Taking Aim at Asthma Around the World: Global Results of the Asthma Insight and Management Survey in the Asia-Pacific Region, Latin America, Europe, Canada, and the United States

APPaRENT 3: Asthma Patients' and Physicians' Perspectives on the Burden and Management of Asthma in Seven Countries

INTRODUCTION

Asthma management is strongly dependent on physician and patient beliefs and perceptions about the disease and its long-term treatment. The APPaRENT 3 study was conducted to explore factors influencing treatment choice and to understand patients' and physicians' attitudes and perspectives on the use of controller inhalers in regular versus flexible dosing for asthma management.

METHODS

This cross-sectional survey of patients with asthma and treating physicians was conducted in seven countries: Indonesia, Malaysia, Philippines, Thailand, Vietnam (patient survey only), Saudi Arabia, and the United Arab Emirates. Assessment was carried out through an online/face-to-face questionnaire, where patients' viewpoints were focused on their attitudes and beliefs about asthma and treatment adherence, whereas physicians' viewpoints were gathered on their attitudes and beliefs about asthma management, knowledge of and adherence to asthma treatment guidelines, and asthma treatment regimens.

RESULTS

Overall, 1400 patients (mean age, 34 years) and 599 physicians (mean age, 43 years) were included in the survey. Physicians similarly prioritised symptom control (39%) and exacerbation reduction (40%) in moderate asthma, whereas patients prioritised symptom control (41%) over exacerbation reduction (22%). Although both groups (physicians, 86%; patients, 84%) perceived asthma as well-controlled, poor management was evident based on Asthma Control Test (ACT) scores (mean, 15.7; standard deviation, 4.14; 82% had an ACT score < 20) and high symptom burden (39% reported nighttime awakenings or early mornings ≥ 2 nights/week). Most patients (76%) with moderate asthma were prescribed regular dosing, with the most common treatment being inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) with as-needed inhaled short-acting β2-agonist (SABA; 20%). Among patients on maintenance and reliever therapy, 93% of patients received a separate inhaled reliever.

CONCLUSIONS

Despite high symptom burden, patients overestimated their level of asthma control. Physicians prioritised controlling symptoms and reducing exacerbations as treatment goals for moderate asthma, often prescribing regular dosing with ICS/LABA with as-needed inhaled SABA.

Advancing assessment of asthma control with a composite tool: The Asthma Impairment and Risk Questionnaire

BACKGROUND

National and international asthma guidelines and reports do not include control tools that combine impairment assessment with exacerbation history in one instrument.

OBJECTIVE

To analyze the performance of the composite Asthma Impairment and Risk Questionnaire (AIRQ) in assessing both domains of control and predicting exacerbation risk compared with the Global Initiative for Asthma (GINA) 4-question symptom control tool (GINA SCT), Asthma Control Test (ACT), and physician expert opinion (EO) informed by GINA SCT responses and appraisal of GINA-identified risk factors for poor asthma outcomes.

METHODS

Multivariable logistic regressions evaluated AIRQ and GINA SCT as predictors of ACT. McNemar's test compared the proportion of patients categorized at baseline as completely or well-controlled by each assessment but with current impairment or previous-year and subsequent-year exacerbations.

RESULTS

The analysis included 1064 patients aged 12 years or older; mean (SD) age 43.8 years (19.3); 70% female; 79% White; and 6% Hispanic or Latino. AIRQ and GINA SCT were highly predictive of ACT well-controlled vs not well-controlled and very poorly controlled (receiver operator characteristic area under curve AIRQ = 0.90, GINA SCT = 0.86, P = .03 AIRQ vs GINA SCT) and ACT very poorly controlled vs well-controlled and not well-controlled asthma (receiver operator characteristic area under curve AIRQ = 0.91, GINA SCT = 0.87, P = .01 AIRQ vs GINA SCT). AIRQ rated fewer patients as having completely or well-controlled asthma who had current impairment (P < .01) or with previous-year and subsequent-year exacerbations (P < .001) than did GINA SCT, ACT, and EO.

CONCLUSION

AIRQ performs better in assessing both domains of current control and predicting exacerbation risk than do control tools and EO informed by GINA SCT and risk factors for poor asthma outcomes.

iPREDICT: proof-of-concept study to develop a predictive model of changes in asthma control

BACKGROUND

The individualized PREdiction of DIsease Control using digital sensor Technology (iPREDICT) program was developed for asthma management using digital technology. Devices were integrated into daily lives of patients to establish a predictive model of asthma control by measuring changes from baseline health status with minimal device burden.

OBJECTIVES

To establish baseline disease characteristics of the study participants, detect changes from baseline associated with asthma events, and evaluate algorithms capable of identifying triggers and predicting asthma control changes from baseline data. Patient experience and compliance with the devices were also explored.

DESIGN

This was a multicenter, observational, 24-week, proof-of-concept study conducted in the United States.

METHODS

Patients (⩾12 years) with severe, uncontrolled asthma engaged with a spirometer, vital sign monitor, sleep monitor, connected inhaler devices, and two mobile applications with embedded patient-reported outcome (PRO) questionnaires. Prospective data were linked to data from electronic health records and transmitted to a secure platform to develop predictive algorithms. The primary endpoint was an asthma event: symptom worsening logged by patients (PRO); peak expiratory flow (PEF) < 65% or forced expiratory volume in 1 s < 80%; increased short-acting β2-agonist (SABA) use (>8 puffs/24 h or >4 puffs/day/48 h). For each endpoint, predictive models were constructed at population, subgroup, and individual levels.

RESULTS

Overall, 108 patients were selected: 66 (61.1%) completed and 42 (38.9%) were excluded for failure to respond/missing data. Predictive accuracy depended on endpoint selection. Population-level models achieved low accuracy in predicting endpoints such as PEF < 65%. Subgroups related to specific allergies, asthma triggers, asthma types, and exacerbation treatments demonstrated high accuracy, with the most accurate, predictive endpoint being >4 SABA puffs/day/48 h. Individual models, constructed for patients with high endpoint overlap, exhibited significant predictive accuracy, especially for PEF < 65% and >4 SABA puffs/day/48 h.

CONCLUSION

This multidimensional dataset enabled population-, subgroup-, and individual-level analyses, providing proof-of-concept evidence for development of predictive models of fluctuating asthma control.

Evaluation of short-acting Beta-2-agonist prescriptions and associated clinical outcomes: Findings from the SABA use IN Asthma (SABINA) study in Asia

Background

The extent of short-acting Beta-2-agonist (β2-agonist) (SABA) use across Asian countries is not well documented. As part of the SABA use IN Asthma (SABINA) III study, we assessed SABA prescriptions and clinical outcomes in patients with asthma from Asia.

Methods

This cross-sectional study recruited patients (aged ≥12 years) with asthma from 8 Asian countries. Data on disease characteristics and asthma treatments were collected using electronic case report forms. Patients were classified by practice type (primary or specialist care) and investigator-defined asthma severity (per Global Initiative for Asthma [GINA] 2017 recommendations). The association of SABA prescriptions with clinical outcomes was analyzed using multivariable regression models.

Results

Overall, 3066 patients were analyzed, with a mean (standard deviation) age of 51.8 (16.7) years; of these patients, 2116 (69%) were female, 2517 (82.1%) had moderate-to-severe asthma and 2498 (81.5%) and 559 (18.2%) were treated in specialist and primary care, respectively. In total, 1423 (46.4%) patients had partly controlled/uncontrolled asthma, with 1149 (37.5%) patients experiencing ≥1 severe asthma exacerbation in the previous year. Overall, 800 (26.7%) patients were prescribed ≥3 SABA canisters in the previous year, which is regarded as overprescription and was associated with a significantly decreased odds of at least partly controlled asthma and increased incidence rates of severe exacerbations (P < 0.01 for both associations).

Conclusion

The findings from this cohort of predominantly specialist-treated patients with asthma indicate SABA overprescription in at least 1 in every 4 patients, and this overprescription is associated with poor clinical outcomes. These data highlight the need for adherence to recently updated asthma treatment recommendations in Asia.

