Improved asthma control is an urgent need worldwide, particularly in children and in less affluent countries, says a group of scientists after a recent global cross-sectional study. They suggest that boosting the availability and affordability of inhaled medicines in less affluent countries should be a priority.
The management and control of asthma across age groups is often inadequate, especially in lower-income nations, they added, with income levels, access to drugs and the condition’s management plans all playing an important role, reports Medpage Today.
Across the 25 nations included in the study of more than 25 000 people with asthma confirmed by a doctor, plans to assist in the management of symptoms were used in 62.8% of children, 53.4% of adolescents, and 47.4% of adults, reported Luis García-Marcos, PhD, of the University of Murcia in Spain, and colleagues from the Global Asthma Network Phase I Study Group.
Well-controlled asthma was seen in 44.1% of children, 55.4% of adolescents, and 61.1% of adults, they wrote in The Lancet Global Health.
Across the three age groups, patients in low- or middle-income countries had a higher likelihood of poor asthma control compared with those in high-income nations: children: adjusted OR 2.33 (95% CI 1.32-4.14); adolescents: OR 3.46 (95% CI 1.83-6.54); adults: OR 4.86 (95% CI 2.55-9.26).
Regardless of asthma severity and country income level, those on a management plan in each age group were nearly twice as likely to be on oral medicine for their asthma and more than twice as likely to receive inhaled treatments.
Among those who did use medication, the most common were inhaled corticosteroids and inhaled short-acting β2 agonists (SABA), with medication use tending to increase directly with the severity of symptoms for participants in each age group. However, 44.8% of children, 60.1% of adolescents, and 55.8% of adults with severe asthma were not on inhaled corticosteroids.
“This lack of control in many asthma cases causes an enormous morbidity,” García-Marcos said. “You shouldn’t, apparently, have any mortality from asthma, but in fact you’ve got it, and those deaths are probably perfectly avoidable if we use treatments correctly.”
“Inadequate asthma control result from several factors, like doctors not following guidelines or strategies, poor adherence by patients to the recommended treatment regimen (including inhaler technique), poor access to healthcare, unavailability or unaffordability of essential asthma medicines, or a combination of these factors,” the study authors wrote.
“Many studies have addressed ways of improving adherence in the past two decades. Individual and community-based interventions to improve awareness, adherence and availability of medicines usually yield good results, as measured by access to medicines, reduced emergency visits and hospitalisations, or improved quality of life.”
Study co-author Refiloe Masekela, PhD, of the University of KwaZulu-Natal, South Africa, said all patients with asthma should have an action plan: “Whether you have an exacerbation, you should know which medication to use for an attack, how often to use it, when to present to a doctor.”
She noted that in the lower-income countries especially, it seemed to be only patients with more severe symptoms who had these plans. “That also just talks to one of the gaps needing to be addressed – that we are not giving enough, or sufficient, education to our patients to have access to these,” she said.
In an editorial accompanying the research, Mariëlle Pijnenburg, PhD, of the University Medical Centre Rotterdam in the Netherlands, and Dr Ian Pavord of the University of Oxford in England, called for improved access to healthcare to help combat asthma severity worldwide.
“Increased availability and affordability of asthma medications, improved implementation of guidelines, objective asthma diagnosis, and biomarker-guided management could help reduce the global burden of asthma,” they wrote. “If these strategies are implemented, we might finally see a global survey showing improvements in outcomes.”
Pavord and another group of researchers recently proposed a single-page guide, published in The Lancet Respiratory Medicine, containing diagnostic and therapeutic approaches to facilitate the implementation of current asthma guidelines in non-specialised settings, where patients often receive care.
There are several limitations to the study, the group noted, including that information on asthma severity was linked with medicine use, so changes as a result of treatment could not be assessed. They added that recall bias may have affected results as well.
Study details
Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study
Luis García-Marcos, Chen-Yuan Chiang, Innes Asher, Guy Marks, Asma El Sony, Refiloe Masekela, et al.
Published in The Lancet Global Health in February 2023
Summary
Background
Asthma is one of the most common non-communicable diseases globally. This study aimed to assess asthma medicine use, management plan availability, and disease control in childhood, adolescence, and adulthood across different country settings.
Methods
We used data from the Global Asthma Network Phase I cross-sectional epidemiological study (2015–20). A validated, written questionnaire was distributed via schools to three age groups (children, 6–7 years; adolescents, 13–14 years; and adults, ≥19 years). Eligible adults were the parents or guardians of children and adolescents included in the surveys. In individuals with asthma diagnosed by a doctor, we collated responses on past-year asthma medicines use (type of inhaled or oral medicine, and frequency of use). Questions on asthma symptoms and health visits were used to define past-year symptom severity and extent of asthma control. Income categories for countries based on gross national income per capita followed the 2020 World Bank classification. Proportions (and 95% CI clustered by centre) were used to describe results. Generalised structural equation multilevel models were used to assess factors associated with receiving medicines and having poorly controlled asthma in each age group.
Findings
Overall, 453 473 individuals from 63 centres in 25 countries were included, comprising 101 777 children (6445 [6·3%] with asthma diagnosed by a doctor), 157 784 adolescents (12 532 [7·9%]), and 193 912 adults (6677 [3·4%]). Use of asthma medicines varied by symptom severity and country income category. The most used medicines in the previous year were inhaled short-acting β2 agonists (SABA; range across age groups, 29·3–85·3% participants) and inhaled corticosteroids (12·6–51·9%). The proportion of individuals with severe asthma symptoms not taking inhaled corticosteroids (inhaled corticosteroids alone or with long-acting β2 agonists) was high in all age groups (934 [44·8%] of 2085 children, 2011 [60·1%] of 3345 adolescents, and 1142 [55·5%] of 2058 adults), and was significantly higher in middle-to-low-income countries. Oral SABA and theophylline were used across age groups and country income categories, contrary to current guidelines. Asthma management plans were used by 4049 (62·8%) children, 6694 (53·4%) adolescents, and 3168 (47·4%) adults; and 2840 (44·1%) children, 6942 (55·4%) adolescents, and 4081 (61·1%) adults had well controlled asthma. Independently of country income and asthma severity, having an asthma management plan was significantly associated with the use of any type of inhaled medicine (adjusted odds ratio [OR] 2·75 [95% CI 2·40–3·15] for children; 2·45 [2·25–2·67] for adolescents; and 2·75 [2·38–3·16] for adults) or any type of oral medicine (1·86 [1·63–2·12] for children; 1·53 [1·40–1·68] for adolescents; and 1·78 [1·55–2·04] for adults). Poor asthma control was associated with low country income (lower-middle-income and low-income countries vs high-income countries, adjusted OR 2·33 [95% CI 1·32–4·14] for children; 3·46 [1·83–6·54] for adolescents; and 4·86 [2·55–9·26] for adults).
Interpretation
Asthma management and control is frequently inadequate, particularly in low-resource settings. Strategies should be implemented to improve adherence to asthma treatment guidelines worldwide, with emphasis on access to affordable and quality-assured essential asthma medicines especially in low-income and middle-income countries.
The Lancet accompanying editorial – Progress to be made in asthma management (Open access)
The Lancet Respiratory – A2BCD: a concise guide for asthma management (Open access)
Medpage Today article – Asthma Control Worldwide Remains Less Than Ideal (Open access)
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