Asthma care in resource-poor settings

Optimizing asthma care in low-to-middle income countries through multisectoral collaboration: recommendation report of the first Philippine Asthma Assembly

INTRODUCTION

Asthma is one of the most common noncommunicable diseases, raising serious concerns about asthma-related deaths globally. Studies have reported safety concerns with short-acting beta-agonists (SABAs) monotherapy. SABA overuse contributes significantly to the healthcare burden in the Philippines. Despite Global Asthma Network's years-long advocacy for equal access to essential medicines at affordable cost, the uptake of international healthcare policies is limited in most low- and middle-income countries, including the Philippines.

AREAS COVERED

We reviewed synthesis of targeted nonsystematic literature searches on prevalence of asthma and asthma-related mortality, SABA overreliance and its adverse events, alternatives to SABA, patient referral, and multidisciplinary team (MDT) approach for asthma management. We describe regional challenges and recommendations for improving asthma care through continued multisectoral collaboration.

EXPERT OPINION

Use of medications like inhaled corticosteroid-formoterol combinations may aid in reducing adverse events including severe exacerbations, hospitalizations, complications from oral corticosteroid use, and long-term treatment costs. Raising patient awareness about preventive measures, proper inhaler techniques, and medication adherence can mitigate burden of uncontrolled asthma. Improving access to asthma medications alongside developing treatment algorithms and referral pathways (including MDT) for primary care physicians will pave the way for optimal asthma care in LMICs, including the Philippines.

Global Considerations in Asthma Treatment: Management in Low Resource Settings

Low-resource settings have a disproportionately higher burden of asthma due to factors that include environmental triggers, access to healthcare, availability of medications, and uncoordinated health systems. The application of guideline-based management can vary, which further impacts the treatment delivered. This chapter aims to outline the global landscape of asthma management, including cultural and social factors, with suggestions for interventions.

Primary Care Management of Asthma Exacerbations or Attacks: Impact of the COVID-19 Pandemic

The COVID-19 pandemic has brought a renewed focus on appropriate management of chronic respiratory conditions with a heightened awareness of respiratory symptoms and the requirement for differential diagnosis between an asthma attack and COVID-19 infection. Despite early concerns in the pandemic, most studies suggest that well-managed asthma is not a risk factor for more severe COVID-related outcomes, and that asthma may even have a protective effect. Advice on the treatment of asthma and asthma attacks has remained unchanged. This article describes some challenges faced in primary care asthma management in adults and in teenagers, particularly their relevance during a pandemic, and provides practical advice on asthma attack recognition, classification, treatment and continuity of care. Acute attacks, characterised by increased symptoms and reduced lung function, are often referred to as exacerbations of asthma by doctors and nurses but are usually described by patients as asthma attacks. They carry a significant and underestimated morbidity and mortality burden. Many patients experiencing an asthma attack are assessed in primary care for treatment and continuing management. This may require remote assessment by telephone and home monitoring devices, where available, during a pandemic. Differentiation between an asthma attack and a COVID-19 infection requires a structured clinical assessment, taking account of previous medical and family history. Early separation into mild, moderate, severe or life-threatening attacks is helpful for continuing good management. Most attacks can be managed in primary care but when severe or unresponsive to initial treatment, the patient should be appropriately managed until transfer to an acute care facility can be arranged. Good quality care is important to prevent further attacks and must include a follow-up appointment in primary care, proactive regular dosing with daily controller therapy and an understanding of a patient's beliefs and perceptions about asthma to maximise future self-management.

The Care of Asthma Patients in Communities with Limited Resources

Asthma care has undergone significant changes over the past several years. Our understanding of the pathophysiology, risk factors, diagnosis, treatment, follow-up and prognosis has changed as more investigations shed new light on all of these aspects. This complexity has resulted in global guidelines aimed at improving the management of asthma patients. Among the multitude of guidelines, those published by the Global Initiative for Asthma (GINA) have achieved widespread and global acceptance. These guidelines cover the spectrum of factors that impact asthma care and include specific recommendations that treating physicians should follow to provide optimal patient care. In this review of asthma care in adult patients, we will outline some of the recommendations issued by GINA and discuss the challenges and limitations to the implementation of these guidelines in communities with limited resources. We will also propose recommendations to overcome these limitations in adult patients.

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.

Health care costs and resource utilization for different asthma severity stages in Colombia: a claims data analysis

BACKGROUND

Asthma is one of the most common chronic respiratory conditions worldwide. Asthma-related economic burden has been reported in Latin America, but knowledge about its economic impact to the Colombian health care system and the influence of disease severity is lacking. This study estimated direct medical costs and health care resource utilization (HCRU) in patients with asthma according to severity in Colombia.

METHODS

This study identified all-age patients who had at least one medical event linked to an asthma diagnosis (CIE-10: J45-J46) between 2004 and 2014. Patients were selected if they had a continuous enrollment and uninterrupted insurance coverage between January 1-2015 and December 31-2015 and were categorized into 4 different severity levels using a modified algorithm based on Leidy criteria. Healthcare utilization and costs were estimated in a 1-year period after the identification period. A Generalized Linear Model (GLM) with gamma distribution and log link was used to analyze costs adjusting for patient demographics.