The Changing Asthma Management Landscape and Need for Appropriate SABA Prescription

Short-acting β2 agonists (SABAs) have been a mainstay of asthma treatment since the 1950s, and have been mainly recommended as-needed for symptom relief alongside daily inhaled corticosteroid (ICS)-based maintenance treatment for the past 30 years. However, patient adherence to regular ICS-based anti-inflammatory maintenance therapy is frequently poor, leading to SABA overuse for symptom relief and associated poor outcomes. At present, there is a lack of consensus between treatment guidelines on how SABA should be used, and as-needed ICS-formoterol is suggested by some as an alternative reliever therapy. Here, we examine the pharmacology and current use of inhaled SABAs, identify that regular dosing of ICS can encourage appropriate SABA use, and appraise the evidence used to support the changing reliever treatment recommendations. We conclude that SABA continues to play an important role in the asthma management landscape, and give our views on how it should be used in patients with mild-moderate asthma, to complement regular ICS-based maintenance treatment.

Over-prescription of short-acting β2-agonists is associated with poor asthma outcomes: results from the African cohort of the SABINA III study

BACKGROUND

The extent of short-acting β₂-agonist (SABA) overuse in Africa remains poorly documented. As part of the SABA use IN Asthma (SABINA) III study, we assessed SABA prescriptions/clinical outcomes in 3 African countries.

METHODS

Data on disease characteristics/asthma treatments were collected from patients (≥12 years) using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma) and practice type (primary/specialist care). Multivariable regression models analyzed associations between SABA prescriptions and outcomes.

RESULTS

Data from 1778 patients (mean age, 43.7 years) were analyzed. Most patients were female (62.4%) and had moderate-to-severe asthma (63.3%), with 57.1 and 42.9% of patients treated in specialist and primary care, respectively. Asthma was partly controlled/uncontrolled in 66.2% of patients, with 57.9% experiencing ≥1 severe exacerbation in the previous 12 months. Overall, 46.5% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (over-prescription); 26.2% were prescribed ≥10 canisters. SABAs were purchased over-the-counter by 32.6% of patients, of whom 79.3% had received SABA prescriptions; 71.9% and 40.1% for ≥3 and ≥10 canisters, respectively. Higher SABA prescriptions (vs. 1-2 canisters) were associated with increased incidence rate of severe exacerbations and lower odds of having at least partly controlled asthma (except 3-5 canisters).

CONCLUSIONS

Findings from this African cohort of the SABINA III study indicate that SABA over-prescription and SABA over-the-counter purchase are common and associated with poor asthma-related outcomes. This highlights the need for healthcare providers/policymakers to align clinical practices with the latest treatment recommendations.

Dupilumab efficacy and safety in Latin American patients with uncontrolled, moderate-to-severe asthma: phase 3 LIBERTY ASTHMA QUEST study

Objective: While advances in asthma care have been made in Latin America, there is still a large unmet need in patients with uncontrolled asthma. This post hoc analysis of the QUEST study assessed safety and efficacy of dupilumab in the subgroup of patients enrolled in Latin American countries with a type 2 inflammatory asthma phenotype (blood eosinophils ≥150cells/µL or FeNO ≥25ppb).Methods: LIBERTY ASTHMA QUEST (NCT02414854) was a phase 3, multinational, randomized, double-blind, placebo-controlled study in patients with uncontrolled, moderate-to-severe asthma. Eligible patients ≥12 years of age were randomized in a 2:2:1:1 ratio to receive 52 weeks of add-on subcutaneous dupilumab 200 or 300mg every 2 weeks or matched-volume placebos. Pre-specified co-primary efficacy endpoints were the annualized rate of severe exacerbations during the treatment period and the change from baseline in pre-bronchodilator FEV₁ at treatment week 12. Asthma control, changes in asthma biomarker levels, and dupilumab safety were also evaluated.Results: 530 (27.9% of the overall QUEST population; dupilumab: 353, placebo: 177) Latin-American patients were recruited; 420 (79.2%) had a type 2 inflammatory asthma phenotype. Dupilumab vs placebo reduced the annualized rate of severe exacerbations by 52.7% (P < 0.001) and increased pre-bronchodilator FEV₁ at week 12 by 0.15L (P < 0.001), in the type 2 population. Safety was consistent with the known dupilumab safety profile.Conclusions: Consistent with the results in the overall population, dupilumab reduced the risk of severe asthma exacerbations and improved lung function in Latin American patients with uncontrolled, moderate-to-severe asthma and a type 2 phenotype.

Global burden of asthma associated with high body mass index from 1990 to 2019

BACKGROUND

High body mass index (BMI) plays a key role in the progression of asthma and asthma related to high BMI resulted in a high burden of disease globally.

OBJECTIVE

This study aimed to explore the geographical and temporal trends in the global burden of asthma associated with high BMI from 1990 to 2019.

METHODS

This is a retrospective analysis with data based on the Global Burden of Disease Study 2019 database. The deaths, disability-adjusted life-years (DALYs), age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) were estimated according to sex, age and sociodemographic indexes (SDI) levels. Estimated annual percentage change (EAPC) was used to evaluate the variation trends of ASMR and ASDR from 1990 to 2019.

RESULTS

In 2019, the number of global asthma deaths and DALYs related to high BMI increased by 69.69% and 63.91% respectively compared with 1990, among which more deaths and DALYs occurred in females. The corresponding ASMR and ASDR showed a slightly decreasing tendency globally. South Asia accounted for the highest number of deaths and DALYs, with India ranked first worldwide in 2019. The number of deaths and DALYs mainly appeared in individuals 60-79 years old and 55-69 years old respectively from 1990 to 2019. The heaviest burden existed in the low-middle SDI region.

CONCLUSION

The global asthma burden associated with obesity increased in absolute value but the standardized burden decreased slightly. Large variations existed in the high BMI-related asthma burdens among sexes, ages and regions.

Prevalence of asthma among children in India: A systematic review and meta-analysis

There is a lack of national-level estimates on the magnitude of asthma among children in India. Hence, we undertook a systematic review and meta-analysis to estimate the prevalence of asthma among children in India. We searched PubMed, Embase, Cochrane Library, and Google Scholar, and included cross-sectional studies reporting data on the prevalence of asthma among children in India. A random-effects model was used to estimate the pooled prevalence of asthma. In the 33 selected studies (pooled sample of 167,626 children), the estimated prevalence of asthma was 7.9% (95% confidence interval: 6.3-9.6%), I2 = 99.1% (P < 0.001). The prevalence was higher among boys and in urban areas. Appropriate training and resources should be made available at the primary healthcare level for early detection and management of asthma in children. A nationwide population-based survey is indicated to provide reliable estimates of the burden of asthma.

SABA prescriptions and asthma management practices in patients treated by specialists in Taiwan: Results from the SABINA III study

PURPOSE

Limited data exist on asthma medication patterns in Taiwan. The objectives of the SABINA III cross-sectional study in Taiwan were thus, to describe patient demographics and clinical features and estimate short-acting β₂-agonist (SABA) and inhaled corticosteroids (ICS) prescriptions per patient.

METHODS

Patients (≥18 years) with asthma were classified by investigator-defined asthma severity per the 2017 Global Initiative for Asthma (GINA) recommendations. Data on asthma symptom control (per GINA 2017 recommendations), severe exacerbation history, and prescribed treatments in the 12 months before study visit were collected using electronic case-report forms. Analyses were descriptive.

RESULTS

Overall, all 294 analyzed patients (mean [SD] age, 57.9 [15.6] years; female, 69%) were enrolled by specialists and had fully reimbursed healthcare. Most patients were classified with moderate-to-severe asthma (93.2%; GINA steps 3-5), were obese (53.4%) and nonsmokers (79.6%), reported high school or university and/or postgraduate education (61.9%), and had ≤2 comorbidities (89.1%). Mean (SD) asthma duration was 8.3 (10.0) years, with 37.8% of patients experiencing ≥1 severe exacerbation 12 months before the study visit. Overall, 62.2%, 26.2%, and 11.6% of patients had well-controlled, partly controlled, and uncontrolled asthma, respectively. Crucially, 19.3% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (overprescription). ICS, ICS + long-acting β_2-agonist fixed-dose combination, and oral corticosteroid bursts were prescribed to 6.5%, 97.3%, and 31.6% of patients, respectively.

