Asthma continues to be a significant problem globally, and the Global Asthma Report lists it as the 14th most important disorder in the world in terms of the extent and duration of disability.
While current treatment programmes are effective for patients with mild-to-moderate asthma, patients who fail to control their disease can escalate to acute asthma or even become unresponsive to current treatment efforts, placing them at increased risk of dying from the disease.
Reasons for poor asthma control
This is according to Professor David Price, Professor of Primary Care Respiratory Medicine at the University of Aberdeen, who presented on the topic "Beyond the Inhaler: Existing Solutions and Trends" at the recent Cipla Respiratory Symposium, which took place in Cape Town on 24 September.
He states that some of the reasons poor asthma control is experienced across the globe include: poor disease control practices; incorrect estimation of disease severity and risk; inadequate symptom control; incorrect use of medication; poor inhaler technique; or a lack of written and personalised asthma action plans. “One vital aspect that has to be improved across the board is communication activities with regards to asthma treatment guidelines.”
He explains that an analysis of real-world primary care patients proved that the odds of achieving asthma control are significantly better for patients initiating ICS (inhaled corticosteroid) therapy via a breath-actuated device (BAI) or a dry power inhaler, compared with a pressurised metered-dose inhaler (pMDI), as well as patients who receive an ICS dose increase via BAI compared with a pMDI.
“Inhaler errors and non-adherence to treatment are the key contributors to poor asthma control. Treatment adherence and inhaler errors have a direct effect on the asthma patient’s outcome. However, new approaches to asthma disease treatment and management are changing the way forward for asthma patients,” he says.
Summary of the evolution of asthma treatment:
1860: At this time the patient had many treatment options to choose from such as smoking stramonium, lobelia or belladonna, or even inhaling ether, chloroform or potassium nitrate fumes. Some doctors may have recommended bleeding, vomiting, emetics, coffee, or a random assortment of products that most probably would not give the patient much relief. Atropine was isolated in 1833 and was readily available as a treatment option to inhale via pipes or cigars.
1910: Epinephrine was used in nebulizers to immediately relieve the effects of an asthma attack. These nebulizers were large, made of glass and the medicine had to be inhaled by squeezing a rubber bulb.
1955: Epinephrine and Isoetharine were available as an inhaler which could be carried by the patient in their pocket. Patients were now able to get instant relief anywhere and anytime. More patients also started taking Theopylline, a pill that improved breathing when taken four times a day.
1970: Terbutaline, a rescue medicine, was introduced to the market and it was stronger than Isoetharine as it lasted 4–6 hours. Terbutaline was later available as an inhaler, called Brethine, Bricanyl or Brethaire.
1982: A new drug, Albuterol, was approved by the Food and Drug Administration and soon became the most popular asthma medicine. The patient got his breath back instantly after an asthma attack and experienced hardly any side effects. It was initially only available as a solution, but inhalers were soon developed. Albuterol continues to be the rescue medicine of choice.
1989: New asthma guidelines recommended that the focus change from treating the symptoms of asthma to preventing it. At this stage, Beclomethasone, Triamcinolone and Flunisolide were the top line asthma medicines to treat chronic asthma.
1994: Salmeterol (Serevent) was introduced to the market as another treatment option. It is a long-acting beta adrenergic that keeps the lungs open for up to 12 hours. It only has to be taken twice a day to prevent asthma symptoms.
1998: Studies showed that asthmatics may benefit from taking beta adrenergic and an inhaled corticosteroid. Only one medicine at that time combined both these medicines and it quickly became the top line medicine to prevent asthma. At this stage a patient’s asthma was so controlled that they hardly ever needed to use an inhaler.
1999: Levalbuterol was another rescue medicine available to patients. Some said that it was stronger than Albuterol with fewer side effects, but the cost of this medicine was much higher.
The present: Currently the focus lies in controlling asthma with preventative medicine, and only using rescue medicine to treat acute asthma symptoms.
“The issue that remains is that asthma control is poor and a major reason is inhaler technique. This needs to be addressed with real urgency and more scrutiny. Patients should at least be in a position where they have access to the most appropriate inhalers for their specific needs and be able to operate their personal devices, as this is quite an unavoidable issue,” urges Professor Price.
Paul Miller, CEO of Cipla SA concludes that; “As we are all interested and invested in the advancement of respiratory care, it is vital to collaborate on the latest information on asthma and allergies to improve patients’ access to proper treatment methods.”
Cipla Respiratory Symposium