Prescribing Patterns For Childhood Asthma Treatment In .

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ORIGINAL ARTICLEPrescribing Patterns for Childhood AsthmaTreatment in General PracticeP W K Chan, MPaeds, M Z Norzila, MPaeds*Division of Respiratory Medicine, University Malaya Medical Center, 50603 Kuala Lumpur, '"Respiratory Unit, InsititutPediatrik, 53000 Kuala LumpurIntroductionPrimary care health providers namely generalpractitioners (GPs) provide an integral componentof health care services in Malaysia. The majority ofhealth problems will be first seen and managed atthis health care level before physician-referral orpatient-self referral to a secondary or tertiaryhealth care facility.Bronchial asthma is the most common chronicrespiratory problem among children in Malaysiawith a physician diagnosis of asthma made inapproximately 10.7% of children aged 13 - 14years 1.As it is a significant clinical burden ingeneral practice, provision of standardized healthcare for childhood asthma is important and may beachieved with the introduction of clinical pr ticeThis article was accepted: 16 December 2002Corresponding Author: Patrick Chan, Department of Paediatrics, University Malaya Medical Center, 50603 Kuala LumpurMed J Malaysia Vol 58 No 4 October 2003475

ORIGINAL ARTICLEguidelines (CPG) that outline treatment strategiesbased on evidence-based medicine 2 Clinicalpractice gUidelines. for childhood asthma inMalaysia have been available in the publishedform since 1996 3 . A summary of this CPG was alsopublished in Medical Journal of Malaysia and isavailable on the Academy of Medicine web page inan effort to increase its distribution andaccessibility among practising doctors 4, 5. There islittle information regarding the treatmentpreference and prescribing patterns for childhoodasthma in general practice in Malaysia. Moreimportantly, adherence of treatment strategiesprovided by GPs to both the local CPG andinternational standards of good clinical practice forchildhood asthma is relatively unknown.We therefore determined the treatment preferenceand prescribing patterns of GPs for childhoodasthma. Accessibility to the CPG for childhoodasthma and adherence to its recommendations asoutlined were also determined.Materials and MethodsA self-administered standard questionnaire wasdistributed to GPs attending a kshop. Only GPs who treat children in theirclinical practice were included. The questionnairewas available only in the English language anddistributed before the workshop began. Thequestionnaire was limited to determining theindividual treatment preferences and prescribingpatterns of the GP for childhood asthma.Accessibility and awareness of the individual GPstowards the CPG for childhood asthma were alsodetermined.One hundred and twenty five GPs received thequestionnaire but only· 115 (92.0%) returned acompleted questionnaire. One hundred and nine(87.2%) completed questionnaires were suitablefor analysis.Def'mitionRelief asthma medication refers to any medicationused for relief of acute asthma symptoms namely476cough, breathlessness and wheeze.Preventerasthma medication· refers to any medicationconsidered by the GP for treating the underlyingairway inflammation of childhood asthma.Inhaled preparation refers to any medicationadministered through the inhaled route bymetered dose inhaler with or without a spacerdevice and dry powered inhaler devices.Statistical analysisData collected was managed with statisticalpackage SPSS 10.0.1 using Windows 1998operating systems (SPSS Inc., Chicago, IL, USA).Comparisons between groups were performedwith the students' t-test and proportions werecompared using chi-square or Fishers exact test,where appropriate. A p value of less than 0.05·wasconsidered significant.ResultsThere were 94 (86.2%) primary GPs and 15 03.8%)paediatric specialist GPs. The median number ofchildren with a clinical diagnosis of asthmamanaged each week by each GP was 30.0(Interquartile range 5.0 - 80.0). Only 36 (33.0%) ofthem had a personal copy of the Malaysian CPGfor childhoo ;l asthma. Fifty-two (71.2%) of the 73GPs who did not have a copy of the CPG have notseen it previously and of these, only 29 (55.8%) ofthem were aware that it was available for use.Ninety-eight (89.9%) of the GPs considered coughor wheeze more than twice a week as anindication to initiate preventive asthma therapy.However, only 60 (55.0%) and 33 (30.3%) GPsconsidered exercise induced wheeze and cough asindications for using preventive asthma therapyrespectively. The GP category. or access to theCPG did not influence the clinical indication forprescribing preventive asthma therapy in theirpractice (Table I).There was an overall preference for using an oralpreparation for relief asthma medication inchildhood asthma. However, the inhaledpreparation was preferred for preventer asthmaMed J Malaysia Vol 58 No 4 October 2003