RESULTS

A total of 20,410 patients were included: 69.5% had mild intermittent, 18.0% mild persistent, 6.9% moderate persistent and 5.5% severe persistent asthma; with mean costs (SD) of $67 (134), $482 (1506), $1061 (1983), $2235 (3426) respectively (p < 0.001). The mean total direct cost was estimated at $331 (1278) per patient. Medication and hospitalization had the higher proportion in total costs (46% and 31% respectively). General physician visits was the most used service (57.2%) and short-acting β-2 agonists the most used medication (24%).

CONCLUSIONS

Health services utilization and direct costs of asthma were highly related to disease severity. Nationwide health policies aimed at the effective control of asthma are necessary and would play an important role in reducing the associated economic impact.

The epidemiology of noncommunicable respiratory disease in sub-Saharan Africa, the Middle East, and North Africa

Noncommunicable diseases (NCDs) are a major and increasing global health issue. The World Health Organization (WHO) estimates that NCDs represent 63% of all global deaths of which 3.9 million are due to chronic respiratory diseases (CRDs) and Chronic Obstructive Pulmonary Disease (COPD) in particular. COPD is now the third most common cause of death globally; 90% of these deaths occur in Low and Middle Income Countries (LMICs). COPD affects 329 million people, almost 5% of the world's population. In addition, asthma affects 334 million people, again representing almost 5% of the world's population. There is limited literature published on the epidemiology of COPD and Asthma from Sub-Saharan Africa (SSA) and Middle East and North Africa (MENA). Both diseases are under-diagnosed and underestimated in both SSA and MENA regions. The burden of COPD in sub-Saharan Africa is disputed and reports offer variable prevalence estimates, ranging from 4.1% to almost 22.2%. SSA and MENA countries report similar mortality rates from COPD of 18 per 100,000 population (2001 data). Asthma is a less common cause of death than COPD but is a major cause of morbidity; WHO estimates that there are 250,000 deaths per year from asthma, mainly in LMICs and it remains in the top twenty causes of disability in children globally. Risk factors for CRD are genetic and environmental; the latter dominated by air pollution exposures including tobacco smoke, household air pollution, outdoor air pollution and occupational exposures.

Pharmacokinetic Comparison of a Unit Dose Dry Powder Inhaler with a Multidose Dry Powder Inhaler for Delivery of Fluticasone Furoate

BACKGROUND

The unit dose dry powder inhaler (UD-DPI) is being considered as an alternative inhaler platform that, if developed, has the potential to improve access to inhaled respiratory medicines in developing countries.

AIM

This study compared the systemic exposure of fluticasone furoate after delivery from the UD-DPI with that from the ELLIPTA^® inhaler.

METHODS

This open-label, five-way cross-over, randomized, single-dose study in healthy subjects evaluated fluticasone furoate systemic exposure of three dose strengths (using four inhalations), 4 × 80 μg [320 μg], 4 × 100 μg [400 μg], and 4 × 140 μg [560 μg]), and two percentages of drug in lactose blends (0.6% and 0.8% by weight) after delivery from the UD-DPI compared with systemic exposures from the ELLIPTA inhaler (4 × 100 μg [400 μg] dose, 0.8% lactose blend). The primary treatment comparisons were area under the concentration-time curve from time 0 to 6 hours [AUC_0-6] and maximum plasma concentration [C_max].

RESULTS

After single-dose administration of fluticasone furoate, systemic exposure was lower from all UD-DPI formulations versus the ELLIPTA inhaler in terms of both AUC_0-6 [AUC_0-6 geometric least squares mean (GLM) ratios confidence interval (90% CI) for: UD-DPI (400 μg 0.8% blend)/ELLIPTA: 0.61 (0.55-0.67) and C_max GLM (90% CI) for: UD-DPI (400 μg 0.8% blend)/ELLIPTA: 0.56 (0.49-0.64)]. Systemic exposures were ∼10% lower for fluticasone furoate UD-DPI for the 0.8% blend versus the 0.6% blend [GLM ratio (90% CI); 0.90 (0.81-1.00) for AUC_0-6 and 0.89 (0.77-1.01) for C_max], and increasing doses of fluticasone furoate from the UD-DPI showed systemic exposures that were approximately dose proportional. All treatments were well tolerated.

CONCLUSIONS

Fluticasone furoate systemic exposure was lower from the UD-DPI than from the ELLIPTA inhaler, but the UD-DPI formulations did demonstrate detectable systemic levels and approximate dose proportionality. Together with the good tolerability shown, these data support further evaluation of the UD-DPI as a potential device for delivering inhaled respiratory drugs.

Assessment of the efficacy and safety of fluticasone propionate and salmeterol delivered as a combination dry powder via a capsule-based inhaler and a multi-dose inhaler in patients with asthma

BACKGROUND

In developing countries, there is a need for access to affordable inhaled respiratory medicines. This study tested the clinical non-inferiority of fluticasone propionate/salmeterol combination (FSC) 50/250 μg Rotacaps^®/Rotahaler^® compared with FSC 50/250 μg Diskus^®.

