriers and facilitators to physical activity, as well as identifying key content and components to include in a [mobile health (mHealth)] intervention,” Tyson said.
Although it is not surprising that an increase in physical activity would benefit patients who suffer from asthma, this study by Tyson and colleagues aimed to examine the effectiveness of interventions that promote physical activity and identify the specific behavior change techniques used.
The authors performed a comprehensive systematic review looking at the literature published in this area dating back to 1990. After identifying 3,685 citations, the authors identified 25 studies that met a predetermined set of inclusion criteria.
The authors were restricted to a narrative review, as a meta-analysis could not be performed due to differences in study designs, methodologic quality, specific interventions used and patient populations enrolled in the selected studies.
Barriers to physical activity in adult asthma have been well-described in the literature and include low self-efficacy and negative beliefs about the ability to be active. This review attempts to understand which interventions and behavior change techniques can help overcome these barriers while promoting physical activity in asthmatics.
“Action planning” and “goal setting” were the most used behavior change techniques in effective interventions. However, due to the study design, the authors were unable to identify specific behavior change techniques that showed promise of effectiveness.
The authors provide examples of evidence-based BCTs that have been shown in other studies to increase the likelihood of interventions being effective, including “practical social support” and “self-monitoring of outcomes of behavior,” but admit that these interventions were lacking in the studies included in this systematic review.
Based on the data presented, exercise interventions only had transient effects on physical activity levels, quality of life and sedentary behavior and had no overall objective improvement in the patient’s asthma control or medication usage.
The authors suggest digital interventions could help address barriers to long-term compliance, citing improved accessibility and convenience compared with traditional in-person care. This recommendation should be considered the authors’ expert opinion because the data lacked a significant number of digital interventions to analyze.
From this review, it is clear that physical activity interventions have the potential to benefit adults with asthma, but further research is required to identify ways to sustain these behaviors. This will require well-designed randomized trials that incorporate digital-physical activity intervention technologies and evidence-based behavior change techniques that sustain motivation and improve adherence.Justin C. Greiwe, MD, FACAAI, FAAAAIPartner, Bernstein Allergy Group Inc.Clinical assistant professor of medicine, University of CincinnatiMember, American College of Allergy, Asthma and Immunology
There is considerable uncertainty over whether adults with asthma should be offered booster vaccines against SARS-CoV-2 and, if so, who should be prioritised for booster vaccination. We were asked by the UK’s Joint Commission on Vaccination and Immunisation to undertake an urgent analysis to identify which adults with asthma were at an increased risk of serious COVID-19 outcomes to inform deliberations on booster COVID-19 vaccines.
Methods
This national incident cohort study was done in all adults in Scotland aged 18 years and older who were included in the linked dataset of Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II). We used data from EAVE II to investigate the risk of COVID-19 hospitalisation and the composite outcome of intensive care unit (ICU) admission or death from COVID-19 among adults with asthma. A Cox proportional hazard model was used to derive adjusted hazard ratios (HRs) and 95% CIs for the association between asthma and COVID-19 hospital admission and ICU admission or death, stratified by markers of history of an asthma attack defined by either oral corticosteroid prescription (prednisolone, prednisone, and dexamethasone) in the 2 years before March 1, 2020, or hospitalisation for asthma before March 1, 2020. Analyses were adjusted for age, sex, socioeconomic status, comorbidity, previous hospitalisation, and vaccine status.
Findings
Between March 1, 2020, and July 27, 2021, 561 279 (12·7%) of 4 421 663 adults in Scotland had clinician-diagnosed-and-recorded-asthma. Among adults with asthma, 39 253 (7·0%) had confirmed SARS-CoV-2 infections, of whom 4828 (12·3%) were admitted to hospital for COVID-19 (among them, an estimated 600 [12·4%] might have been due to nosocomial infections). Adults with asthma were found to be at an increased risk of COVID-19 hospital admission (adjusted HR 1·27, 95% CI 1·23–1·32) compared with those without asthma. When using oral corticosteroid prescribing in the preceding 2 years as a marker for history of an asthma attack, the adjusted HR was 1·54 (95% CI 1·46–1·61) for those with three or more prescribed courses of oral corticosteroids, 1·37 (1·26–1·48) for those with two prescribed courses, 1·30 (1·23–1·37) for those with one prescribed course, and 1·15 (1·11–1·21) for those without any courses, compared with those aged 18 years or older without asthma. Adults with asthma were found to be at an increased risk of COVID-19 ICU admission or death compared with those without asthma (adjusted HR 1·13, 95 % CI 1·05–1·22). The adjusted HR was 1·44 (95% CI 1·31–1·58) for those with three or more prescribed courses of oral corticosteroids, 1·27 (1·09–1·48) for those with two prescribed courses, 1·04 (0·93–1·16) for those with one prescribed course, and 1·06 (0·97–1·17) for those without any course, compared with adults without asthma.
