This year’s World Asthma Day is dedicated to uncovering misunderstandings in asthma and disseminating accurate information to patients, prescribers and caretakers. In this blog, the editor-in-chief of Asthma Research and PracticeAndras Bikov discusses the common misconception that the only necessary treatment for mild asthma is an inhaler.
Despite the prevalence of asthma, there are still many misunderstandings about treatment and the correct use of drugs. The goal of World Asthma Day 2021 is to dispel these misunderstandings.
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Asthma affects over 10% of the world’s population and is the most common chronic disease in children. Despite the spread of this disease, there are still a lot of misunderstandings about the treatment and proper use of drugs.
Treatments for Asthma
The two main characteristics of asthma are chronic inflammation and repeated narrowing of the airways. For efficient and successful treatment both these symptoms need to be addressed. Anti-inflammatory drugs like inhaled corticosteroids (ICS) are used as “control drugs” to treat inflammation, and bronchodilators like short-acting beta2 agonists (SABA), also called reliefs, help widen the airways. These two drugs have long been the mainstays for the treatment of asthma.
Using an aid without control drugs has become common practice.
However, to get the highest success rate, they must be used together. Unfortunately, this doesn’t always happen – instead, using a non-control drug device has become a common practice.
There are many reasons for that. For example, many asthma patients are concerned about the side effects of corticosteroids (ICS) such as osteoporosis, cataracts, infections, or oral thrush. In addition, short-acting bronchodilators like SABAs work quickly and provide relief more quickly than anti-inflammatory drugs, which take longer to show signs of improvement.
However, this is not good practice, even for people with mild asthma. People with mild asthma have asthmatic symptoms, but very rarely. These symptoms often occur in special circumstances, such as: B. in the environment or in the allergy season.
Previous evidence shows that these people are still at high risk for fatal exacerbations and using short-acting bronchodilators without ICS is not without its risks. Patients receiving this therapy are at greater risk of hospitalizations, near-fatal asthma attacks, and deterioration in lung function. In addition, frequent use of SABA can lead to airway hyperactivity, which can lead to more severe symptoms and lead to patients developing tolerance to the treatment. This means that higher doses of SABA are required to get the same effect.
In addition, we have to accept that chronic inflammation in the airways is also present in patients with rare or mild symptoms. If left untreated, it can cause potentially irreversible destruction and reshaping of the airways. ICS treatment also has its advantages. Early anti-inflammatory treatment has been associated with better lung function and lower future ICS dose requirements. In other words, anti-inflammatory treatment not only prevents exacerbations, but also mitigates the long-term damage caused by an event.
Anti-inflammatory treatment (ICS) not only prevents exacerbations, but also alleviates the long-term damage caused by an event.
The blame is not just on the patient, however. In fact, most national and international guidelines have endorsed the use of SABAs independently of anti-inflammatory agents for the treatment of mild, intermittent asthma. This is worrying as it leads to bad practices by prescribers who may start treatment without a solid diagnosis of asthma and who may not consider and monitor the long-term risks of SABA treatment. It also sends conflicting messages to patients that their asthma does not require controller medication, so the process of starting them with a controller in the future could pose some challenges.
What can we do to convince patients to change their practice? The Global Asthma Initiative has endorsed a strategy to address this problem. They suggest starting treatment with ICS-formoterol, a fast-acting long-acting beta2 agonist, instead of the typical short-acting beta2 agonist (SABA) as an adjuvant.
Maintenance use of ICS-formoterol combinations has long been recognized as beneficial for some patients with asthma. More recently, however, these combinations have become available as aids for patients with mild asthma. These patients do not need to use maintenance therapy, only the ICS-containing agent. Clinical studies have shown that the use of an ICS-SABA reliever was associated with better control of asthma and a lower rate of exacerbations compared to SABA alone.
It is also very important to be honest about the possible side effects of ICS. About 90% of asthma patients experienced at least one mistake while using their inhaler, and almost half of asthma patients experience oral side effects such as cough, voice changes, loss of taste, or thrush. These problems can easily be minimized by giving the lowest dose of ICS possible, promoting proper oral hygiene, and educating patients and their caregivers on the correct inhalation technique. Proper training from asthma nurses has been shown to result in better technique, lower symptom scores, and fewer side effects.
Clear discussion of the risks of SABA treatment and further studies on mild asthma are unmet needs. On this World Asthma Day as editor-in-chief for Asthma Research and PracticeI welcome submissions on these and other topics dedicated to clearing these misconceptions about asthma treatment and providing education to patients, prescribers, and caretakers.