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Holiday from drugs? A big NO for asthma control! By Shobha Shukla

An estimated 300 million people are living with asthma worldwide with an additional 100 million new cases expected to be added by 2025. WHO estimates that 15 million disability adjusted life years (DALYs) are lost annually because of this chronic disease that kills an estimated 250,000 people annually? The Sustainable Development Goals (SDGs) hold the promise of reducing deaths from non-communicable diseases (NCDs) by one third by 2030 - a tall order indeed, as far as asthma is concerned.

Global Initiative for Asthma (GINA) guidelines say that asthma management should be based on achieving and maintaining complete asthma control. But an increasing body of evidence suggests that asthma is under-treated and uncontrolled in many parts of the world. Achieving good control of asthma will lead to fewer exacerbations and is also associated with less airway inflammation. Good control will require stepping up treatment, especially in those patients who are more severe, and then stepping down, once good control is established.

Dr PK Thomas, a respiratory physician of Chennai, gave an overview of the status of asthma control in India during the 18th National Conference on Pulmonary Diseases (NAPCON 2016) held in Mumbai. He said that while earlier studies reported a median prevalence of 3% - more than 30 million Indians living with asthma - growing evidence suggests that this is a gross underestimate. Despite availability of reliable diagnostic tools, effective and affordable inhaled drugs, and qualified doctors, asthma remains to be poorly managed in India, with 45% of asthma patients not ever had a lung function test done. The economic burden of asthma in India is estimated to be huge: INR 4852.86 crores (INR 48.5 billion) in 2016, he said.

Dr Thomas referred to the Asia Pacific-Asthma Insights and Management (AP-AIM) India Study that highlights that asthma management in India remains very poor. Even though 91% of the patients perceived their asthma to be under complete or partial control, when analysed using GINA guidelines, none of them had completely controlled asthma, 60% had partly controlled asthma and 40% uncontrolled asthma. 64% patients believed that regular controller medication for asthma is not required and 50% had apprehensions about the use of inhaled corticosteroids.

While the key treatment for asthma is inhaled corticosteroid (ICS) therapy, only about one third of India’s asthma patients use them, with a majority preferring the oral route of medication. Even among those on inhaler therapy, 75% either overuse or underuse inhaled corticosteroids. The result is that a large proportion of patients lead a worsened quality of life.

According to Dr Thomas, poor asthma management in India is due to lack of adequate knowledge and awareness about diagnosis and treatment management of asthma. Many patients remain undiagnosed or wrongly diagnosed in clinical practice; and even those who get diagnosed are poorly or inadequately treated. There is clearly a need to change the mindset of the Indian patients and educate them that suffering is not a norm for asthma and that with proper treatment and regular use of inhaled medications, most of them can lead a near normal and healthy life.

In an exclusive interview with CNS (Citizen News Service), Dr Paul Jones, Emeritus Professor of Respiratory Medicine at St George's University London said that if asthma is not treated properly it can lead to long term damage to the lungs. However, good control of asthma is possible anywhere. ICS therapy is the cornerstone of asthma control and should continue lifelong. No Drug holidays off ICS treatment, he insisted.

Studies indicate that if a country simply gets all asthma patients to use ICS, rates of hospital admission and asthma deaths drop significantly. Recognising that proper management could entail out of pocket costs to asthma patients in countries like India, Jones said that one should remember that poorly controlled asthma results in a lot more hospital admissions, and that will cost the patient a lot more than what is needed for daily use of ICS therapy.

Asthma is a complex disease. Apart from being genetic, it can also be caused by early childhood exposure to different factors such as maternal smoking (even before the baby is born), or paternal smoking and childhood exposure to organic matter. There is some evidence that children who grow up on farms have less asthma than those who grow up in urban areas. Perhaps, one of the reasons why asthma is getting more common in urban areas is that people are now living in cleaner homes and so immune systems of children are developing differently. Smoking cessation is one life style change that, along with medication, can really help people control their asthma, stressed Jones.

Asthma in children and in adults needs to be managed and treated differently. “A significant proportion of children with asthma will remit for a very long time, whereas once an adult has asthma, they have it for the rest of their lives, unless it is of an extremely mild form. The pharmacological treatment of asthma in adults and children is different too. In adults the most effective treatment is a combination of ICS and long-acting Beta-agonist bronchodilators (LABA), whereas in children treatment should be based on use of ICS alone. Use of LABA in children results in increased hospitalisations and exacerbations. Even in adults, whose asthma is adequately controlled through ICS, LABA should not be used along with ICS. Use of SMART (single maintenance and reliever treatment) with LABA alone, without use of a long-term asthma control medication, is associated with poor control and more airway inflammation as compared to control directed fixed dose inhalers”.

Moreover, while adult patients need to be on ICS medication all the time, there is evidence that children can be on ICS for a duration—few months or even a year or two—when their asthma is troublesome and then can stop the ICS if, and only if, their asthma is completely controlled—no symptom at all— over a long period of time, explained Jones.

Asthma, like other chronic diseases, is not curable but it is very much controllable. Persons living with asthma can lead a near to normal life just through proper asthma management. There is more realisation now that severe lung diseases like asthma and COPD are related to poor asthma control in children. So we must really focus our attention to controlling asthma in children better than before.