Interpretation
Adults with asthma who have required two or more courses of oral corticosteroids in the previous 2 years or a hospital admission for asthma before March 1, 2020, are at increased risk of both COVID-19 hospitalisation and ICU admission or death. Patients with a recent asthma attack should be considered a priority group for booster COVID-19 vaccines.
Funding
UK Research and Innovation (Medical Research Council), Research and Innovation Industrial Strategy Challenge Fund, Health Data Research UK, and Scottish Government.
There is emerging evidence that immunity after COVID-19 vaccination wanes, especially against the Delta variant of concern.1, 2 Many countries have been discussing booster doses to ensure that people remain protected against SARS-CoV-2 as the winter months approach. By Nov 15, 2021, more than 170 million booster doses had been administered worldwide.3 In the USA, booster vaccinations are available for Pfizer-BioNTech vaccine recipients who completed their initial series at least 6 months ago, including those aged 65 years and older, those aged at least 18 years who have underlying medical conditions, those who work in high-risk settings, and those who live in high-risk settings.4 Israel started its booster campaign aimed at those aged over 50 years and has administered over three millions third doses of Pfizer-BioNTech vaccine to date.3 Turkey began administering booster vaccines in July, 2021, to health-care workers and people older than 50 years.5 Similar initiatives are underway in other countries, including Cambodia, Thailand and Uruguay.5Research in contextEvidence before this studyUnderstanding which adults with asthma are at an increased risk of serious COVID-19 outcomes is of critical importance in deliberations on prioritisation of booster vaccines. We searched PubMed for observational studies, with no language restrictions, using the terms “SARS-CoV-2”, “COVID-19”, “hospitalisation”, “hospital admission”, “death”, “adults”, and “asthma”, for studies published between March 1, 2020, and Sept 16, 2021. We found six studies that investigated the association between markers of asthma severity and risk of severe COVID-19 outcomes among adults. Five of these six studies showed that asthma severity, defined using different patterns of inhaled and oral corticosteroid prescribing, were associated with increased risks of serious COVID-19 outcomes. Of these five studies, only one assessed and reported an increased risk of COVID-19 hospital or intensive care unit (ICU) admission in adults with severe asthma, and the remaining four studies found that severe asthma was associated with an increased risk of COVID-19 death. The sixth, smaller study, which investigated a single hospital in England, found no association between markers of asthma severity and COVID-19 deaths, possibly because the study was underpowered. Through the peer review process, we were alerted to an additional study that assessed the risk of severe COVID-19 outcomes in adults with different asthma phenotypes. The authors found an association between markers of asthma severity and severe COVID-19 outcomes, but this was not observed in those with features suggestive of underlying type 2 inflammatory asthma.Added value of this studyWe report on risk factors for severe COVID-19 outcomes in adults with asthma during different waves of the pandemic, taking vaccination status into account. We found that adults with a history of an asthma attack in the preceding 24 months (defined by either two or more oral corticosteroid prescriptions or previous asthma hospitalisation) had an increased risk of COVID-19 hospital admission and the composite outcome of ICU admission or death, when compared with those with no asthma. These increased risks remained after adjusting for age, sex, socioeconomic status, comorbidity, previous non-asthma hospitalisation, and COVID-19 vaccine status. Our study has added UK evidence using nationwide population-level data and quantified the strength of associations across different waves of the pandemic, taking vaccination status into account.Implications of all the available evidenceWe provide national evidence that adults aged 18 years and older with a history of an asthma attack in the preceding 24 months are at an increased risk of COVID-19 hospital admission and ICU admission or death. These findings have been used by the UK Joint Commission on Vaccination and Immunisation to inform policy decisions on which adults with asthma to prioritise for COVID-19 booster vaccination.The UK Joint Commission on Vaccination and Immunisation (JCVI) issued interim advice on COVID-19 booster vaccination on June 30, 2021, indicating that any COVID-19 booster programme should be offered to the most vulnerable people first (ie, those at the greatest risk of serious COVID-19 outcomes). The UK COVID-19 booster vaccine programme started in September, 2021, with the aim of maximising individual protection for the most vulnerable individuals and reducing the potential risk of the UK National Health Service (NHS) surge capacity being breached over the coming winter. The individuals prioritised thus far are care home residents, people aged over 40 years, frontline health and social care workers, clinically extremely vulnerable adults, and those who are immunosuppressed.6There have been several reports indicating that adults with severe asthma might have an increased risk of severe COVID-19 outcomes, namely hospitalisation, intensive care unit (ICU) admission, and death.7, 8, 9, 10, 11, 12 According to the Global Initiative for Asthma (GINA), asthma severity is generally seen as a retrospective assessment of the treatment required to minimise symptoms or exacerbations, whereas asthma control relates to how a patient experiences symptoms and the risk of exacerbations.13 Therefore, asthma control can relate to severity, but might also be affected by adherence, inhaler technique, and exposure to triggers (eg, smoking or allergen exposure).13 However, the existing evidence base showing that adults with asthma are at the highest risk of serious COVID-19 outcomes is difficult to interpret, since there have been no previous studies investigating asthma risk during different waves of the pandemic and taking vaccination status into account. As a result, there is considerable uncertainty over whether adults with asthma should be offered booster vaccines against SARS-CoV-2 and, if so, who should be prioritised for booster vaccination.In response to a request from the UK JCVI, we sought to use our national surveillance platform to investigate the risk of hospitalisation, ICU admission, and death from COVID-19 among adults with markers of history of an asthma attack in the preceding 24 months.