Prescribing Patterns for Childhood Asthma Treatment in General Practicemedication [Figure 1]. GPs were more likely to usean inhaled preparation for both relief andpreventer medication for children 5 yearscompared to those between 2 - 5 years. Paediatricspecialist GPs were more likely to prescribemedication by the inhaled route compared to theirprimary GP counterparts (Table II). Accessibilityto the ePG for childhood asthma did not influencethe prescribing pattern in clinical practice (TableIII). Oral ketotifen was the most commonpreventer medication prescribed for children aged2-5 years while for children aged more than 5years; inhaled corticosteroids were morecommonly prescribed. The prescribing treatmentchoice of GPs for childhood asthma is shown inFigure 2.Table I: Relationship between general practitioner category and access to the childhood asthmaCPG to indication for asthma preventive therapy (n 109-)Clinical IndicationCough or wheezemore than 2 timesper weekExercise inducedwheezeExercise inducedcoughPrimary generalpractitioner(n 94)83 (88.3%)Paediatrics specialistgeneral practitioner(n IS)15 (100.0%)p value53 (56.4%)30 (31.9%) No personalaccess to CPG(n 73)65 (89.0%)p value0.063Personal accesstoCPG(n 36)33 (91.7%)7 (46.7%)0.27119 (52.8%)41(56.2%)0.8353 (20.0%)0.3558 (22.2%)25 (34.2%)0.265 0.848Table II: Treatment preference for childhood asthma and general practitioner categories(n 109)Preferred preparationPrimary general practitioner(n 94)Children aged 2 - 5 yearsRelief asthma medicationOralInhaled0.037Preventer asthma medicationOralInhaledChildren aged 5 yearsRelief asthma medicationOralInhaledPreventer asthma medicationOralInhaledMed J Malaysia Vol 58 No 4 October 2003 Paediatric specialistgeneral practitioner(n 15)p value66 (70.2%)28 (29.8%)6 (40.0%)9 (60.0%)0.03748 (51.1%)46 (48.9%)1 (6.7%)14 (93.3%)0.00157 (60.6%)37 (39.4%)3 (20.0%)12 (80.0%)0.00424 (25.5%)70 (74.5%)1 (6.7%)14 (93.3%)0.018 477

ORIGINAL ARTICLETable III: Treatment preference for childhood asthma and personal access to the clinical practice.guidelines for asthma (n 109)Personal access to CPG(n 36)Preferred preparationp valueNo personal access to CPG(n 73) Children aged 2 - 5 years,.Relief asthma medicationOralInhaledPreventer asthma medicationOralInhaled22 (61.1%)14 (38.9%)50 (68.5%)23 (31.5%)0.52114 (38.9%)22 (61.1%)35 (47.9%)38 (52.1%)0.42320 (55.5%)16 (44.5%)40 (54.8%)33 (45.2%)0.5528 (40.0%)28 (60.0%)17 (23.3%)57 (76.7%)0.577Children aged 5 yearsRelief asthma medicationOralInhaledPreventer asthma medicationOralInhaledFigure I:Preparation preference for relief and preventer asthma medication in general practice (no Oral preparation80 109)90Inhaled preparation8070P 0.017060605050n40403030202010100 --1---0 --'----Children aged 2 - 5 yearsChildren aged 5 yearsRelief asthma medication478Children aged 2 - 5 yearsChildren aged 5 yearsPreventer asthma medicationMed J Malaysia Vol 58 No 4 October 2003