CONCLUSION

Despite treatment by specialists and fully reimbursed healthcare, findings indicate room for improvement in asthma control and SABA prescription practices in Taiwan, emphasizing the need to adhere to latest evidence-based guidelines.

Asthma in the Americas: An Update: A Joint Perspective from the Brazilian Thoracic Society, Canadian Thoracic Society, Latin American Thoracic Society, and American Thoracic Society

Asthma affects a large number of people living in the Americas, a vast and diverse geographic region comprising 35 nations in the Caribbean and North, Central, and South America. The marked variability in the prevalence, morbidity, and mortality from asthma across and within nations in the Americas offers a unique opportunity to improve our understanding of the risk factors and management of asthma phenotypes and endotypes in children and adults. Moreover, a better assessment of the causes and treatment of asthma in less economically developed regions in the Americas would help diagnose and treat individuals migrating from those areas to Canada and the United States. In this focused review, we first assess the epidemiology of asthma, review known and potential risk factors, and examine commonalities and differences in asthma management across the Americas. We then discuss future directions in research and health policies to improve the prevention, diagnosis, and management of pediatric and adult asthma in the Americas, including standardized and periodic assessment of asthma burden across the region; large-scale longitudinal studies including omics and comprehensive environmental data on racially and ethnically diverse populations; and dissemination and implementation of guidelines for asthma management across the spectrum of disease severity. New initiatives should recognize differences in socioeconomic development and health care systems across the region while paying particular attention to novel or more impactful risk factors for asthma in the Americas, including indoor pollutants such as biomass fuel, tobacco use, infectious agents and the microbiome, and psychosocial stressor and chronic stress.

Cost-Effectiveness of Once-Daily, Single-Inhaler Indacaterol Acetate/ Glycopyrronium Bromide/ Mometasone Furoate in Patients with Uncontrolled Moderate-to-Severe Asthma in Canada

Purpose

We evaluated the cost-effectiveness of high-dose indacaterol acetate (IND)/glycopyrronium bromide (GLY)/mometasone furoate (MF) (150/50/160 μg, once daily) compared with high-dose salmeterol/fluticasone (SAL/FLU; 50/500 µg, twice daily)+tiotropium (TIO; 5 µg, once daily) (SAL/FLU+TIO) and with high-dose SAL/FLU (50/500 µg, twice daily) for the treatment of inadequately controlled moderate-to-severe asthma.

Patients and Methods

A Markov model estimated the incremental cost-effectiveness ratio of treatment with high-dose IND/GLY/MF compared with SAL/FLU+TIO and high-dose IND/GLY/MF compared with SAL/FLU. The model included three health states (day-to-day symptoms without exacerbations, day-to-day symptoms with exacerbations, and death) with a 4-week cycle length. A lifetime time horizon was used. Exacerbation rates and utility values were derived from ARGON and IRIDIUM clinical trials. Canadian dollars (CAD$, 2020) were applied.

Results

IND/GLY/MF was the less costly and more effective treatment strategy compared with SAL/FLU+TIO and SAL/FLU in the base-case analyses. IND/GLY/MF had lower costs (CAD $33,501 versus CAD $50,907) and higher quality-adjusted life-years (QALYs) (18.37 versus 18.06 QALYs) compared with SAL/FLU+TIO. Compared with SAL/FLU, IND/GLY/MF had lower costs (CAD $33,408 versus CAD $36,577) and higher QALYs (19.33 versus 19.04 QALYs). IND/GLY/MF was the most cost-effective option in all scenarios tested.

Conclusion

IND/GLY/MF was cost-effective at a willingness-to-pay threshold of CAD $50,000/QALY in patients with uncontrolled, moderate-to-severe asthma versus SAL/FLU+TIO and SAL/FLU in the base case and all scenarios tested.

Short-acting β2-agonist prescriptions are associated with poor clinical outcomes of asthma: the multi-country, cross-sectional SABINA III study

Background

To gain a global perspective on short-acting β₂-agonist (SABA) prescriptions and associated asthma-related clinical outcomes in patients with asthma, we assessed primary health data across 24 countries in five continents.

Methods

SABINA III was a cross-sectional study that employed electronic case report forms at a study visit (in primary or specialist care) to record prescribed medication(s), over-the-counter (OTC) SABA purchases and clinical outcomes in asthma patients (≥12 years old) during the past 12 months. In patients with ≥1 SABA prescriptions, associations of SABA with asthma symptom control and severe exacerbations were analysed using multivariable regression models.

Results

Of 8351 patients recruited (n=6872, specialists; n=1440, primary care), 76.5% had moderate-to-severe asthma and 45.4% experienced ≥1 severe exacerbations in the past 12 months. 38% of patients were prescribed ≥3 SABA canisters; 18.0% purchased OTC SABA, of whom 76.8% also received SABA prescriptions. Prescriptions of 3–5, 6–9, 10–12 and ≥13 SABA canisters (versus 1–2) were associated with increasingly lower odds of controlled or partly controlled asthma (adjusted OR 0.64 (95% CI 0.53–0.78), 0.49 (95% CI 0.39–0.61), 0.42 (95% CI 0.34–0.51) and 0.33 (95% CI 0.25–0.45), respectively; n=4597) and higher severe exacerbation rates (adjusted incidence rate ratio 1.40 (95% CI 1.24–1.58), 1.52 (95% CI 1.33–1.74), 1.78 (95% CI 1.57–2.02) and 1.92 (95% CI 1.61–2.29), respectively; n=4612).

Conclusions

This study indicates an association between high SABA prescriptions and poor clinical outcomes across a broad range of countries, healthcare settings and asthma severities, providing support for initiatives to improve asthma morbidity by reducing SABA overreliance.

Findings from SABINA III, which included 8351 patients from 24 countries, indicate that across treatment steps and clinical care settings, high SABA prescriptions were associated with higher rates of severe exacerbations and poorer asthma controlhttps://bit.ly/2VHBISg

A questionnaire validated using local treatment guidelines may better predict future asthma risk: MARGIN study

BACKGROUND

Asthma patients often feel satisfied with their current treatment, even when they have been diagnosed as uncontrolled by physicians. The present study investigated the differences in the evaluation of asthma control levels between patients and physicians, and the prediction of future risks.

METHODS

Asthma patients receiving inhaled corticosteroid/long-acting beta-2 agonists for 4 weeks or more were enrolled and followed-up for 24 weeks. Asthma control levels were evaluated using the following guidelines: Asthma Prevention and Management Guideline, Japan (JGL) and Global Initiative for Asthma (GINA) by physicians, and the Japan Asthma Control Survey (JACS) and a 6-item Asthma Control Questionnaire (ACQ6) by patients, at weeks 0 and 24. Analysis for predictive factors influencing exacerbation was performed using JGL, GINA, JACS, and ACQ6 at week 0.

RESULTS

A total of 420 patients were enrolled. Comparison of the distribution of asthma control levels assessed by physicians and patients showed no statistically significant difference between JGL and JACS (P = 0.19), suggesting a symmetric distribution, while ACQ6 demonstrated a significant difference versus JGL and GINA (both P < 0.001). The predictive factors for exacerbation were unscheduled visits based on GINA (rate ratio; 0.25, 95% CI; 0.14, 0.44), and the use of oral steroids on 3 consecutive days based on JGL (rate ratio; 0.42, 95% CI 0.22, 0.82) and JACS (rate ratio; 0.22, 95% CI; 0.13, 0,40).

CONCLUSIONS

Our study suggests that evaluation based on treatment guidelines and the questionnaire validated according to the local treatment guidelines is important for improved assessment of asthma control levels and the reduction of future risk.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000030419.