Methods
Study design
This national incident cohort study was done in all adults in Scotland aged 18 years and older who were included in the linked dataset of Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II). EAVE II is a Scotland-wide COVID-19 surveillance platform that has been used to track and forecast the epidemiology of COVID-19, inform risk stratification assessment, and investigate vaccine effectiveness and safety.1, 14, 15, 16, 17, 18, 19 It comprises national health-care datasets on 5·4 million people (approximately 99% of the Scottish population) deterministically linked through the Community Health Index (CHI) number, which is a unique identifier used in all health-care contacts across NHS Scotland. We used data from EAVE II to describe the demographic profile of adults with asthma who had SARS-CoV-2 infections, COVID-19 hospital admissions, and ICU admissions or deaths. We used the composite outcome of ICU admission or death because there have been concerns about possible rationing of access to ICU beds, particularly in the early phases of the pandemic. We also undertook a national incident cohort analysis to investigate risks of hospitalisation, ICU admission, or deaths in adults with asthma, stratified by markers of history of an asthma attack. The cohort was set up on March 1, 2020 (retrospectively assigned as it was shortly before the first person was admitted to hospital due to COVID-19 in Scotland). All individuals were followed up from March 1, 2020, until the date of death or the end of follow-up (July 27, 2021), whichever came first.Ethics approval was obtained from the National Research Ethics Service Committee, Southeast Scotland 02 (reference number 12/SS/0201). The Public Benefit and Privacy Panel Committee of Public Health Scotland approved the linkage and analysis of the de-identified datasets for this project (1920-0279).
Data sources and procedures
The national datasets linked using CHI number were the Electronic Communication of Surveillance in Scotland (national database for all virology testing), primary care (demographics and clinical history), the Scottish Morbidity Record (which records hospitalisations), National Records of Scotland (which records mortality data), and Prescribing Information System (for prescription data). A data linkage diagram is available in the appendix (p 17).Asthma and other risk groups of interest were measured on March 1, 2020, and defined by the QCOVID risk prediction algorithm, which consists of 30 clinical characteristics (including asthma) identified from primary care records that are known to be associated with an increased risk of serious COVID-19 outcomes in adults (appendix p 1).20 We excluded one risk group that had substantial missing data (ethnicity data were missing for 1 858 385 [42%] of participants; further details are given in the appendix p 3). This resulted in 28 risk groups in addition to asthma being included and analysed as potential confounders (appendix p 3).We also assessed the risk of COVID-19 hospitalisation and ICU admission or death stratified by two markers of history of an asthma attack. First, we used previous oral corticosteroid prescribing (prednisolone, prednisone, and dexamethasone) as a marker of history of an asthma attack in the 2 years before March 1, 2020. Second, we used hospitalisation for asthma before March 1, 2020. This included all hospitalisations with a primary admission diagnosis based on International Classification of Diseases Tenth Revision codes J45 and J46 within 2 years before March 1, 2020.Building on methods that have previously been described in detail,17, 21 we defined individuals who tested positive with real-time RT-PCR as having SARS-CoV-2 infections. We defined a COVID-19 hospital admission as being hospitalised within 14 days following a positive RT-PCR test for SARS-CoV-2, including those who tested positive while being hospitalised, or those who were hospitalised with an admission diagnosis of COVID-19 (appendix p 2). COVID-19 related deaths were all-cause deaths occurring within 28 days after a positive test for SARS-CoV-2 that were registered with National Records Scotland and included death certification, or deaths with COVID-19 on the death certificate as the cause of death.
