Recent research in Kenya has highlighted the issue of over-prescription and over-use of asthma inhalers – used by millions of sufferers worldwide – with experts saying this can put people at risk and compromise their long-term health.
In South Africa, asthma affects more than 20% of children and 10%-15% of adults, with an alarming number of deaths occurring annually.
Apart from the inhalers masking the severity of an asthma attack, frequent or unnecessary use can reduce their effectiveness over time, leading to diminished symptom control and the need for higher doses of medication – further exacerbating potential side effects (tachyphylaxis or tolerance), and increasing the potential for the body to become less responsible to the medication.
Inhalers contain bronchodilators, usually a short-acting beta-agonist (SABA) which works by relaxing the muscles in the airways, making it easier to breathe during an asthma attack.
The latest research – the recently published SABINA III study – flags the issue of over-prescription and over-the-counter purchase of these reliever pumps, despite new treatment guidelines.
Professor Ismail Kalla, a pulmonologist and HoD of Internal Medicine at the University of Witwatersrand, said asthmatic patients have been overusing their blue SABA symptom-reliever inhalers for decades, in the mistaken belief that it was the best way to control symptoms, he told IOL.
In line with new global and locally endorsed asthma treatment guidelines, a low-dose inhaled corticosteroid (ICS) formoterol therapy is now recommended as needed, regardless of asthma severity.
This combination inhaler contains an anti-inflammatory agent that reduces airway inflammation and provides controlled relief.
The SABINA III study, published in BMC Primary Health Care, reveals a slow adoption of new guidelines, showing that nearly 75% of patients had used more than three SABA canisters in the past year, and more than 55% of them were prescribed more than 10 canisters.
The research team also found that more than 50% of patients with mild asthma had uncontrolled symptoms.
Poor adherence to maintenance medication is believed to be the main reason for this continued lack of control.
“A global study found that excessive inflammation causes 176m asthma attacks annually. These attacks can be frightening, dangerous, and costly for the patients,” said Kalla.
To educate people living with asthma, and to help them reduce their risk of attacks, AstraZeneca is running the Break Over-Reliance campaign, through which they can assess their levels of over-reliance via the digital assessment tool called the Reliever Reliance Test.
This evidence-based questionnaire empowers patients to assess their over-reliance on their blue reliever inhaler, SABA, by answering five short questions, and Kalla urged asthmatics to take the test.
“When you consider South Africa’s prevalence of asthma is among the highest in the world, the case for better control is urgently needed,” he said.
Study details
Over-prescription of short-acting β2-agonists remains a serious health concern in Kenya: results from the SABINA III study
Jeremiah Chakaya, Jared Mecha & Maarten Beekman.
Published in BMC Primary Health Care on 8 July 2023
Abstract
Background
Despite a high asthma burden in Kenya, insights into asthma management practices, including prescription of short-acting β2-agonists (SABAs), are lacking. Therefore, this study describes patient demographics, disease characteristics, and asthma treatment patterns in the Kenyan cohort of the SABA use IN Asthma (SABINA) III study.
Methods
Patients with asthma (aged ≥ 12 years) with medical records containing data for ≥ 12 months prior to the study visit from 19 sites across Kenya were included in this cross-sectional study and classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma [GINA] recommendations) and practice type (primary/specialist care). Data on severe exacerbation history, prescribed asthma treatments, and over-the-counter (OTC) SABA purchases in the 12 months before the study visit and asthma symptom control at the time of the study visit were collated using electronic case report forms. All analyses were descriptive in nature.
Results
Overall, 405 patients were analysed (mean age, 44.4 years; female, 68.9%), of whom 54.8% and 45.2% were enrolled by primary care clinicians and specialists, respectively. Most patients were classified with mild asthma (76.0%, GINA treatment steps 1−2) and were overweight or obese (57.0%). Only 19.5% of patients reported full healthcare reimbursement, with 59% receiving no healthcare reimbursement. The mean asthma duration of patients was 13.5 years. Asthma was partly controlled/uncontrolled in 78.0% of patients, with 61.5% experiencing ≥ 1 severe exacerbation in the preceding 12 months. Crucially, 71.9% of patients were prescribed ≥ 3 SABA canisters, defined as over-prescription; 34.8% were prescribed ≥ 10 SABA canisters. Additionally, 38.8% of patients purchased SABA OTC, of whom 66.2% purchased ≥ 3 SABA canisters. Among patients with both SABA purchases and prescriptions, 95.5% and 57.1% had prescriptions for ≥ 3 and ≥ 10 SABA canisters, respectively. Inhaled corticosteroids (ICS), ICS with a long-acting β2-agonist fixed-dose combination, and oral corticosteroid bursts were prescribed to 58.8%, 24.7%, and 22.7% of patients, respectively.
Conclusions
SABA over-prescription occurred in almost three-quarters of patients, with over one-third of patients purchasing SABA OTC. Therefore, SABA over-prescription is a major public health concern in Kenya, underscoring an urgent need to align clinical practices with latest evidence-based recommendations.
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