Global Asthma Management and Control
Most symptoms of asthma in people of any age should be able to be controlled; this is the clear aspiration of asthma guidelines, strategies, and health professionals. However, good control is not always achieved due to factors such as failing to follow the latest relevant national or international guidelines (widely accessible), low adherence to treatment regimens (including poor inhaler technique), and in many low resource settings, unavailability or high cost of quality-assured, essential asthma medicines.
A global perspective on how asthma is managed, and its gaps is crucial for developing and implementing further interventions to improve asthma control in different settings.
Accordingly, the Global Asthma Network (GAN) Phase I study included several questions on asthma control and management including the use of inhaled and oral medicines as well as the availability of a personal written asthma plan. Inhaled medicines were grouped as short-acting β2-agonists (SABA), long-acting β2-agonists (LABA), inhaled corticosteroids (ICS) and combinations of ICS and LABA (ICS+LABA). Oral medicines were grouped as: leukotriene receptor antagonists (LTRA); oral SABA (oSABA); theophylline; and oral corticosteroids (OCS). Questions, designed to address the degree of asthma control, were also included i.e. in the past 12 months urgently visiting the doctor, attending the Emergency Department (ED), and/or being admitted to the hospital for asthma symptoms.
This chapter focuses on individuals participating in GAN Phase I whose asthma was confirmed by a doctor, in three age groups: children (6–7 year olds); adolescents (13–14 year olds); and their parents/guardians (adults). Asthma was categorised into three groups depending on the symptoms suffered in the past 12 months. Individuals with severe asthma symptoms were defined as those with current wheeze who, in the past 12 months, had ≥4 attacks of wheeze, or ≥1 night per week sleep disturbance from wheeze, or wheeze affecting speech. Those with symptoms, but not as severe as the above definition, were considered as having mild asthma. Those without symptoms were the asymptomatic group.
Lack of control of asthma was defined as the need (in the past 12 months) of urgently visiting their doctor ≥4 times; or attending to the ED ≥4 times; or being admitted to the hospital ≥1 times for asthma symptoms. Those urgently visiting their doctor <4 times; or attending the ED also <4 times; but not admitted to hospital, were considered as partially controlled. Those who had no urgent visits or attendance were considered well controlled.
Asthma was confirmed by a doctor in 6.3% of children in 44 centres in 16 countries; 7.9% of adolescents in 63 centres in 25 countries; and 3.5% of adults in 43 centres in 17 countries. Overall, 44.1% of the children, 55.4% of the adolescents and 61.1% of the adults with asthma had their asthma well controlled. There was an important proportion whose asthma was uncontrolled (25.3%, 22.3% and 16.0%, respectively for children, adolescents, and adults (Figure 1).
Figure 2 shows the frequency with which inhaled and oral medications were taken by asthmatic children, adolescents and adults depending on the type of asthma symptoms they experienced (asymptomatic, mild, or severe). The percentage of individuals with severe asthma symptoms who used any asthma medicine was usually higher than those with mild asthma. Information on inhaled medication was provided by all centres in the three age groups, while oral medication data was available for only some centres. Two approaches not recommended by international guidelines were reported: (i) oSABA and theophylline, used in all age groups but in a much lower proportion; and (ii) LABA alone, especially among adolescents and adults, in which the proportion was comparable to that of ICS or ICS+LABA.
The proportion of patients with uncontrolled, partially controlled, and well controlled asthma who used ICS or ICS+LABA was 51.6%, 46.0%, and 25.9% for children; 39.5%, 29.2%, and 14.5% for adolescents; and 45.3%, 37.8, and 17.1% for adults, respectively.
Having a written asthma plan was most frequent in children (62.8%); the respective figures for asymptomatic, mild, and severe asthma being 56.4%, 62.9% and 71.4%. About half of the adolescents (53.4%) had a written asthma plan, higher when asthma was more severe (48.6%, 53.0% and 63.6%, respectively). Adults had the lowest proportion of individuals with asthma with written asthma plans (47.5%) and followed the same trend (38.5%, 44.8%, and 62.9%, respectively). The pattern of asthma plans being more frequent in people with severe asthma suggests that when doctors think that asthma is more severe, they use plans in their management strategy for better controlling the disease.
In people with asthma, only about one half have symptoms that are well controlled. This proportion could be increased if the medicines recommended in current guidelines were used, rather than outmoded medicines such as LABA alone, oSABA, or theophylline. This would be possible if affordable, quality-assured, essential asthma medicines included in the guidelines were available to all people with asthma worldwide.
