Journal Club

July 1, 2007

Asthma step-down strategy * Inadequate fluoride in bottled water * Smoking in movies * Osteoarticular infection

• What's a good step-down strategy for treating mild, persistent asthma?

To answer this question, investigators compared three treatment strategies in about 1,300 patients with mild asthma that was well controlled with low-dose inhaled fluticasone (Flovent HFA) given twice a day. The patients were drawn from 19 clinics associated with the American Lung Association's Asthma Clinical Research Centers. Average age of participants was 30.8 years; over one half were women and over one third were black or Hispanic. Patients included children as young as 6 years.

One group of patients in the 16-week trial received montelukast (Singulair) (5 mg or 10 mg) once daily; another group was given fluticasone (100 mg) plus salmeterol (Advair) (50 mg) once daily. The third group of patients continued the pretrial regimen of inhaled fluticasone (100 mg twice daily). All patients visited the clinic after two, four, eight, 12, and 16 weeks of treatment. Primary outcome was the time to treatment failure, which was defined by seven general measures of asthma control.

Commentary:

The advantage of this two-drug, once-a-day therapy may be increased patient compliance or adherence to the medication regimen. For management of any disease, chronic or acute, the simpler the better.

• Drinking little or no tap water poses risk of inadequate fluoride

Consumption of bottled and filtered water has increased dramatically in recent years. Some of these products lack fluoride, and bottled water labels are not required to disclose if or how much fluoride the bottle contains. This phenomenon led investigators to wonder if many children do not drink tap water, which often is fluoridated, and are instead consuming nonfluorinated filtered or bottled water, a practice that could have a substantial negative effect on oral health and family pocketbooks.

To determine what kind of water parents give their children and to define water filter and fluoride use, investigators administered a 15-question written questionnaire to 216 parents during a two-week study period. Respondents were parents of children cared for in an urban public health center in Salt Lake City; about 80% were Latino and approximately half had been born in Mexico. About 41% had an annual income of less than $15,000. But water preferences proved not to be associated with annual income level.

About one third of the parents said they never drank tap water, and 41.2% said that they never gave tap water to their children. Of the children who drank no tap water, about 60% always drank bottled water, and 35.6% drank only filtered water. The most common reasons for avoiding tap water were taste, fears of illness, and being told by someone to avoid tap water. Latino parents were less likely than non-Latino parents to drink tap water and to give it to their children. Latinos also were more likely than non-Latinos to believe that tap water might make them sick (42% versus 11%). About 40% of the parents who never gave their children tap water did not use fluoride supplements. Questionnaire responses also revealed that only 17.5% of physicians ask parents what type of water their children drink (Hobson WL et al: Arch Pediatr Adolesc Med 2007;161:457).