Management of Asthma Exacerbations in Southeast Asian Tertiary Care

BACKGROUND

There have been limited reports looking into the care of patients with asthma exacerbations admitted to tertiary hospitals in Southeast Asia. This study aims to determine the extent in which the 2019 Global Initiative for Asthma (GINA) guidelines were being met.

METHODS

A retrospective study of patients with asthma exacerbations admitted to the University of Malaya Medical Centre (UMMC) and Pantai Hospital Kuala Lumpur (PHKL), Malaysia from 1 July 2019 to 31 December 2019.

RESULTS

There were significant numbers of patients with previous admissions for asthma in both centres, with almost 50% experiencing an exacerbation in the previous year. Approximately 75% of the patients considered their asthma to be controlled when asked, despite many of them having had a history of acute exacerbations in the previous year. When cross-checked, the level of GINA-defined asthma control remained low, with only 6.4% of the patients deemed to have good control, while asthma was partially controlled in 25.6% of the patients and uncontrolled in 68% of the patients. About 72.1% of the patients reported daytime symptoms, 65.1% of the patients reported night-time symptoms, 70.9% of the patients required frequent usage of rescue inhalers and 72.1% of the patients reported some limitation in their activity prior to the current asthma exacerbation. Almost a quarter of the patients who were admitted had severe or life-threatening exacerbations as defined by GINA. These patients had more hospitalizations in a year and were more likely to have previous admissions requiring non-invasive and invasive ventilation. They were also more likely to be on GINA Step 5 treatment, had a lower mean percent predicted FEV1 and a higher baseline blood eosinophil count. Multivariate analysis revealed that baseline eosinophil count were independently associated with severe or life-threatening asthma exacerbations (odds ratio: 1.01, 95% confidence interval: 1.00-1.01, p=0.001). Failure to adhere to daily controller medications was high in this study (37.2%).

CONCLUSION

Although the management of asthma exacerbations in tertiary hospitals in Southeast Asia is largely congruous with international guidelines, there is room for improvement. As there is a marked discrepancy between patient-perceived and guideline-defined asthma control, efforts to increase awareness on the dangers of uncontrolled asthma are warranted.

[Uncontrolled asthma in children and adolescents exposed to pesticides in an area of intense agribusiness activity]

The study aimed to analyze factors associated with uncontrolled asthma in schoolchildren exposed to pesticides in a medium-sized municipality in the state of Mato Grosso, Brazil. This was a case-control study of children 6 to 7 and 13 to 14 years old in Primavera do Leste, in 2016. Cases were defined as schoolchildren that met the criteria for uncontrolled asthma based on International Study of Asthma and Allergies in Childhood (ISAAC) questions, and controls were selected from the same schools as the cases, after randomization, at a 1:1 ratio. Data collection used the questionnaires from Phases I and II of ISAAC and an additional questionnaire on pesticide exposure. Descriptive, bivariate, and logistic da e regression analyses were performed with the individual and environmental sociodemographic, and economic variables. 319 cases and 319 controls were selected, totaling 638 participants in the study. In the final da logistic model, the variables family income greater than 4 minimum wages (OR = 14.36; 95%CI: 8.89-23.20), maternal schooling up to incomplete secondary (OR = 16.32; 95%CI: 8.96-29.75), prematurity (OR = 13.25; 95%CI: 4.83-36.41), and low birthweight (OR = 17.08; 95%CI: 5.52-52.90) remained associated with uncontrolled asthma. Of the pesticide exposure variables, presence of household member working in agriculture (OR = 5.91; 95%CI: 2.11-16.53), living near farming activities (OR = 3.98; 95%CI: 1.47-11.76), and spraying areas near the household (OR = 4.20; 95%CI: 1.49-11.87) were related to the outcome. In this study, pesticides and sociodemographic, neonatal, and childhood conditions proved related to uncontrolled asthma in schoolchildren.

Patients' and physicians' attitudes and perception about asthma in the Gulf: A subset analysis from the Asthma Insights and Management Survey in the Gulf and Russia

Background: Asthma is a prevalent disorder in the Gulf region. However, available data concerning asthma control and patients' perception with regard to their disease are still insufficient. Objective: To investigate patients' perception and behavior with regard to the asthma-related burden, the level of asthma control, and asthma management in three Gulf countries. Methods: This study presented a subset analysis of the Asthma Insights and Management survey about the asthma burden and management in the Gulf region and Russia. In this subset analysis, we retrieved the data of the patients from Saudi Arabia, United Arab Emirates, and Kuwait. Results: The current survey's population was composed of 452 patients. One hundred fifty-four patients (34.1%) rated themselves as having poorly controlled asthma, whereas 60.3% of the patients perceived their asthma as completely or well controlled. However, only two patients (0.4%) had controlled asthma according to the global asthma guidelines criteria for asthma control. Most of the patients (67.7%) reported that their asthma got worse when outdoors. Almost 70% of the patients on daily control plus a quick relief regimen reported that their asthma got worse when they were outdoors. Over the past 12 months, 95 patients (21%) reported asthma exacerbation. More than half of the included patients experienced an asthma attack that stopped their activities, whereas 54.2% of the patients were forced to leave work or school due to an asthma attack, and 53.1% had to cancel an appointment or had to go to bed due to the severity of the attack. With concern to asthma management, only 30.5% of the patients were given a lung function test for the assessment of their asthma. A written action plan for asthma treatment was developed by the physician or the practice nurse for only 21.7% of the patients. Conclusion: In the Gulf region, asthma exerts a substantial burden on patients who are affected. Such a burden significantly impacted patients' quality of life.

Patient-Selected Treatment Goals in Severe Asthma

BACKGROUND

Goal-orientated health care accounts for patient preferences and values, not just physician treatment aims. The Global Initiative for Asthma (GINA) management strategy states that clinicians should elicit patients' own treatment goals as a central part of care. Despite this recommendation, data on patients' treatment goals are sparse among patients with severe asthma.

OBJECTIVE

The objective of this study is to investigate the relationship between rates of treatment adherence and goal achievement, and patient-selected goals.

METHODS

Thematic analysis was used to characterize patient-selected goals. Previously undescribed goal categories in asthma were identified, quantified, and related to clinical characteristics. Goal achievement was aligned with objectively measured treatment adherence.

RESULTS

Three categories of patients-selected goals were identified from 2 randomized control trials: disease-specific (n = 98 [51%] and n = 92 [54%], respectively), function-related (n = 90 [48%] and n = 61 [36%]), and knowledge (n = 1 [1%] and n = 17 [10%]). Only 53% of goals aligned with clinician treatment goals. Patients who chose disease-specific goals were more likely to achieve both control and their specified goal (n = 98 [45%], odds ratio: 1.789, confidence interval: 1.066-3.001). Male participants are more likely to focus on disease-specific goals. Patients who achieved their goals were more likely to be T2-high, have an elevated fractional exhaled nitric oxide (FeNO) at their first visit, and have a lower FeNO value at their final visit. Interestingly, adherence rates decline significantly for those who achieve their goals.

CONCLUSION

Almost half of patient-selected goals do not align with GINA clinical asthma management goals. Participants who chose goals that do align with clinicians were more likely to achieve them.

Severe asthma: adding new evidence - Latin American Thoracic Society

This document constitutes a summary of the clinical practice guidelines (CPGs) prepared at the initiative of the Latin American Thoracic Society (ALAT). Due to new evidence in the treatment of severe asthma, it was agreed to select six clinical questions, and the corresponding recommendations are provided herein. After considering the quality of the evidence, the balance between desirable and undesirable impacts and the feasibility and acceptance of procedures, the following recommendations were established. 1) We do not recommend the use of an inhaled corticosteroid (ICS) plus formoterol as rescue medication in the treatment of severe asthma. 2) We suggest performing many more high-quality randomised studies to evaluate the efficacy and safety of tiotropium in patients with severe asthma. 3) Omalizumab is recommended in patients with severe uncontrolled allergic asthma with serum IgE levels above 30 IU. 4) Anti-interleukin (IL)-5 drugs are recommended in patients with severe uncontrolled eosinophilic asthma (cut-off values above 150 cells·µL⁻¹ for mepolizumab and above 400 cells·µL⁻¹ for reslizumab). 5) Benralizumab is recommended in adult patients with severe uncontrolled eosinophilic asthma (cut-off values above 300 cells·µL⁻¹). 6) Dupilumab is recommended in adult patients with severe uncontrolled allergic and eosinophilic asthma and in adult patients with severe corticosteroid-dependent asthma.