Prescribing Patterns for Childhood Asthma Treatment in General PracticeFigure II:Prescribing preference for childhood asthma treatment among generai practitioners (n tInhaledterbutalineOral osteroids20406080Relief asthma medicationDiscussionGlobal asthma treatment guidelines 6 and moreimportantly, a local ePG for childhood asthmatreatment have been developed to achieve astandardized treatment regime; specifically a. consistent prescribing pattern of effective asthmatreatment and preferably non- use of treatment oflimited or no value.The general principles of the treatment ofchildhood asthma are fairly straight forwardnamely the use of the inhaled route for medicationand prescribing effective anti-inflammatorytherapy for clinical situations clearly outlined.However, several interesting and pertinentobservations that possibly reflect childhoodasthma treatment in general practice weredemonstrated in our study. Firstly, the oral formwas favoured for relief and still prescribed forpreventer medications. This preference for theoral route for asthma medication is not unique toour study population as it is a similar observationin neighbouring Singapore and Thailand7 ,8. It isMed J Malaysia Vol 58 No 4 October 200310203040506070nPreventer asthma medicationobvious that the oral route is the simpler and lessfordrugadministration.costly methodFurthermore, although untrue, the apparentdifficulty for young children to use inhaledmedication even with a spacer device maydiscourage GPs from routinely prescribing it forasthmatic children. Our GP study populationindirectly demonstrated this observation, aschildren aged 2-5 years were less likely to beprescribed medication via the inhaled routecompared to children more than 5 years old.Nonetheless, the GP is not entirely responsible fora preference of the oral route for childhood asthmatreatment, as many Asian parents themselvesappear to harbour a negative impression ofinhaled therapy9. Misconceptions of a potential foraddiction and increased adverse effects associated'with inhaled therapy discourage its use lO ,l1.The treatment of chronic asthma includes the useof effective anti-inflammatory therapy. There wasan overwhelming preference for choosingketotifen as an oral preventer medication in479

ORIGINAL ARTICLEchildren aged 2-5 years although it is notrecommended in the CPG for childhood asthmatreatment. Ketotifen has not been shown to beeffective in the treatment of childhood asthmaeven when compared to a placebo 12 and moreimportantly did not appear tb have any therapeuticeffect on the underlying airway hyper-reactivity I3.Nonetheless, this observation is not confined toMalaysia as ketotifen is also very commonly usedamong general paediatricians in Thailand 8 and itspopularity is mostly likely due to the ease of oraladministration and its association with anincreased appetite, an effect favoured by manyAsian parents. Cromones were the least likely antiinflammatory therapy to be prescribed. Therelatively frequent need to administer cromoneslike sodium cromoglycate for symptom control is amajor obstacle in ensuring satisfactory compliance.Moreover, a recent systemic review of the efficacyof inhaled sodium cromoglycate concluded thatthere was insufficient evidence that it had abeneficial effect for childhood asthma I4. Thecombination of these factors clearly account for itslack of popularity as a treatment choice forchildhood asthma.It is obvious that the development and publishingof treatment guidelines and publishing them aloneachieved little as only one-third of our studypopulation had personal access to the childhoodasthma CPG. Nonetheless, personal access to theCPG did not ensure adherence to the CPGrecommendations. In addition to a persistingpreference for oral therapy for asthma medication,important clinical symptoms like exercise inducedwheeze and cough were not uniformly consideredas indications for preventer asthma medication byour GP population. The 2 most important aspectsthat follow the development of a CPG forchildhood asthma are its dissemination andimplementation 15. Dissemination must includeeducational activities like round table discussions480and lectures that promote familiarity andunderstanding of the CPG. Ongoing treatment orprescription audits and educational programmesthat monitor the changes in prescribing patternsand treatment strategies that adhere to the CPGmust be performed for CPG implementation.An obvious shortcoming of our study was that theGP population surveyed might more likely useinhaled corticosteroids for asthma as they wereinvited to attend an asthma workshop that wassponsored by a pharmaceutical establishment thatpromoted heavily the inhaled form of treatmentand regular use of corticosteroids for asthma.Nonetheless, despite this possible bias, theprescribing patterns of this GP population stillshowed that the oral route for asthma medicationremains an important route in general practice andeven preferred for young children. Ketotifendespite its questionable clinical efficacy and costremains a popular choice for preventer medicationand may reflect frequent under-treatment ofairway inflammation in general practice.The prescribing patterns for childhood asthma ingeneral practice from our study suggests thatMalaysian children with asthma categories thatrequire preventer asthma treatment may notalways be identified or prescribed effectivepreventer treatment.Although the CPG wasdeveloped for this objective, non-adherence andlack of awareness among GPs regarding the CPGsuggest failure of its dissemination andimplementation.AcknowledgementWe would like to thank the Malaysian ThoracicSociety for allowing this study to be carried outand Glaxo-Smith-Kline Malaysia for partialsponsorship of the study.Med J Malaysia Vol 58 No 4 October 2003

