The under-use of inhaled corticosteroids results in poor asthma control.

ESSENTIALS OF ASTHMA MANAGEMENT

The criteria for successfully managed asthma have been described by the Global Initiative for Asthma (GINA). The Union follows these same criteria closely in its own guidelines:

  • no symptoms or very mild
  • symptoms
  • no attacks
  • no emergency department visits
  • no limitation of activities
  • no airflow limitation (PEF ≥ 80% of predicted value)
  • minimal bronchodilator use ( less than 2 times/week)
  • the least side effects possible.

Inhaled corticosteroids are essential to success

Inhaled corticosteroids are essential for achieving these goals and managing patients with persistent asthma over the long-term. However, studies have found that health care workers often don’t prescribe inhaled corticosteroids for asthma. When they do prescribe them, patients often abandon them and rely on bronchodilators instead. They believe that bronchodilators are effective because these medicines provide quick relief from symptoms and that inhaled corticosteroids are not effective because they observe no immediate, obvious effect from them. Consequently patients are likely to under-use inhaled corticosteroids.

Projects undertaken by The Union evaluated asthma treatment outcomes after one year of follow-up. They found that asthma severity and symptom frequency reduced significantly when patients took treatment regularly. However, practitioners demonstrated only moderate adherence to guidelines for grading the severity of their patients’ asthma, and poor adherence to guidelines as regards prescribing inhaled corticosteroids. A substantial proportion of patients also stopped taking their inhaled corticosteroids.

Falling short of success

Survey after survey shows these effective medicines are not being used.

The USA

The Asthma in America national population survey revealed that only 26.2% of persons who had had persistent asthma symptoms in the previous month reported using inhaled corticosteroids. The percentage was even lower among smokers and persons reporting lower income, less education and present unemployment, all of whom were significantly less likely to report current use of inhaled corticosteroids.

Europe

The Asthma Insights and Reality in Europe study revealed that 46% of patients had daytime symptoms, and 30% had asthma-related sleep disturbances at least once a week. In the past 12 months, 25% of patients reported an unscheduled urgent care visit; 10% had one or more emergency room visits; and 7% were hospitalised overnight due to their asthma. Yet, the proportion of patients who used inhaled corticosteroids was low. The study found that in the previous four weeks, 63% of patients had used bronchodilators, but only 23% used inhaled corticosteroids.

Asia Pacific

The Asthma Insights and Reality in the Asia-Pacific study revealed that in China, Hong Kong, Korea, Malaysia, The Philippines, Singapore, Taiwan and Vietnam, 51.4% of respondents had daytime asthma symptoms, and 44.3% reported sleep disturbances caused by asthma in the preceding four weeks. Survey respondents also reported that 43.6% had been hospitalised, attended an emergency room or made unscheduled emergency visits to other health care facilities for treatment of asthma during the previous 12 months. While 56.3% reported using bronchodilators, only 13.6% reported current use of inhaled corticosteroids.

Globally

The global Asthma Insights and Reality surveys observed that asthma had a substantial impact on patients’ lives with considerable loss of school days and work days and that the current level of asthma control worldwide was unsatisfactory.

What is needed to manage asthma effectively in low- and middle-income countries?

The under-use of inhaled corticosteroids results in poor asthma control, frequent unplanned visits to the emergency room, more hospitalisations, and an unnecessary reduction in quality of life for those who live with asthma. To turn this situation around requires action on several fronts:

Apply guidelines for standard case management of asthma

The Union’s asthma guidelines were pilot tested in health centres in Algeria, Guinea, Ivory Coast, Kenya, Mali, Morocco, Syria, Turkey and Vietnam. Investigators concluded that the measures were feasible, effective and cost effective, with reductions in the severity of asthma for the majority of patients, and the almost complete disappearance of visits to emergency services and hospitalisations.

Train clinicians and health care workers to identify asthma patients

In Huaiyuan County, Anhui Province, China, a project with The Union revealed that asthma was not being diagnosed in the participating facilities before the project was introduced. Patients presenting with cough and difficult breathing were usually diagnosed with chronic bronchitis and treated with a combination of antibiotics, systemic steroids, xanthine derivatives and/or oral beta-2 agonists.

Inhaled corticosteroids had never been available prior to the project. After training, health workers identified a substantial number of asthma patients who were treated with inhaled corticosteroids and inhaled salbutamol. This project suggested not only that asthma can be a “hidden disease”, but also that health workers can be trained to provide standardised case management of asthma.

Ensure quality-assured essential asthma medicines are accessible and affordable

.The high cost of inhaled corticosteroids is a major barrier to asthma management in low- and middle income countries. The Union’s Asthma Drug Facility, along with several countries running pilot projects, has demonstrated that quality-assured essential asthma medicines can be procured at low prices.

Serve chronic patients effectively

The huge majority of asthma patients are only being treated on an emergency basis – when they arrive in the emergency department with an acute attack of asthma. Health services need to be organised for the long-term management of asthma, with trained health care workers and regular follow-up of patients. This will reduce emergency visits and hospitalisations, and empower patients and their families to manage their asthma.

Collect and monitor data to assure quality of care

To evaluate the effectiveness and quality of asthma care, an information system allowing outcome assessment of registered asthma patients and overall evaluation of asthma management should be established for facilities providing care.

Educate patients to overcome fears and encourage self-management

Patient education is essential to prevent unnecessary concerns about asthma and asthma medicines. Patients need to learn that inhaled corticosteroids are not addictive or dangerous. They need to understand that their condition is ongoing, possibly lifelong, and that it is variable (i.e., the timing and extent of symptoms varies). They also need to learn how to manage their asthma: how and when to take their medicines and when to seek help from health care facilities.

Governments need to help set up long-term management of asthma

An uninterrupted supply of essential asthma medicines, organised services and trained human resources are the minimum requirements for health services to manage asthma.

- Chiang Chen-Yuan, Nadia Aït-Khaled

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