Severe #asthma: evidence @ALAToraxhttps://bit.ly/34jYhg2

Perspectives on decisions for treatment and care in severe asthma

Background

Severe asthma is a subtype of asthma that can be hard to control, resulting in an exceptional impact on an individual's quality of life. The aim of this review article is to explore the misalignment of perceptions of severe asthma among different stakeholders to identify how to reduce burden and improve delivery of care.

Results

The misalignment of perspectives is best reflected in randomised controlled trials (RCTs) in asthma treatments, which are often designed for regulatory approval with a focus on exacerbations with no direct input from the individuals that the treatments are designed for. Based on a literature review and the clinical experience of the authors to overcome this disparity, the goals of people with severe asthma need to be incorporated throughout their care, from study design to the day-to-day management of their condition. Improved education for individuals and their support network will provide them with resources and knowledge so that they can effectively communicate their needs to other stakeholders involved in their care.

Conclusion/recommendation

A collaborative effort from all stakeholders is essential to ensure efficient management of asthma and a reduction in asthma burden on individuals and society.

Optimal Asthma Control: Time for a New Target

The stepwise approach to pharmacological treatment in adult asthma mandates that asthma treatment is progressively stepped up to achieve symptom control and reduce the risk of exacerbations and stepped down after a period of prolonged control. This review proposes that in adults without good asthma control, well-controlled asthma can only be achieved in approximately 70% of patients across the strata of severity, and only if there is a progressive increase in inhaled corticosteroid/long-acting β₂ agonist therapy to a maintenance inhaled corticosteroid dose that causes the same magnitude of systemic side effects as oral prednisone at a 5-mg daily dose. Another consideration is that in a person with asthma, there are numerous overlapping disorders that can present with symptoms indistinguishable from asthma, comorbidities that contribute to poor control and lifestyle/environmental factors that require treatment in their own right and that if specifically managed might lead to better outcomes. The disparity between patients' perceptions and guideline assessment of control may be due to partially controlled asthma being associated with near-maximal levels of quality of life, with minimal impairment. Finally, it is widely assumed that asthma symptom control equates to elimination of risk of asthma attacks, an assumption that may not apply to many patients, particularly those with more severe asthma. We propose that further research be undertaken to determine the optimal levels of asthma control and the potential value of different treatment targets, such as control of type-2 airway inflammation, that can be achieved with currently available treatment, based on efficacy, side effects, and cost.

Position statement: asthma in Latin America. IS short-acting beta-2 agonist helping or compromising asthma management?

In Latin-America, with 603 million inhabitants, the average prevalence of asthma is estimated at 17%, but with wide fluctuations, ranging from 5% in some cities (Mexico) to 30% in Costa Rica. The risk of severe exacerbations seems to be higher in Latin America compared with other regions. A majority of patients uses daily quick-relief medication, with the belief that it is the most important treatment because of its rapid onset of action; without treating the underlying inflammation. Overuse of short-acting beta₂ agonists (SABAs) is associated with increased risk of asthma deaths in a dose-response manner. Beta₂ agonists increase the severity of asthma through enhanced bronchial hyperresponsiveness and reduced lung function. Also, it has been shown that overreliance on SABA delays recognition of a potentially life-threatening asthma attack. We believe that overreliance on SABA in asthma is also an important public health issue. The fact that SABA use in GINA is not supported by a randomized trial but by an anonymous paper; makes us guess that we use SABA just because we are used to do so. In 2019 GINA strategy introduces one of the most important changes in the management of Asthma in the past 30 years, highlighting anti-inflammatory reliever therapy. A combination of low dose ICS/fast action bronchodilator will not only treat symptoms, but more importantly the underlying inflammation, protecting patients from preventable asthma attacks. After 50 years of a SABA centric approach in asthma management, it is time to leave behind a treatment based just on the bronchodilation and tackle the inflammation.

Impact of asthma control on different age groups in five Latin American countries

Background

Asthma is a chronic airway inflammatory condition of the airway and is classified as controlled, partially controlled, and uncontrolled. Patients with uncontrolled asthma are at greater risk for hospitalizations and visits to emergencies, and the condition has greater impact on their daily lives. The aim of this study was to evaluate asthma control, the use of health resources, and asthma's impact on the activities of daily living of patients with different age groups in 5 Latin American countries.

Methods

This was a retrospective analysis of The Latin America Asthma Insights and Management (LA AIM) study carried out in Argentina, Brazil, Mexico, Venezuela, and Puerto Rico. Asthmatics were splited into 3 age groups: 12–17, >17–40 and > 40 years old. An interview face to face was carried out and patients answered a questionnaire of 53 questions related to 5 main domains of asthma: symptoms, impact of asthma on daily living activities, patients' perceptions of asthma control, exacerbations, and treatment/medication.

Results

A total of 2167 asthmatics were interviewed. There was a low percentage of controlled patients (mean 9%) in all 3 groups with no particular difference among the five countries, but Venezuelan patients had a 71% chance of having uncontrolled asthma (p < 0.001).

Conclusion

In the 3 age groups, patients experienced poor asthma control, with no significant differences among the countries. Patients who used control medication had a greater chance of controlling their asthma, and those who had emergency health care visits had a greater chance of having uncontrolled asthma.

2020 Brazilian Thoracic Association recommendations for the management of asthma

The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

Evaluation of a Diagnostic Therapeutic Educational Pathway for Asthma Management in Children and Adolescents

Background: Limited evidence exists for the effectiveness of educational programs that improve pediatric asthma control in real-world settings. We aimed to assess the impact of a diagnostic, therapeutic, and educational pathway (DTEP) for asthma management in children and adolescents attending an asthma referral center. Methods: This is a retrospective population-based cohort study, including two groups of patients with asthma, aged 6-17 years and residing in the Local Health Authority (LHA) of Brescia, Italy: (a) the children who followed a DTEP (intervention group) and (b) all the children residing in the LHA who did not follow DTEP (control group). The incidence rates (IRs) of hospitalization, emergency room visit, use of outpatient services, and drug prescription for dyspnea, wheezing, or respiratory symptoms were computed for time before and after attending DTEP in the intervention group and for "early" and "late" time since asthma diagnosis in the control group. Results: There were 9,191 patients included in the study, 804 of whom followed DTEP. In the before-DTEP/early time, the intervention and control groups showed similar IRs for all the outcomes apart from emergency room visits (IRs of 138.6 and 60.3 per 1,000 person-years, respectively). The IRs decreased from before to after DTEP and from early to late time in both groups. The IR decrease for emergency room visits was significantly higher in the intervention than in the control group (-51.3 and -28.2%, respectively; IRR = 0.61, P = 0.001). Conclusion: The DTEP can increase patients' capability in managing asthma and preventing asthma attacks.

A multinational observational study identifying primary care patients at risk of overestimation of asthma control

Factors related to the discrepancy between patient-perceived and actual disease control remain unclear. Identifying patients at risk of overestimation of asthma control remains elusive. This study aimed to (i) investigate the relationship between patient-reported and actual level of asthma control (ii), compare the characteristics between patients who believe their asthma is well controlled that accurately report ‘well-controlled’ asthma with those that do not, and (iii) identify factors associated with inaccurately reported ‘well-controlled’ asthma. A historical, multinational, cross-sectional study using data from the iHARP (initiative Helping Asthma in Real-life Patients) review service for adults with asthma prescribed fixed-dose combination therapy. Data from 4274 patients were analysed. A major discrepancy between patient-reported and Global Initiative for Asthma defined asthma control was detected; 71.1% of patients who reported ‘well-controlled’ asthma were inaccurate in their perception despite receiving regular maintenance therapy. Significant differences were noted in age, gender, body mass index, education level, medication use, side effects, attitudes to preventer inhaler use, inhaler technique review and respiratory specialist review between patients who accurately reported ‘well-controlled’ asthma and those who did not. Independent risk factors associated with inaccurately reported ‘well-controlled’ asthma were: having taken a maximum of 5–12 puffs or more of reliever inhaler on at least one day within the previous 4 weeks; being female; having seen a respiratory specialist more than a year ago (rather than in the previous year); and having required oral corticosteroids for worsening asthma in the previous year. The study highlighted the significant hidden burden associated with under-recognition of poor asthma control, on the part of the patient and the need for targeted interventions designed to address the continuing discrepancy between perceived and actual disease control.

