ORIGINALLY PUBLISHED
13 September 2021
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Surveillance data from both Europe and the US have shown that nearly half of asthma patients remain uncontrolled on their current treatment.1-3 Patients with asthma are at risk of asthma exacerbations (attacks), regardless of age, severity, adherence to controller medication, or asthma control.1,4,5 Exacerbations are a major cause of morbidity and mortality;6 even patients diagnosed with mild asthma are at risk of an exacerbation.4
There are an estimated 136 million asthma exacerbations globally per year,7 with the worldwide annual number of emergency room visits due to asthma an estimated 116 million.8 In the US, there are more than 10 million exacerbations per year,9 resulting in more than 1.8 million visits to emergency department,9 170,000 hospitalisations9 and more than 4,000 deaths.9
These attacks are both physically threatening and emotionally significant for many patients10 and can be fatal.11,12
Beyond the emotional and physical cost, poorly managed asthma also carries a hefty economic and societal burden. When accounting for the amount spent annually on asthma-related medication and hospital admissions, as well as indirect costs such as lost work and school days, this puts a significant strain on not only the people living with this disease and their families, but also on healthcare systems.12
SABA-only approach shown to leave patients at risk of asthma attacks
Asthma is a chronic, inflammatory respiratory disease with variable symptoms.6,12 This inflammation drives airway narrowing and exacerbations, resulting in asthma symptoms.13
Many patients with asthma use short-acting beta2-agonist (SABA) rescue inhalers (or bronchodilators), such as albuterol*, to treat their disease.14-16 Though a SABA provides fast symptom relief, it does not address the underlying inflammation, leaving patients at risk of severe exacerbations.17 Exacerbations that in turn can result in impaired quality of life,18 frequent oral corticosteroid (OCS) use19 and hospitalisation.19
In the US, around 44% of patients across all asthma severities exacerbated once or more over a 12-month period, regardless of SABA or maintenance use,20 often requiring a short course of OCS to bring their symptoms under control.21
Even short-term treatment of exacerbations with OCS is associated with an increased risk of adverse health conditions, including type 2 diabetes, depression/anxiety, renal impairment, cataracts, cardiovascular disease, pneumonia and fracture.6,22,23 These adverse effects can further add to the burden of asthma.
SABA use of more than three canisters per year is associated with an increased risk of exacerbations, independent of asthma control and maintenance therapy with an inhaled corticosteroid (ICS).24,25 Data from the largest real-world observational analysis of asthma inhaler therapy, SABA Use IN Asthma (SABINA), showed that in Europe and North America, the incidence of severe exacerbations increased with increasing SABA canister prescription/possession, independent of maintenance therapy.24,25 Data from the UK showed that using three or more SABA inhalers a year resulted in a 20% increased risk of exacerbations in people with mild asthma and a 24% increased risk in people with moderate to severe asthma.26
Ensuring clinical guidelines are put into practice
International recommendations from the Global Initiative for Asthma (GINA) recommend anti-inflammatory rescue therapy to treat symptoms and inflammation concomitantly, and treatment with a SABA alone is no longer recommended.6 The National Asthma Education and Prevention Programme (NAEPP) guidelines in the US conditionally recommend either daily low-dose ICS and as-needed SABA for quick relief therapy, or as-needed ICS and SABA used concomitantly for individuals aged 12 years and older with mild persistent asthma to reduce the risk of exacerbations.27
However, patients become attached to their SABA rescue inhaler, believing it is the best way to control their asthma. Patient behaviour underestimates the need to take daily maintenance medication and prioritises quick relief when needed. In one survey, 90% of patients reported they want treatments that provide immediate relief and 34% said they used less maintenance medication (which is usually prescribed alongside their SABA inhaler) when they felt well.28
Early reliance by patients on SABA is quickly established as it is often the first medicine prescribed and because it provides rapid relief from the breathlessness symptoms they experience.29-31 This means that during symptom onset, many patients instinctively reach for their SABA inhaler.
The rationale for prescribing a combination of an ICS and a bronchodilator together is that it aligns with the patients’ preference for an as-needed treatment approach for their asthma, driven by day-to-day symptom levels and following their natural behaviour to treat symptoms as and when they arise. However, at the same time, it also provides treatment for elevated airway inflammation when it is needed most.29,32
What needs to change in asthma management?
Far too many people with asthma have their lives disrupted by exacerbations that could be prevented. A combined approach focusing on inhaled combination medicines that provide symptom relief whilst also addressing underlying inflammation should be central to asthma management to optimise patient outcomes.
Strategies to achieve better outcomes for patients will also need to include increased awareness of the risks of using a SABA alone to manage asthma, as well as careful monitoring of SABA use to help identify those patients at risk of future exacerbations.
*Albuterol is also known as salbutamol
References
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Veeva ID: Z4-51128
Date of preparation: December 2022