Statistical analysis
A Cox proportional hazard model was used to derive the hazard ratios (HR) and 95% confidence intervals (CIs) for the association between history of an asthma attack in the preceding 24 months and COVID-19 hospital admission and ICU admission or death. This model, with calendar time as the timescale, eliminates the need to model the underlying temporal trends as these are estimated as the baseline hazard. The Cox model adjusted for a penalised spline of age, sex, socioeconomic status, body-mass index (BMI), number of other risk groups of interest (ie, those identified by the QCOVID algorithm), number of non-asthma related hospitalisations within the 2-year period before March 1, 2020, and vaccine status. Socioeconomic status was determined using the Scottish Index of Multiple Deprivation (SIMD).22 The SIMD classification is based on deprivation quintiles: quintile 1 refers to the most deprived and quintile 5 refers to the most affluent. The SIMD was assigned according to residential postcode. BMI was categorised into less than 18·5 kg/m2, 18·5–24·9 kg/m2, 25·0–29·9 kg/m2, 30·0–34·9 kg/m2, and 35 kg/m2 or greater, and not recorded.20 Adjusted for previous hospitalisation was used as a marker of severity or health-care seeking behaviour. Vaccine status was included in the Cox model as a time-dependent variable with five statuses: no vaccination or before vaccination, within 27 days after first dose, 28 days or more after first dose, within 27 days after second dose, and 28 days or more after second dose. Individuals who had a second vaccine dose within 28 days of their first dose would not have the status 28 days after first dose and would go straight from within 27 days after first dose to within 27 days after second dose at the date of second dose. Post-hoc interaction tests were done between vaccine status and history of asthma attack in the preceding 24 months in the adjusted Cox model. If the interaction tests (likelihood ratio χ2 test) were significant (P<0·01), the interaction was included in the Cox model with vaccination status as an effect modifier. By contrast, if the interaction test was not significant, vaccination status was included in the model as a covariate. All analyses were carried out in adults (≥18 years). Anyone with missing SIMD or BMI data was excluded from the Cox models. We also did a post-hoc investigation to see if the magnitude of the differences between the asthma markers investigated and no asthma varied across the different waves of the pandemic (first wave: March 1, 2020, to July 31, 2020; second wave before vaccination programme started: Aug 1, 2020, to Dec 7, 2020; second wave after the vaccination programme started: Dec 8, 2020, to May 17, 2021; third wave: May 18, 2021, to end of study).The Cox proportional hazards models used sampling weights, which were used to correct for the size of the registered general practice population being greater than the population in Scotland (in part due to individuals who had recently moved). These weights were derived by matching the age and sex numbers in the general practice data to the Scottish population data. This adjustment ensured that the denominators in the tables matched the Scottish population.The models were fit to a dataset with all events and a random sample, without replacement, of 100 individuals per event with sample weights calculated to represent the sampling fraction and thus ensure the correct calculation of the person-years at risk for the whole population. A combined weight (sampling weights from the random sampling procedure and the weights used to correct for the size of Scottish population) was used in the statistical modelling.A sensitivity analysis was carried out using a 1-year look back before March 1, 2020, for the markers of history of an asthma attack. We also conducted a sensitivity analysis only looking at those who tested positive for SARS-CoV-2 and measured the markers of history of an asthma attack at the date of test to see if the risk of severe COVID-19 outcome was higher in those with history of an asthma attack in the preceding 24 months following testing positive. This was to account for adults with prior oral corticosteroids prescribing or previous hospitalisation for asthma after March 1, 2020, but before their SARS-CoV-19 infections. Misdiagnosis of asthma is common in primary care, especially in older patients. We did a post-hoc stratified analysis in those with and without coexisting chronic obstructive pulmonary disease (COPD) and investigated the association between history of an asthma attack in the preceding 24 months and COVID-19 hospitalisation within each stratum. We also did a post-hoc subgroup analysis only including those younger than 50 years to minimise the risk of confounding by COPD and a subgroup analysis reporting on separate ICU admission and mortality outcomes.We followed the strengthening the STROBE checklist23 to guide transparent reporting of this cohort study (appendix pp 4–5). Analyses were done in R version 3.6.1.
Role of the funding source
The funder of the study had no role in study design, data collection, data analysis, data interpretation, or the writing of the report.