Prescribing Patterns for Childhood Asthma Treatment in General Practice1.International Study of Asthma and Allergies inChildhood (ISAAC) committee.Worldwidevariations in the prevalence of asthma symptoms:the International Study of Asthma and Allergies inChildhood (ISAAC). Eur Respir J. 1998; 12: 315-35.9.Cornett G],Lee BW. Treating childhood asthma inSingapore: when west meets east. BM] ] 1993; 308:1282-4.10. Lim SH, Goh AYT, Tan AL, Kee BW. Parents'perceptions towards their children are used ofinhaled medication for asthma therapy. J PaediatrChild Health 1996; 32: 306-9.2.Grimshaw ]M, Russel IT. Effects of clinicalguidelines in medical practice: a systematic reviewof rigorous evaluations. Lancet 1993; 342: 1317-22.3.Academy of Medicine and Ministry of HealthMalaysia.Clinical practice guidelines formanagement of childhood asthma; 1996.4.Azizi BHO, Mohan], Koh CT, et al. Guidelines formanagement of childhood asthma: a consensus'statement. Med] Mal 1997; 52: 416-27.,12. Loftus BG, Price ]F. Long-term, placebo-controlledtrial of ketotifen in the management of preschoolchildren with asthma.] Allergy Clin Immunol 1987;79: 350-5.5.Clinical Practice ,Guidelines section. Academy /cpg.html).13. Graff-Lonnevig V, Hedlin G. The effect of ketotifenon bronchial hyper-reactivity in childhood asthma. ]Allergy Clin Immunol. 1985; 76: 59-63.6.Global Initiative for Asthma, World HealthOrganization, National Heart, Lung and BloodIn titute. Asthma Management and Prevention Revised 1998.7.Tan WC, Chia KS, Goh LG. Choices and preferencesin asthma management. Sing Med] 1992; 33: 590 414. Tasche M]A, Uijen H]M, Bernsen RMD, de ]ongste]C, van der Wouden ]c. Inhaled disodiumcromoglycate (DSCG) as maintenance therapy inchildren with asthma: a systematic review. Thorax2000; 55: 913-208. Vihcyanond P, Hatchaleelaha S, ]intavorn V,Kerdsomnuig S. How pediatricians manage asthmain Thailand. Pediatr Pulmonol 2001: 32: 109-14.Med J Malaysia Vol 58 No 4 October 200311. Chan PWK, Debruyne ]A. Parental concern towardsinhaled therapy use in asthmatic Malaysianchildren. Pediatr Int 2001; 42: 547-51.15. Partridge MR. The implementation of asthmaguidelines in general practice. Respir Med 1997; 91:575-7.481

childhood asthma is relatively unknown. We therefore determined the treatment preference and prescribing patterns of GPs for childhood asthma. Accessibility to the CPG for childhood asthma and adherence to its recommendations as outlined were also determined. Materials and Metho

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