Inhaled corticosteroid use during pregnancy among women with asthma: A systematic review and meta-analysis

BACKGROUND

Studies demonstrate the prescription rate for inhaled corticosteroids (ICS) decreases in early pregnancy, possibly increasing exacerbation risk. This could be related to non-adherence to prescribed asthma medication or medication cessation by the patient or doctor. ICS use during pregnancy has not previously been summarized in a systematic review.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the use of ICS during pregnancy among asthmatic women, specifically: (1) the prevalence of use, (2) changes of use during pregnancy compared with pre-pregnancy and (3) medication adherence among ICS users.

METHODS

We systematically searched literature in Embase, MEDLINE, CINAL and Cochrane, using terms related to asthma, pregnancy and medication use. All English articles reporting ICS among pregnant women with asthma were included. Prevalence, changes in ICS use during pregnancy and ICS adherence were pooled using STATA (version 15.0, StataCorp USA).

RESULTS

A total of 4237 references were retrieved in the initial search. Screening and review led to the inclusion of 52 articles for one or more aims (Aim 1: N = 45; Aim 2, N = 13; and Aim 3, N = 5). The pooled prevalence of ICS use during pregnancy was 41% (95%CI 36%-45%); 49% (95%CI 44%-55%) in Europe, 39% (95%CI 32%-47%) in Australia and 34% (95%CI 27%-41%) in North America. In eight prescription databases, ICS prescription rates lowered in the first trimester of pregnancy, compared with pre-pregnancy, increased in the second trimester and decreased in the third trimester. Five studies reported ICS adherence among pregnant women, using four measures of self-reported non-adherence. In two comparable studies, pooled ICS non-adherence was 40% (95%CI 36%-44%).

CONCLUSIONS

The prevalence of ICS use among pregnant women with asthma is 41% and varies widely between countries and continents, and prescription rates for ICS change throughout pregnancy. More studies are needed to investigate ICS adherence during pregnancy in women with asthma.

Four seasons of Czech asthma study: asthma characteristics and management reality in the Czech Republic

Objective: To describe the characteristics and management of asthma in clinical practice in the Czech Republic in the context of international guidelines and clinical realities.Methods: Data were collected over four seasons from summer 2016 to spring 2017 and are mostly presented using descriptive statistics.Results: We obtained valid data for 4557 adult patients with asthma, including detailed phenotyping (71% eosinophilic allergic, 10% eosinophilic non-allergic, 19% non-eosinophilic non-allergic asthma) from 58 allergologists and 56 pulmonologists. The average time to diagnosis was 3 years. In more than half of the subjects, bronchodilator testing (BDT) results were available at primary diagnosis. More than 10% of physicians did not test for mold allergy. Occupational asthma was diagnosed in 0.7% of subjects. According to the attending physician, 68% of patients had well-controlled and 10% had uncontrolled asthma. Ninety-four percent of patients were on preventive treatment, with 91% using an inhaled corticosteroids (ICS) at an average dose of 705 µg/day budesonide equivalent. Approximately 75% of patients were on an ICS/LABA, with 91% using fixed combinations. Among patients using ICS/formoterol, a maintenance and reliever therapy regime was prescribed in 67%.Conclusions: The quality of asthma management in the Czech Republic is comparable to that of other developed countries and better in some respects (frequent BDT, phenotyping, and use of preventive treatment). Nevertheless, there is unnecessary delay in diagnosis and lack of research on possible environmental causes (workplace, molds). Pharmacotherapy shows good adherence to guidelines. Although 10% of patients show poor control, there is concurrently a trend for overtreatment.

A review of the burden and management of mild asthma in adults - Implications for clinical practice

Mild asthma is present in 50-75% of patients with asthma and is defined by the Global Initiative for Asthma as asthma that can be well controlled with low-intensity treatments (Steps 1 and 2). Despite this definition, 'mild' asthma is often not well controlled in reality, and can have a significant impact on an individual's symptom burden and quality of life. We performed a PubMed literature search to investigate the burden of 'mild' asthma in the lives of patients, including future risk and asthma control, and the current management strategies. While clinical guidelines recommend long-term, daily, low-dose inhaled corticosteroids (ICS) for 'mild' asthma, published data suggest that ICS are often under-prescribed or used intermittently as symptoms arise. Furthermore, patients and physicians tend to overestimate disease control, impacting the accuracy of diagnosing 'mild asthma' and subsequent management. This disconnect may be amplified by miscommunication between patients and physicians, limited objective assessment of control, and differences in guidelines. As with moderate and severe asthma, current evidence supports early initiation of regular ICS in 'mild' asthma to address the underlying inflammation, achieve symptom control and reduce risk of exacerbations. Adherence to ICS treatment is key and can be improved by educating both patients and healthcare professionals. The results of this literature search challenge the term 'mild' asthma and suggest strategies to improve the proactive management of the disease to enable patients to live symptom-free.

Asia-Pacific Survey of Physicians on Asthma and Allergic Rhinitis (ASPAIR): physician beliefs and practices about diagnosis, assessment, and treatment of coexistent disease

Background

Asthma and allergic rhinitis (AR) frequently coexist, and having both asthma and AR is associated with uncontrolled asthma and a heavier disease burden. The Asia-Pacific Survey of Physicians on Asthma and Allergic Rhinitis (ASPAIR) aimed to assess physicians’ perceptions and their management practices for patients with coexistent disease.

Materials and methods

A total of 1,204 general physicians and pediatricians from six countries in Asia, who routinely treat asthma patients, were interviewed in-person. Physicians were questioned about their attitudes and beliefs of coexistent asthma-AR, how they diagnose and treat patients, and their knowledge of international guideline recommendations.

Results

Physicians reported that 45% of their patients with asthma have coexistent AR and 37% of their patients with AR have coexistent asthma. Most physicians (77%) agreed that coexistent asthma-AR is a genuine condition and that patients suffer worse symptoms with both the conditions vs one alone (86%). Although nearly all agreed that both asthma and AR should be treated (91%) and that intranasal (INS) and inhaled corticosteroids (ICS) could be given concurrently to these patients, 40% also thought that treating both conditions effectively at the same time is difficult, and approximately a quarter believed that corticosteroid therapy should be delayed in children for both asthma and AR. While there was universal recognition and acceptance that guidelines provide sufficient information for treating uncontrolled coexistent disease (≥80% physicians in all countries), physicians revealed that 41% of their asthma patients are treated with short-acting rescue medications alone, and only 47% responded that treatment with concurrent INS and ICS, as recommended in the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines, was their preferred treatment for coexistent disease.

Conclusion

The ASPAIR survey demonstrates a widespread acceptance of coexistent asthma-AR, and the associated burden, but highlights the need for increased healthcare practitioner communication and awareness to improve appropriate treatment and management of these coexistent conditions.