Results
4 421 663 adults in the EAVE II linked dataset who were aged 18 years or older on March 1, 2020, were included in the analysis. 561 279 (12·7%) adults had clinician-diagnosed-and-recorded asthma. Among adults with asthma, 39 253 (7·0%) had confirmed SARS-CoV-2 infections, of whom 4828 (12·3%) were admitted to hospital for COVID-19 (among them, an estimated 600 [12·4%] might have been due to nosocomial infections). There were 1600 (4·1%) ICU admissions and 1206 (3·1%) deaths, of which 1186 (98·3%) had COVID-19 recorded as the cause of death on the death certificate. The baseline characteristics for adults with asthma stratified by markers of history of an asthma attack are available in the appendix (pp 6–7).The numbers of adults being tested for SARS-CoV-2, testing positive, and being admitted to hospital with COVID-19 per 100 000 people were higher in adults with asthma (irrespective of history of an asthma attack) compared with those without asthma (table 1). The number of COVID-19 ICU admissions or deaths in adults without a recent asthma attack was similar to those without asthma, but higher in those with a history of an asthma attack in the preceding 2 years. Adults with a history of an asthma attack in the preceding 2 years (defined by either previous oral corticosteroid prescription or asthma hospitalisation) had higher rates of COVID-19 hospitalisation and ICU admission or death compared with those with better-controlled asthma. The absolute rates of COVID-19 hospitalisation in adults with three or more, two, one, or zero prescribed courses of oral corticosteroids were 2375, 1600, 1274, and 642 per 100 000 people, respectively. The absolute rate of COVID-19 hospitalisation was 3290 per 100 000 people in adults with previous hospitalisation for asthma and 835 per 100 000 people in adults without previous hospitalisation for asthma.Table 1Number and rate (per 100 000 people) of being tested, testing positive, COVID-19 hospitalisation, ICU admission, and deaths in adults with asthma, stratified by markers of history of an asthma attack
Asthma with 0–1 course(s) of OCS and no previous hospitalisation
580 684
273 907 (47·2%)
39 915 (6·9%)
4590 (0·8%)
1625 (0·3%)
465 (0·1%)
1292 (0·2%)
Asthma with ≥2 courses of OCS or previous hospitalisation
160 910
82 932 (51·5%)
9058 (5·6%)
3424 (2·1%)
1476 (0·9%)
316 (0·2%)
1267 (0·8%)
Data are n or n (%). Denominators of the percentages are those listed in the overall number column. ICU=intensive care unit. OCS=oral corticosteroid.* ICU deaths referred to those who had COVID-19-related ICU admissions or COVID-19-related death with or without previous ICU admissions.† OCS prescriptions for prednisolone, prednisone, and dexamethasone in the 2-year period before March 1, 2020.‡ Hospitalisation for asthma within 2-year period before March 1, 2020.§ The no asthma group under variable asthma was derived using only the general practitioner-recorded diagnosis whereas the no asthma group under the variable history of an asthma attack (OCS prescription) was derived using both general practitioner diagnosis and prescribing records; therefore, patients who never had asthma recorded in their general practice records, but had OCS prescriptions were not included in the second no asthma group, but were included in the first asthma group (using only general practitioner records), which explains the smaller group size.
Adults with asthma were found to be at an increased risk of COVID-19 hospital admission (adjusted HR 1·27, 95% CI 1·23–1·32) compared with those without asthma. When using oral corticosteroid prescribing in the preceding 2 years as a marker for history of an asthma attack, the adjusted HR was 1·54 (95% CI 1·46–1·61) for those with three or more prescribed courses of oral corticosteroids, 1·37 (1·26–1·48) for those with two prescribed courses, 1·30 (1·23–1·37) for those with one prescribed course, and 1·15 (1·11–1·21) for those without any courses, compared with those aged 18 years or older without asthma (table 2). 1 858 385 (42%) of the cohort had missing ethnicity so this variable was not adjusted for in the Cox model. 43 467 (1%) of the cohort had missing BMI and 42 132 (1%) of the cohort had missing SIMD and were excluded from the adjusted Cox model. Vaccination was slightly less effective in reducing COVID-19 hospitalisation in those with a history of an asthma attack as measured by oral corticosteroid use in the preceding 2 years compared with those without asthma (Pinteraction=0·0020). For those without asthma, the adjusted HR of at 28 days or more after the second dose of vaccine versus unvaccinated individuals was 0·15 (95% CI 0·14–0·17), whereas for those with three or more courses of oral corticosteroids the adjusted HR was 0·23 (0·19–0·28; figure; appendix p 8). The difference in COVID-19 hospitalisations between those with a history of asthma attack as measured by oral corticosteroid use and those without asthma was larger in the third wave of the COVID-19 pandemic (adjusted HR for three or more courses of oral corticosteroids vs no asthma 2·05, 95% CI 1·75–2·39 compared with 1·56, 1·40–1·74 in the first wave of the COVID-19 pandemic; appendix p 9).Table 2HRs for COVID-19 hospitalisation, ICU admissions, or deaths for those with different markers of history of an asthma attack and those with no asthma in adults
Previous prescribed OCS as a marker of history of an asthma attack
No asthma
20 678
1 (ref)
9193
1 (ref)
Asthma with no course of OCS
2827
1·15 (1·11–1·21)
955
1·06 (0·97–1·17)
Asthma with one course of OCS
1817
1·30 (1·23–1·37)
681
1·04 (0·93–1·16)
Asthma with two courses of OCS
814
1·37 (1·26–1·48)
330
1·27 (1·09–1·48)
Asthma with three or more courses of OCS
2553
1·54 (1·46–1·61)
1134
1·44 (1·31–1·58)
Previous hospitalisation for asthma as a marker of history of an asthma attack
No asthma
23 845
1 (ref)
10 689
1 (ref)
Asthma without previous hospitalisation
4643
1·24 (1·20–1·29)
1557
1·11 (1·03–1·19)
Asthma with previous hospitalisation
201
3·01 (2·59–3·49)
47
2·24 (1·56–3·20)
HRs were derived using Cox proportional hazard models adjusted for age, sex, socioeconomic status, body-mass index, number of risk groups of interest, number of non-asthma-related hospitalisations within the 2-year period before March 1, 2020, and vaccine status. HR=hazard ratio. ICU=intensive care unit. OCS=oral corticosteroid.* ICU admissions or deaths referred to those who had COVID-19-related ICU admissions or COVID-19-related death with or without previous ICU admissions.
