Asthma affects over 10% of the population worldwide, and is the most common chronic disease in children. However, despite the pervasiveness of this disease, misconceptions regarding treatment and proper use of medications still abound.
Treatments for asthma
The two main hallmarks of asthma are chronic inflammation and repeated narrowing of the airways. For efficient and successful treatment, both of these symptoms need to be addressed. Anti-inflammatory medications, such as inhaled corticosteroids (ICS), are used as the ‘controller medication’ to treat the inflammation, and bronchodilators, like short acting beta2-agonists (SABA), also called relievers, help expand the airways. These two medications have long been the mainstays for the treatment of asthma.
The usage of a reliever without any controller medication has become common practice.
However, to have the highest rate of success, they need to be used in conjunction with one another. Unfortunately, this does not always occur – instead, the usage of a reliever without any controller medication has become common practice.
There are many reasons for this. For example, many patients with asthma are worried about the side effects of corticosteroids (ICS), such as osteoporosis, cataracts, infections, or oral thrush. Furthermore, short acting bronchodilators like SABAs work quickly and provide relief faster than anti-inflammatory medications, which take longer to show signs of improvement.
Misconceptions in treatment
However, this is not a good practice, even for those with mild asthma. Those with mild asthma have asthmatic symptoms, but very rarely. These symptoms will often appear up in special circumstances, such as environmental exposure or allergy season.
Previous evidence illustrates that these individuals are still at high risk for fatal exacerbations, and short-acting bronchodilator use without ICS is not without risks. Patients on this therapy are at higher risks for hospitalizations, near-fatal asthma attacks, and worsening of lung function. In addition, frequent SABA use can cause airway hyperactivity, which can lead to more severe symptoms and cause the patients to develop a tolerance to the treatment, meaning that higher SABA doses are necessary to achieve the same effect.
Additionally, we must accept that even in patients with infrequent or mild symptoms, chronic inflammation is still present in the airways. If left untreated, it could lead to potentially irreversible destruction and remodeling in the airways. ICS treatment has its benefits as well. Early anti-inflammatory treatment has been associated with a better lung function and lower future ICS dose need. In other words, anti-inflammatory treatment not only prevents from exacerbations, but also mitigates the long-term damage caused by an event.
Anti-inflammatory treatment (ICS) not only prevents from exacerbations, but also mitigates the long-term damage caused by an event.
The blame does not lie solely with the patients, however. In fact, most national and international guidelines have supported the use of SABAs independently of anti-inflammatories as treatment for mild, intermittent asthma. This is concerning, as it encourages bad practice by the prescribers, who may start treatment without a solid diagnosis of asthma and may not consider and monitor the long-term risks of SABA treatment. It also sends conflicting messages to the patients that their asthma does not necessitate a controller medication, making the process of starting them on a controller in the future, could present some challenges.
What can we do to convince patients to change their practice? The Global Initiative for Asthma has endorsed a strategy to tackle this problem. They propose starting treatment with ICS-formoterol, a rapid-onset long acting beta2-agonist, in place of the typical short acting beta2-agonist (SABA), as a reliever.
Taking ICS-formoterol combinations for maintenance purposes has long been recognized as beneficial to some patients with asthma. However, more recently, these combinations have become available as a reliever medications for those with mild asthma. These patients do not need to use any maintenance treatment, only the ICS-containing reliever. Clinical trials have shown that using an ICS-SABA reliever was associated with a better control of asthma and lower exacerbation rate compared to SABA treatment alone.
It is also very important to speak honestly about the potential side effects of ICS. Around 90% of patients with asthma have experienced at least one error when using their inhaler, and almost half of asthma patients experience oral side effects, such as cough, change in voice, loss of taste, or thrush. These problems can easily be minimized by administering the lowest ICS dose possible, as well as encouraging proper oral hygiene and educating patients and their caretakers on correct inhaler technique. Proper education by asthma nurses has been proven to lead to better technique, lower symptom scores, and fewer side effects.
Clear discussion about the risks of SABA treatment and more studies in mild asthma are unmet needs. On this World Asthma Day, as the Editor-in-Chief for Asthma Research and Practice, I welcome submission of papers in these topics and any others that are dedicated to dispelling these misconceptions regarding asthma treatment, and provide education to patients, prescribers, and caretakers.