Asthma management in the Asia–Pacific region

Authors


  • Conflict of interest statement: L.B. has received speaker honorary and has been on the advisory board of AstraZeneca, GlaxoSmithKline and Boehringer Inghelheim.

Abstract

See article, Volume 18 Number 6 page 957

Philip Thompson and colleagues report on the Asthma Insight and Management (AIM) survey from the Asia–Pacific region undertaken in 2011.[1] The last survey, the Asthma Insights and Reality in Asia–Pacific, was performed in 2000 when a total of 108 360 households were screened and 2323 adults surveyed.[2] In 2011, 80 761 households were screened and 3630 adults agreed to participate. That compares well in comparison with a (AIM) survey in North America conducted in 2009, screening 60 682 households with 2499 participating adults.[3] The AIM Asia–Pacific recruited participants from Australia, China, Hong Kong, India, Korea, Malaysia, the Philippines, Singapore and Taiwan, while the 2000 survey included the Philippines and Vietnam instead of Australia and India. This makes direct comparisons between studies difficult, and indeed the authors counsel against such a comparison given the different sample selections, sample size, questionnaires and interview methods.

Neither the 2000 or 2011 studies found that the cost of medications was the primary barrier to asthma treatment. Instead, the surveys highlighted that the fear of side-effects was the primary factor. It is possible that countries with low inhaled corticosteroid (ICS) use, including China, India and South Korea, also had the highest use of ‘pills’, a mixture of prednisone and theophylline. The use of ICS as preventer medication is still low at 39%, although it has significantly improved from 13% in 2000. The percentage of participants using ICS has more than doubled in China, Hong Kong, Malaysia and Singapore. This would validate the author's perception that the economic growth in the Asia–Pacific region is revolutionizing asthma care. Yet an important question is whether patients' asthma is better controlled given this improvement.

A key finding from the AIM Asia–Pacific survey is that more than half of the participants felt that their asthma is completely or well controlled. However, at the same time, 64% reported an exacerbation in the last 12 months lasting for a mean of 5 days, and 66% reported missing work or school due to asthma. Applying the Global Initiative for Asthma definition of asthma control to this cohort, 40% have uncontrolled asthma, 58% partially controlled asthma and only 2% controlled asthma. As such, this large epidemiological survey provides[4] clinicians more real-life information than a randomized control trial using carefully screened and selected patients. Strong evidence exists that the best treatment for asthma is an ICS-based treatment regime. However, currently less than half of the at-risk population in the Asia–Pacific region receive this regime, and more than half report days off school and work with associated loss of productivity.

Excellent scientific research explains why the use of ICS to control asthma is biologically plausible, providing a strong management option. We can draw on level 1A evidence that ICS will reduce asthma exacerbations and improve health-related quality of life. Epidemiological surveys such as this AIM Asia–Pacific survey, together with local audit data, provide a grounding for the next challenge: to apply this evidence to the creation of individualized management plans for cultural groups, communities and individuals. The AIM Asia–Pacific survey has great potential to enable informed health-care providers the tools to translate level 1A evidence into personalized medicine in order to provide solutions that are better tailored to the individual patient than the traditional ‘one size fits all’ approach.

Doctors and health-care providers should be encouraged to reflect on how such solutions can be implemented in their local setting; some potential issues for consideration are as follows:

  • Clinicians need to appreciate the influence of culture on the management of asthma. The belief set of patients, incorporating their perspectives on asthma and their treatment preference, is at the heart of whether they accept treatment plans.[5] If the thoughts and fears a patient has about asthma and its treatments are understood, the health-care provider can address these concerns, making it easier to agree on a management plan. This will decrease their asthma symptoms and may improve their beliefs of how others perceive them once they are empowered to participate.[6]
  • Implementation of evidence-based international guidelines remains suboptimal. The reasons for this are unknown despite this topic having been discussed widely at an international level.[7] Rather, creative approaches have been attempted to encourage doctors to comply with guidelines, like an award-winning video clip from Britain.[8] The United States AIM survey reported that ICS monotherapy was the preferred treatment for mild and moderate persistent asthma; however, a third of patients were not using any prescription medication for their asthma.[3] Adherence to guidelines and observance of a management plan represent ‘the elephants in the room’. The AIM Asia–Pacific survey highlights this for the Asia–Pacific region.
  • Health-care professionals and respiratory physicians in particular have a responsibility to advocate for their asthma patients. Nurse specialists, practice nurses, asthma educator pharmacists and other health practitioners are acknowledged as crucial contributors to the delivery of asthma care. However, the Asia–Pacific AIM survey results show that more needs to be done: for example, approximately half of the patients were worried about the use of oral or inhaled steroids. While social media is becoming a necessary part of communication with patients, Shah et al. showed in her studies how working with peer groups at school and work can improve asthma management.[9]
  • Over the next decade, it is likely that therapy will be able to be tailored to certain phenotypes of asthma. These ‘designer biological agents’ will probably come at a high cost.[10] At the same time, well-established medications will be coming ‘off-patent’. This will open the door to pragmatic and highly cost-effective treatment regimes. The promotion of continued use of off-patent medications will be the responsibility of respiratory clinicians.

In summary, the authors of this large AIM Asia–Pacific survey have provided us with information for our patients. Taken together with local audits, this will enable us to tailor treatment to the needs of our patients in the future, moving towards an area of personalized medicine.

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