When using previous hospitalisation for asthma as the marker of history of an asthma attack, the adjusted HR was 3·01 (95% CI 2·59–3·49) for those with hospitalisation for asthma in the previous 2 years and 1·24 (1·20–1·29) for those without hospitalisation for asthma in the previous 2 years compared with those aged 18 years and older without asthma (table 2).Adults with asthma were found to be at an increased risk of COVID-19 ICU admission or death compared with those without asthma (adjusted HR 1·13, 95 % CI 1·05–1·22). The adjusted HR was 1·44 (95% CI 1·31–1·58) for those with three or more prescribed courses of oral corticosteroids, 1·27 (1·09–1·48) for those with two prescribed courses, 1·04 (0·93–1·16) for those with one prescribed course, and 1·06 (0·97–1·17) for those without any course, compared with adults without asthma (table 2). The adjusted HR was 2·24 (95% CI 1·56–3·20) for those with previous hospitalisation for asthma and 1·11 (1·03–1·19) for those with no previous hospitalisation for asthma compared with those aged 18 years and older without asthma (table 2). Separate analyses for ICU admission and death are shown in the appendix (p 10).The sensitivity analyses using 1-year retrospective data up to March 1, 2020, for the two markers of history of an asthma attack also yielded similar results (appendix p 11). Sensitivity analyses focusing on those who tested positive for COVID-19 and measuring the markers of history of an asthma attack at the date of test showed similar results (appendix p 12). For the group of people without COPD, asthma had a stronger effect on COVID-19 hospitalisation compared with the group of people with COPD (appendix p 13). Similarly, for people younger than 50 years, asthma had a stronger effect on severe COVID-19 outcomes (ICU admission or death) compared with the general population (appendix p 14). The univariable analysis for all the risk factors, including COPD, is available in the appendix (p 15).
Discussion
We found that adults with a prescription of two or more courses of oral corticosteroids or asthma hospitalisation in the preceding 2 years are at an increased risk of both COVID-19 hospitalisation and ICU admission or death compared with those without asthma. This would translate into 160 910 adults with asthma aged 18 years or older who have received two or more courses of oral corticosteroids or previous hospitalisation for asthma in Scotland during the study period who might be prioritised for COVID-19 vaccines, which when scaled-up to the UK would equate to around 1 930 920 adults (assuming the same prevalence of severe asthma in the other UK nations).24 If we restricted our analysis to only those who received two or more courses of oral corticosteroids in the preceding 2 years, this would translate into around 158 000 adults in Scotland, which is similar to the number (around 160 000) if we used both markers of history of an asthma attack (previous asthma hospitalisation or two or more courses of oral corticosteroids in the preceding 2 years). There might be some protection against severe COVID-19 in those who did not have a recent asthma attack, but our findings were not significant.Our study has several strengths. We developed a national linked dataset and have created a platform that allowed rapid access to and analysis of data from routinely collected national electronic health record data. Therefore, this study is less susceptible to recall or misclassification bias than are studies that rely on primary data collection. The use of a large population aided study power, facilitating estimation of HRs in different markers of history of an asthma attack and different outcomes. The study is likely to have excellent generalisability across the UK and potentially across other countries with similar demographics and health systems. Finally, we have been able to show that the associations found were similar across different phases of the pandemic (and hence across variants in circulation).Our study has several limitations. There were relatively small absolute numbers of people with previous asthma hospitalisations, so these data should be interpreted with care. However, our results were broadly consistent across different measures of previous asthma attack. We were unable to assess the association between asthma severity or control, as defined by GINA, and COVID-19-related risks. We included 28 risk groups that were defined by the QCOVID prediction algorithm,21 but we might have missed some important risk groups. Adults with a history of an asthma attack in the preceding 2 years had an increased rate of being tested compared with those with no recent asthma or without asthma. This might be because they could be more likely to be admitted to hospital and therefore more likely to have routine SARS-CoV-2 testing and screening in hospital than those with no recent asthma attack or without asthma. This could partly explain why there was little difference between the waves in effect estimates for asthma. There might also have been different health-care seeking behaviours among adults with a history of asthma attack, which might have resulted in increased chances of being tested for SARS-CoV-2. Although our Cox models were adjusted for potential confounders, unmeasured confounders could still have influenced our estimates. Our analysis did not include some potentially important confounders (such as ethnicity) because of the lack of reliable recording of this variable within Scottish electronic health records, with the consequence that residual confounding remains a possibility. Prescribing of oral corticosteroids was in people with a history of asthma, so our assumption is that these steroids were given for an asthma attack. However, we cannot be sure that this was the case. The indication for treatment and length