STAT6 inhibitory peptide reduces dendritic cell migration to the lymph nodes to control Th2 adaptive immunity in the mouse lung

Type 2 immunity in the lung is promoted through the release of innate cytokines, including TSLP, from lung structural cells. These cytokines drive Type 2 immunity in part through upregulation of OX40L on dendritic cells (DCs). DCs expressing OX40L are potent inducers of Th2 differentiation. We have shown previously that STAT6 inhibitory peptide (STAT6-IP), a cell penetrating peptide designed to inhibit the STAT6 transcription factor, reduces the induction of Th2 adaptive immunity in murine models of respiratory syncytial virus infection. Here we show that intranasal administration of STAT6-IP at the time of antigen priming with ovalbumin (OVA), in conjunction with the Nod2 agonist, MDP, reduced frequencies of CD11b⁺ lung DCs expressing OX40L. Consistent with these reductions, fewer activated DCs were localized to the lung draining lymph nodes in STAT6-IP-treated mice. Upon OVA challenge four weeks later, mice treated with STAT6-IP at the time of OVA/MDP priming did not develop airway hyperresponsiveness (AHR) and had reduced influx of eosinophils into the airways, mucus production, and serum OVA-specific IgE levels. Our findings provide evidence that the long-lasting inhibitory effects of STAT6-IP are due in part to inhibition of DC responses that drive maladaptive Th2 adaptive immunity and allergic airways disease.

Cross-sectional study on Asthma Insights and Management in the Gulf and Russia

Background: Asthma is a chronic and complex lung disease that is not completely understood. It involves airway inflammation, reversible airflow obstruction, and bronchial hyperresponsiveness. The most common symptoms are recurrent wheezing, chest tightness, shortness of breath, and coughing. Objective: The Asthma Insights and Management study gathered information on the burden of asthma in the Gulf region (United Arab Emirates, Kuwait, Saudi Arabia) and Russia. Methods: This was a cross-sectional, multinational, noninterventional, two-phase study that collected data from patients ages ≥ 12 years, through interviews and a survey questionnaire. Phase 1 consisted of survey questions focused on estimating the asthma prevalence in the community. Phase 2 was designed to assess the level of asthma control, asthma-related perceptions and behaviors, and presentation patterns. Data were summarized by using descriptive analyses. Results: Analysis of data of 711 patients revealed that the prevalence of asthma among patients who lived in the community was 7.9% and that 66% subjectively perceived their asthma as being controlled. However, 97% of the patients' asthma were partially controlled or uncontrolled based on the Global initiative for Asthma control classification. Troubling symptoms were daytime coughing (33.3%) and shortness of breath (20.3%). With respect to medications for asthma, 76.2% of the patients reported the use of quick relief medication and 80.8% of maintenance medication during the past 4 weeks. Asthma exacerbation in the past year was reported by 40% of adults and adolescents in the study. Conclusion: The results showed that a significant proportion of the patients experienced bothersome symptoms and that many had a lack of knowledge about asthma control and treatment recommendations, which indicated that there is a need for improvements in patient education and asthma care in the Gulf and Russia regions.

Comparison of clinical characteristics and management of asthma by types of health care in South Korea

Background

Data on the clinical characteristics of asthma patients including utilization of medical facilities, disease management, and healthcare costs by types of health care are insufficient.

Methods

We evaluated data on 729,343 asthma patients from the Health Insurance Review and Assessment Service (HIRA) database of Korea between July 2013 and June 2014.

Results

Most asthma patients were treated via primary care (81.7%), followed by tertiary (17.8%) and secondary (0.5%) care. Patients requiring secondary or tertiary care exhibited more comorbidities and exacerbations than those treated via primary care, and utilized more medical facilities (associated with higher medical costs). The prescription rate of leukotriene receptor antagonists (LTRAs) was relatively high for those receiving all types of health care, ranging from 62% to 78%. However, the prescription rate of inhalants containing corticosteroids was significantly lower in patients treated via primary care than those receiving secondary or tertiary care (P<0.001). In addition, pulmonary function testing (PFT) was performed less often in patients treated via primary care than in those receiving secondary or tertiary care (P<0.001).

Conclusions

Most patients with asthma were treated via primary care; however, those receiving secondary or tertiary care exhibited substantial utilization of medical facilities with high costs. Diagnostic measures and the prescription of inhalants containing corticosteroids in primary care require urgent attention.

Continued Innovation in Respiratory Care: The Importance of Inhaler Devices

When it comes to the use in inhalers in the management of chronic obstructive pulmonary diseases, there are many options, considerations and challenges, which health care professionals need to address. Considerations for prescribing and dispensing, administering and following up, education, and adherence; all of these factors impact on treatment success and all are intrinsically linked to the device selected. This review brings together relevant evidence, real-life data and practice tools to assist health care professionals in making decisions about the use of inhalers in the management of chronic obstructive pulmonary diseases. It covers some of the key technical device issues to be considered, the evidence behind the role of inhalers in disease control, population studies which link behaviors and adherence to inhaler devices as well as practice advice on inhaler technique education and the advantages and disadvantages in selecting different inhaler devices. Finally, a list of key considerations to aid health care providers in successfully managing the use of inhaler devices are summarized.

Using medication utilization information to develop an asthma severity classification model

Background

Claims data are currently widely used as source data in asthma studies. However, the insufficient information in claims data related to level of asthma severity may negatively impact study findings. The present study develops and validates an asthma severity classification model that uses medication utilization in Taiwan National Health Insurance claims data.

Methods

The National Health Insurance Research Database was used for the years 2006–2012 and included a total of 7221 patients newly diagnosed with asthma in 2007 for model development and in 2008 for model validation. The medication utilization of patients during the first year after the index date was used to classify level of severity, and the acute exacerbation of asthma during the second through fourth years after the index date was used as the outcome variable. Three models were developed, with subjects classified into four, three, and two groups, respectively. The area under the receiver operating characteristic curve (AUC) and the Kaplan-Meier survival curve were used to compare the performances of the classification models.

Results

In development data, the distribution of subjects and acute exacerbation rate among the stage 1 to stage 4 were: 62.71%, 5.54%, 22.79%, and 8.96%, and 8.17%, 9.55%, 11.97%, and 14.91%, respectively. The results also showed the higher severity groups to be more prone to being prescribed oral corticosteroids for asthma control, while lower severity groups were more likely to be prescribed short-acting medication and inhaled corticosteroid treatment. Furthermore, the results of survival analysis showed two-group classification was recommended and yield moderate performance (AUC = 0.671). In validation data, the distribution of subjects, acute exacerbation rates, and medication uses among stages were similar to those in development data, and the results of survival analysis were also the same.

Conclusions

Understanding asthma severity is critical to conducting effective, scholarly research on asthma, which currently uses claims data as a primary data source. The model developed in the present study not only overcomes a gap in the current literature but also provides an opportunity to improve the validity and quality of claims-data-based asthma studies.

Physician perspectives on the burden and management of asthma in six countries: The Global Asthma Physician Survey (GAPS)

Background

Despite recognition of asthma as a growing global issue and development of global guidelines, asthma treatment practices vary between countries. Several studies have reported patients’ perspectives on asthma control. This study presents physicians’ perspectives and strategies for asthma management.

Methods

Physicians seeing ≥4 adult patients with asthma per month in Australia, Canada, China, France, Germany, and Japan were surveyed (N=1809; ≈300 per country). A standardised questionnaire was developed for this study and administered by telephone, online or face-to-face. Statistics were weighted to account for the sampling scheme.

Results

Physicians estimated that 71% of their adult patients received maintenance medication, with adherence monitored by 76–97% of physicians. Perceived major barriers to patient adherence included: patients taking treatment as needed; acceptance of symptoms; and patients not perceiving treatment benefits. Written action plans (37%) and technology (15%) were seldom employed by physicians to aid patients’ asthma management. Physicians rarely (10%) used validated patient-reported questionnaires to monitor asthma control, instead monitoring selected symptoms, exacerbations, and/or lung function measurements. Awareness of single maintenance and reliever therapy (SMART/MART) varied among countries (56–100%); although most physicians (72%) had prescribed SMART/MART, the majority (91%) co-prescribed a short-acting bronchodilator at least some of the time.

Conclusions

These results show that physicians generally do not employ standardised tools to monitor asthma control or to manage its treatment and that despite high awareness of SMART/MART, the strategy appears to be commonly misapplied. Better education for patients and physicians is required to improve asthma management and resulting patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0492-5) contains supplementary material, which is available to authorized users.

