背景:2017年4月,墨西哥哮喘指南(GUIMA)发布。发射前,探讨了与指南关键问题相关的医师知识。
方法:向5个治疗哮喘的医学专业的董事会认证医师发送了一项SurveyMonkey®调查。根据GUIMA循证建议对每个专业的答复进行分析。我们在这里介绍治疗部分。
结果:总共364名过敏症患者(ALLERG),161名肺科医师(PULM),34ENT,239名儿科医生(PED)和62名全科医生(GP)回复了调查,247-83-14-135-37分别完成了调查。当哮喘很可能被ALLERG54%时,肺活量测定不是常规指标,PULM47%,ENT39%,PED65%,GP64%。向患有间歇性哮喘的医生提出的虚构病例被ALLERG9%错误地用ICS治疗,PULM11%,ENT28%,PED10%,GP11%。ALLERG25%错误地接受了ICS-LABA的轻度持续性病例,PULM26%,ENT33%,PED27%,GP23%。中度持续性哮喘的一线选择是ICS(中位剂量),而不是ICS(低)+ALLERG的LABA29%,PULM25%,ENT17%,PED27%,GP23%和严重哮喘维持治疗PULM20%,ALLERG-ENT-PED-GP22-34%未能指示LABA。关于指南建议使用一种吸入器来维持和抢救中度至重度哮喘,PULM45%,ALLERG-ENT-PED-GP56-80%(p<0.00001),错误地表明可以使用ICS-沙美特罗,而不是ICS-福莫特罗。不再推荐口服β2或茶碱,但PULM37%和ALLERG-ENT-PED-GP42-62%(p<0.01)仍然表明它们的使用。在严重哮喘中,61-73%的医生考虑在治疗中添加LTRA;只有PULM38%,另外,S12-25%考虑添加噻托溴铵(p<0.001),3-17%考虑添加奥马珠单抗,这两个指南都推荐了附加组件。至于怀孕期间的哮喘,大多数接受调查的人不知道布地奈德是ICS的一线选择。最后,81-97%的小组成员认可过敏原免疫疗法,作为一个可行的附加组件,符合GINA/GEMA/GUIMA建议。
结论:一项在线调查可以发现与哮喘治疗相关的知识差距。有趣的是,接受调查的医生倾向于过度治疗轻度哮喘病例,因此,显然为节省成本留下了空间。在推广SMART(单一维护和缓解治疗)方法时应谨慎,这只能用ICS-福莫特罗完成。许多医生选择不适合这种方法的其他组合。在所有接受调查的专业中,轻度和重度哮喘管理都有很大的改善空间。
BACKGROUND: In April 2017 the Mexican Asthma Guidelines (GUIMA) were published. Before the launch, physicians\' knowledge was explored related to key issues of the guideline.
METHODS: A SurveyMonkey® survey was sent out to board-certified physicians of 5 medical specialties treating asthma. Replies were analyzed per specialty against the GUIMA evidence-based recommendations. We present the treatment part here.
RESULTS: A total of 364 allergists (ALLERG), 161 pulmonologists (PULM), 34 ENTs, 239 pediatricians (PED) and 62 general practitioners (GPs) replied to the survey and 247-83-14-135-37 respectively finished it. Spirometry is not routinely indicated when asthma is very probable by ALLERG 54%, PULM 47%, ENT 39%, PED 65%, GP 64%. A fictitious case proposed to the physicians with intermittent asthma was erroneously treated with ICS by ALLERG 9%, PULM 11%, ENT 28%, PED 10%, GP 11%. The mild persistent case received mistakenly ICS-LABA by ALLERG 25%, PULM 26%, ENT 33%, PED 27%, GP 23%. The first-line option for moderate persistent asthma was ICS(median dose) instead of ICS(low)+LABA for ALLERG 29%, PULM 25%, ENT 17%, PED 27%, GP 23% and in severe asthma maintenance treatment PULM20%, ALLERG-ENT-PED-GP 22-34% failed to indicate LABA. Concerning the guidelines\' recommendation to use one inhaler for maintenance & rescue in moderate-to-severe asthma, PULM45%, ALLERG-ENT-PED-GP 56-80% (p < 0.00001), erroneously indicated ICS-salmeterol could be used, instead of ICS-formoterol. Oral β2 or theophylline are no longer recommended, but PULM 37% and ALLERG-ENT-PED-GP 42-62% (p < 0.01) still indicate their use. In severe asthma 61-73% of physicians consider adding LTRA to the treatment; only PULM38%, OTHERS12-25% consider adding tiotropium (p < 0.001) and 3-17% consider adding omalizumab, both guideline recommended add-ons. As for asthma in pregnancy, most surveyed are not aware budesonide is the 1st line option ICS. Finally, 81-97% of the group-members recognized allergen immunotherapy, as a viable add-on, in line with GINA/GEMA/GUIMA recommendations.
CONCLUSIONS: An online survey could detect knowledge-gaps related to asthma treatment. Interestingly, surveyed physicians tended to over-treat the milder asthma cases, thus clearly leaving room for cost-savings. Caution should be taken in the promotion of the SMART (single-maintenance-and-reliever-treatment) approach, which can only be done with ICS-formoterol. Many physicians opt for other combinations not apt for this approach. Among all surveyed specialties there is ample room for improvement in mild and severe asthma management.