of the prescription would have been helpful in this respect, but these data were unfortunately unavailable within our dataset.Similar findings have been reported elsewhere.7, 8, 9, 10, 11, 12 Specifically, five studies found an increased risk of COVID-19 death and two studies found an increased risk of COVID-19 hospital or ICU admission in adults with severe asthma.7, 8, 9, 10, 11, 12 No association was observed between severe asthma and COVID-19 deaths in one study, which could have been because of the small study sample size, which only included data from a single English hospital.25 Particularly high risks of COVID-19 hospital admission, ICU admission, and death have been reported in patients with asthma using high doses of inhaled corticosteroids and those with recent oral corticosteroid use for asthma (in the past 1–2 years).7, 8, 9, 12 Our study has contributed to UK evidence using nationwide population-level data and quantified the strength of associations between history of an asthma attack in the preceding 2 years and markers of severe COVID-19 outcomes across different waves of the COVID-19 pandemic, accounting for vaccination status. Our analysis shows that these findings remained robust, regardless of the wave of the pandemic, public behaviour, changes in clinical management, and vaccination policy.Building on this work, it is important to characterise in more detail the markers of history of an asthma attack for severe COVID-19 outcomes in adults and to investigate underlying mechanisms that predispose such adults to these increased risks. This analysis underscores the importance of maintaining good asthma control and careful monitoring of adults with history of an asthma attack if they develop SARS-CoV-2 infection. The finding that two vaccination doses were effective in reducing the risk of serious COVID-19 outcomes in those with a previous recent asthma attack, but less so than in those without asthma, underscores the need for additional vaccine doses in this subsection of the population with asthma. With booster vaccines being administered or planned internationally and nationally, together with other public health surveillance data, policy makers will be able to use data from our study to inform decisions on booster vaccination priorities among adults with asthma.In conclusion, we provide national evidence that adults with two or more courses of oral corticosteroids or asthma admission in the preceding 2 years were associated with an increased risk of COVID-19 hospital admission and ICU admission or death in Scotland. The findings from this linkage of multiple data sources have helped inform UK policy deliberations on vaccine boosters for adults with asthma.
The asthma medication montelukast (Singulair, Merck) is linked to increased reports of depression and nightmares in adults and children, as well as aggression in children, according to a review of voluntary adverse event reports published online September 20 in Pharmacology Research & Perspectives.
“Because of the high incidence of neuropsychiatric symptoms — especially nightmares — after using montelukast in both children and adults, the clinician should discuss the possibility of these adverse events with the patient and parents,” first author Meindina Haarman, MSc, from University Medical Center Groningen, The Netherlands, said in a news release.
Haarman and colleagues say this is the first study to analyze reports of adverse drug reactions related to montelukast in both children and adults.
Montelukast is used in maintenance therapy for adults and children with asthma and allergic rhinitis. Commonly reported adverse reactions include upper airway infection, fever, rash, nausea, vomiting, diarrhea, and elevated liver enzymes.
Sleep disorders and psychiatric symptoms have also been reported. In 2009, the US Food and Drug Administration mandated that the drug label of montelukast and other drugs in this class list neuropsychiatric symptoms such as depression and suicidality as possible adverse reactions.
Montelukast has also been linked to allergic granulomatous angiitis, also called Churg-Strauss syndrome, a rare autoimmune condition that causes inflammation of small and medium-sized blood vessels in people with airway allergies. The condition can affect various organs, especially the lungs and digestive tract, and can be life-threatening in some cases.
To better characterize the safety profile of montelukast in regular clinic use, the researchers conducted a retrospective study of all adverse drug reactions in children and adults reported to the Netherlands Pharmacovigilance Center Lareb and the World Health Organization (WHO) Global database (VigiBase®) up to 2016.
Overall, there were 331 montelukast-related adverse drug reactions in the Dutch database and 17,723 in the WHO database. Slightly less than one third of the reports in each database involved patients younger than 19 years (32.3% and 32.4%, respectively).
In the analysis, the researchers used the reporting odds ratio (ROR), which provides an estimate of whether an adverse event is disproportionately reported for a certain drug compared with all other drugs. Notably, ROR cannot say anything about causality.
Depression was the most frequently reported adverse reaction overall in the global WHO database (ROR, 6.93; 95% confidence interval [CI], 6.5 – 7.4). Among children only, the most commonly reported ADR was aggression (ROR, 29.77; 95% CI, 27.5 – 32.2).
In the Dutch database, headache was the most frequently reported adverse reaction overall in both adults (ROR, 2.26; 95% CI, 1.61 – 3.19), and children (ROR, 3.18; 95% CI, 2.66 – 3.70).
Other commonly reported adverse reactions in both the Dutch and WHO databases included nightmares in both children and adults. In the WHO database, suicidal ideation was also commonly reported.