METHODS

A multi-centre, randomised, double-blind, double-dummy study evaluated 12 weeks, twice daily treatment of FSC 50/250 μg administered using Rotacaps/Rotahaler or Diskus inhaler in a crossover design in patients with asthma (pre-bronchodilator forced expiratory volume in 1 s (FEV₁) 40%-85% of predicted, FEV₁ reversibility ≥12%, prior stable dose with inhaled corticosteroid (ICS) or ICS/long acting beta-agonist). The primary efficacy endpoint, change from baseline in trough morning FEV₁ at Day 85, was analysed using a model for repeated measures analysis. The pre-defined criterion for non-inferiority was the lower limit of the CI (0.025, one-sided significance level) for the treatment difference (Rotacaps/Rotahaler-Diskus) in least squares (LS) mean change from baseline, being greater than -125 mL. Secondary endpoints included serial FEV₁ measurements, morning peak expiratory flow (PEF), rescue medication use, day- and night-time asthma symptoms, Asthma Control Test (ACT) scores, and serial cortisol measured over 12 h (area under the curve (AUC_0-12)).

RESULTS

Treatment with FSC 50/250 μg via Rotacaps/Rotahaler or Diskus resulted in a similar LS mean increase from baseline in trough FEV₁ at Day 85 (231 mL and 203 mL respectively). The difference in the model-adjusted LS mean change was 28 mL (95% CI -24 mL, 80 mL), fulfilling the criterion for non-inferiority. Data for all secondary endpoints were similar for the two treatments, supporting the primary endpoint findings. Both treatments were well tolerated and demonstrated similar safety profiles.

CONCLUSION

This study demonstrated the clinical non-inferiority of FSC 50/250 μg when administered using Rotacaps/Rotahaler compared with administration using Diskus in patients with asthma, and suggests there is no difference in the risk:benefit profile between the two FSC inhalers.

Asthma insights from Jordan: cross-sectional observational study

OBJECTIVE

The burden of uncontrolled asthma on patients in Jordan is largely unknown. This study assessed different aspects of asthma clinical features: the level of asthma control, its correlation with quality of life, and possible predictors of asthma control.

METHODS

Face-to-face interviews with asthmatic patients (≥16 years old) in north Jordan from 2013 to 2014 were conducted. Outcomes measures were assessed using the asthma control test (ACT), the mini asthma quality of life questionnaire (mini-AQLQ), and the Generic health-related quality of life (EQ-5D). The relationship between asthma control and quality of life was examined using Spearman's correlation coefficient. Predictors of asthma control were determined using multivariable logistic regression adjusted for confounders.

RESULTS

A total of 255 patients were recruited (mean age 45.16 years, 74.5% female). Approximately one-third of subjects (30.6%; n = 78) had controlled asthma (ACT ≥ 20). A strong correlation between asthma control and both mini-AQLQ and EQ-5D scores was identified (p < 0.001). Subjects who required to step-up treatment (OR = 0.12, 95% CI: 0.02-0.63, p = 0.01) and with acute asthma exacerbation (OR = 0.32, 95% CI: 0.18-0.58, p < 0.001) were independently associated with poor asthma control.

CONCLUSIONS

Most of the recruited patients have not achieved optimal asthma control and was associated with low quality of life. The study highlights that even in low-income countries, a simple assessment tool such as the ACT can be utilized to screen and categorize asthma control. This approach would facilitate a better treatment plan and eventually improve asthma control and quality of life in asthma patients.

Montelukast for the high impact of asthma exacerbations in Venezuela: a practical and valid approach for Latin America?

Background

Asthma affects mainly Venezuela’s urban and poor majority. Exacerbations bring about a high demand in health services, thus becoming a significant public health problem. In general, asthma control programs (GINA) with use of inhaled steroid medications have proven effective, although their implementation in real life remains cumbersome. Montelukast could be a useful and practical tool for these deprived socioeconomic sectors.

Methods

This real-life pilot study was conducted in a prospective, double blinded, placebo-controlled manner with randomized and parallel groups. Asthmatics that had never used leukotriene modifiers were recruited and followed-up every three months. The main outcome was the number of exacerbations meriting use of nebulized bronchodilators administered by the health care system.

Results

Eighty-eight asthmatic patients were enrolled, between children and adults. Groups were comparable in: demographic data, previous use of other medications, ACT scores, pulmonary functions (Wright Peak Flow meter), allergy status (Skin Prick Test) as well as adherence to the prescribed Montelukast treatment. By an intention to treat (ITT), a total of 64 patients were included for analysis. For the three and six months time points the difference between placebo and Montelukast was found to be significant (p < 0.03 and p < 0.04, respectively). Such trends continued for the rest of the year, but without statistical significance, due to patient attrition.

Conclusions

This real-life pilot study shows that a simplified strategy with oral Montelukast was practical and effective in controlling exacerbations in an asthmatic population of a vulnerable community from Caracas. Such an approach reinforces the role of primary care in asthma treatment.