Disease burden of mild asthma in China

BACKGROUND AND OBJECTIVE

The impact, treatment patterns and control of mild asthma are poorly understood for Chinese patients. This study describes the characteristics, therapeutic interventions and burden of mild asthma on patients residing in major cities of China.

METHODS

The Respiratory Disease Specific Program 2015, a cross-sectional survey, was conducted with Chinese physicians and their patients. The survey assessed clinical characteristics, asthma symptoms, exacerbations, rescue inhaler usage, treatment adherence, asthma control, work and activity impairments and healthcare utilization for patients prescribed Global Initiative for Asthma (GINA) Step 1 or 2 treatment defined mild asthma.

RESULTS

From a total sample of 988 patients, 229 patients met the criteria for mild asthma, with 25.3% classified as Step 1 and 74.7% as Step 2. Overall, 12.6% of patients were considered of high adherence to prescribed treatment. Physicians reported that 75% of patients overall were well controlled, although well-controlled asthma as defined by GINA was achieved in only 14.2% of patients. 26.5% of patients indicated daily use of as-needed rescue medication in the last 4 weeks. 17.8% of patients experienced ≥1 exacerbations in the last 12 months and impaired work productivity was 27.2% overall.

CONCLUSION

Less than 15% of patients were well controlled according to GINA criteria despite physicians reporting the majority of patients were well controlled. Over one-fourth of patients relied on daily rescue inhaler medication, while exacerbation frequency and work and activity impairment were higher than might reasonably be expected in a mild asthmatic population.

Asthma hospitalisation trends from 2010 to 2015: variation among rural and metropolitan Australians

Background

Asthma remains a leading cause of illness, where primary care can assist to reduce hospitalisations through prevention, controlling acute episodes, and overall management of asthma. In Victoria, Asthma hospitalisations were as high as 3.1 hospitalisations per 1000 population in 1993–94. The primary aims of this study are to: determine if changes in asthma hospitalisations have occurred between 2010 and 2015; determine the key factors that impact asthma hospitalisation over time; and verify whether rural and urban asthma hospitalisations are disparate. A secondary aim of the study is to compare 2010–2015 results with asthma data prior to 2010.

Methods

Hospital separation data from 1 July 2010 to 30 June 2015 were obtained through the Victorian Admitted Episodes Dataset and other agencies. Data included sex, age, Local Government Area, private or public patient, length of stay, and type of discharge. Asthma and predictor variables were analysed according to hospital separation rates after adjusting for smoking and sex. Hierarchical multiple regression examined the association between asthma and predictor variables.

Results

During the study period, 49,529 asthma hospital separations occurred, of which 77.5% were in metropolitan hospitals, 55.4% hospital separations were aged 0–14 years, and 21.7% were privately funded. State-wide hospital separations were 1.85 per 1000 population and were consistently higher in metropolitan compared to rural areas (1.93 vs 1.64 per 1000 population). When data among metropolitan adults aged 15 and over were analysed, an increase in the proportion of smokers in the population was reflected by an increase in the number of hospital separations (Adj OR 1.035). Further, among rural and metropolitan children aged 0–14 the only predictor of asthma hospital separations was sex, where metropolitan male children had higher odds of separation than metropolitan females of the same age (Adj OR 4.297). There was no statistically meaningful difference for separation rates between males and females in rural areas.

Conclusions

We demonstrated a higher overall hospital separation rate in metropolitan Victoria. For children in metropolitan areas, males were hospitalised at higher rates than females, while the inverse was demonstrated for children residing in rural areas. Therefore, optimising asthma management requires consideration of the patient’s age, gender and residential context. Primary health care may play a leading role in increasing health literacy for patients in order to improve self-management and health-seeking behaviour.

Lack of asthma and rhinitis control in general practitioner-managed patients prescribed fixed-dose combination therapy in Australia

OBJECTIVES

The first aim of the study (i) assess the current asthma status of general-practitioner-managed patients receiving regular fixed-dose combination inhaled corticosteroid and long-acting beta₂ agonist (FDC ICS/LABA) therapy and (ii) explore patients' perceptions of asthma control and attitudes/behaviors regarding preventer inhaler use.

METHODS

A cross-sectional observational study of Australian adults with a current physician diagnosis of asthma receiving ≥2 prescriptions of FDC ICS/LABA therapy in the previous year, who were recruited through general practice to receive a structured in-depth asthma review between May 2012 and January 2014. Descriptive statistics and Chi-Square tests for independence were used for associations across asthma control levels.

RESULTS

Only 11.5% of the patients had controlled asthma based on guideline-defined criteria. Contrarily, 66.5% of the patients considered their asthma to be well controlled. Incidence of acute asthma exacerbations in the previous year was 26.5% and 45.6% of the patients were without a diagnosis of rhinitis. Asthma medication use and inhaler technique were sub-optimal; only 41.0% of the preventer users reported everyday use. The side effects of medication were common and more frequently reported among uncontrolled and partially controlled patients.

CONCLUSIONS

The study revealed the extent to which asthma management needs to be improved in this patient cohort and the numerous unmet needs regarding the current state of asthma care. Not only there is a need for continuous education of patients, but also education of health care practitioners to better understand the way in which patient's perceptions impact on asthma management practices, incorporating these findings into clinical decision making.

Patient adherence and effective communication

BACKGROUND

Poor adherence to inhaled corticosteroid medication is a critical problem for asthma because it contributes to morbidity and mortality through poor asthma control, frequent asthma exacerbations, acute care visits, and oral corticosteroid use.

OBJECTIVE

To discuss evidence-based, time-efficient strategies that can be adopted by most practitioners to try to increase patient adherence.

METHODS

Asthma management guidelines and other key publications are used to enhance discussion.

RESULTS

Establishing patient-centered, collaborative care that permits effective patient-practitioner communication can improve adherence, thus leading to improved asthma outcomes. One critical strategy is shared decision making, in which the patient and the practitioner share relevant information, discuss risks vs benefits of various treatment options, express treatment preferences, deliberate the options, and agree on treatment. Asthma self-management education, which emphasizes self-efficacy, is also essential. The education necessary to provide those skills depends in part on consideration of the patient's health literacy. Practitioners also have at their disposal a variety of tips and techniques to improve communication and gather information not only at the patient-practitioner level but also at the practitioner-practitioner level, such as within a group practice or within a health care system.

CONCLUSION

To improve patient adherence, clinicians need to consider a variety of factors and implement strategies that directly target underlying issues. Strategies may include customizing and simplifying learning and intervention regimens, identifying barriers to adherence and addressing them, ensuring patient support structures are in place, and improving self-efficacy and health literacy.

Asthma: epidemiology of disease control in Latin America - short review

Asthma is reported as one of the most common chronic diseases in childhood, impairing the quality of life of patients and their families and incurring high costs to the healthcare system and society. Despite the development of new drugs and the availability of international treatment guidelines, asthma is still poorly controlled, especially in Latin America. Original and review articles on asthma control or epidemiology with high levels of evidence have been selected for analysis among those published in PubMed referenced journals during the last 20 years, using the following keywords: "asthma control" combined with "Latin America", " epidemiology", "prevalence", "burden", "mortality", "treatment and unmet needs", "children", "adolescents", and "infants". There was a high prevalence and severity of asthma during the period analyzed, especially in children and adolescents. Wheezing in infants was a significant reason for seeking medical care in Latin American health centers. Moreover, the frequent use of quick-relief bronchodilators and oral corticosteroids by these patients indicates the lack of a policy for providing better care for asthmatic patients, as well as poor asthma control. Among adults, studies document poor treatment and control of the disease, as revealed by low adherence to routine anti-inflammatory medications and high rates of emergency care visits and hospitalization. In conclusion, although rare, studies on asthma control in Latin America repeatedly show that patients are inadequately controlled and frequently overestimate their degree of asthma control according to the criteria used by international asthma treatment guidelines. Additional education for doctors and patients is essential for adequate control of this illness, and therefore also for reduction of the individual and social burden of asthma.