Eight patients also reported allergic granulomatous angiitis to the Dutch database, whereas the WHO database had 563 reports of the condition. All patients survived.
The authors noted that the relationship between montelukast and allergic granulomatous angiitis is unclear. Some studies have suggested that the two are not connected, whereas others have suggested a causal relationship. More research is needed to clarify this relationship, they write.
“However, it has been reported that the symptoms of allergic granulomatous angiitis disappeared in some patients after withdrawing montelukast. This can be seen regarded as an argument for a causal relationship,” the authors write.
Until more data are available, “patients treated with montelukast should be followed to detect signs and symptoms of allergic granulomatous angiitis,” they advise.
They also note that the relationship between Montelukast and depression remains unclear. Asthma has been linked to increased depression and lower quality of life, so reports of depression may actually reflect symptoms of the underlying disease and not an adverse reaction to the drug.
“Further research is required to reveal the mechanism for the higher incidence of neuropsychiatric symptoms in patients using montelukast in comparison with other medications,” they conclude.
The authors mention several study limitations. Both databases relied on voluntary reporting of symptoms, which could have lead to underreporting. Also, the study cannot prove montelukast causes these adverse reactions.
For many , the idea of cannabis being used as an asthma treatment can feel a bit backwards. After all, one of the most common ways cannabis is ingested is by smoking, a method that would seem to be detrimental to those with asthma. However, recent studies have found that cannabis in any form (even smoked) can greatly benefit those suffering from the symptoms of asthma.
Can Marijuana Treat Asthma?
First let’s take a closer look at asthma and what it actually means to have it. Asthma is a fairly common lung disease that results in the narrowing of the airway passage. Due to this narrowing, those suffering from asthma frequently experience feeling out of breath, wheezing or uncontrollable coughing.
While treatment can be used to reduce the effects patients with asthma experience, there is currently no cure for the condition. Asthma attacks can come in many forms and can be triggered by a number of factors including allergies or exercise. While asthma doesn’t reduce your life expectancy, being caught in an intense asthma attack without the proper treatment can be fatal.
So how does a substance that can be smoked help treat asthma? The explanation can be found by examining where asthma begins. Asthma is a chronic inflammatory disease, while cannabis is known for its powerful anti-inflammatory effects. This means cannabis works in an opposite effect to other substances like tobacco and can actually help expand the lungs instead of constricting them.
Editor’s Note: A 2015 animal study in the Journal of Pharmacology and Experimental Therapeutics identified THC specifically as the active compound in cannabis that could benefit people suffering from asthma. They found that THC had anti-inflammatory and bronchodilator effects on airways (very similar to the effect Ventolin has on the lungs during an asthma attack). This is great news!
So how powerful can a cannabis treatment actually be? For those suffering from an asthma attack the results are practically instantaneous and are similar to the results found with some of the more common name brand inhalers.
If you or someone you know is suffering from asthma and would like to seek cannabis as a treatment option, be sure to check out your state’s list of qualifying medical conditions for medicinal cannabis to see if you are eligible for such a treatment option.
Other Ways to Treat Asthma Naturally
If you’re looking for more natural forms of asthma treatment, talk to your doctor about the following options:
Using what you know about managing your asthma can give you control over this chronic disease. When you control your asthma, you will breathe easier, be as active as you would like, sleep well, stay out of the hospital, and be free from coughing and wheezing.To learn more about how you can control your asthma, visit CDC’s asthma site.
Asthma is one of the most common lifelong chronic diseases. One in 13 Americans (more than 24 million) lives with asthma, a disease affecting the lungs and causing repeated episodes of wheezing, breathlessness, chest tightness, and coughing.
Although asthma cannot be cured, you can control your asthma successfully to reduce and to prevent asthma attacks, also called episodes. Successful asthma management includes knowing the warning signs of an attack, avoiding things that may trigger an attack, and following the advice of your healthcare provider.
In most cases, we don’t know what causes asthma, and we don’t know how to cure it. Some things may make it more likely for one person to have asthma than another person. If someone in your family has asthma, you are more likely to have it. Regular physical exams that include checking your lungs and checking for allergies can help your healthcare provider make the right diagnosis. Then you and your healthcare provider can make your own asthma management plan so that you know what to do based on your own symptoms.
Using your asthma medicine as prescribed and avoiding common triggers that bring on asthma symptoms, such as smoke (including second-hand and third-hand tobacco smoke), household pets, dust mites, and pollen will help you control your asthma.
Make sure you are up to date on vaccinations that help protect your health. Respiratory infections like influenza (flu) can be very serious for you, even if your asthma is mild or your symptoms are well-controlled by medication. Flu can trigger asthma attacks and make your asthma symptoms worse, and is more likely to lead to other infections like pneumonia. Getting the recommended vaccines will help you stay healthier.
The important thing to remember is that you can control your asthma.
Asthma deaths have decreased over time.
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