Over-Reliance Linked to Increased Risk of Asthma Attacks and Death

Asthma is an inflammatory condition of the airways affecting more than 339-million1 people globally. In South Africa, more than 20% of children and 10-15% of adults have asthma2. For those living with the illness, it can reduce quality of life in varying degrees and it’s not uncommon to be hospitalised during an attack. Despite changes in the approach to treatment and evidenced-based medications to manage the condition, an alarming number of South Africans still die from asthma every year.

With the fifth highest asthma death rate in the world3, the importance of local research such as the recently published SABINA III study cannot be overstated. The new study primarily set out to review asthma SABA prescription patterns among South African patients. The findings were conclusive, showing over-prescription and over-the-counter purchase of the reliever pump to be widespread, despite the new guidelines in place for treating the illness. According to Professor Ismail Kalla, Pulmonologist, Head of Department - Internal Medicine, University of Witwatersrand, the significant overuse of the blue SABA reliever pump is a serious problem for South African asthma patients.

Prof Kalla adds that for decades asthmatic patients have been overusing their blue SABA symptom-reliever inhaler (which provides rapid and temporary relief) and underusing their anti-inflammatory maintenance medication. Many patients feel dependent on their SABA blue inhaler, mistakenly believing this to be the best way to control their symptoms.

“In line with the new global, and locally endorsed asthma treatment guidelines, we no longer prescribe SABA blue reliever inhalers alone as the preferred reliever therapy for mild asthma. Instead, we recommend the use of a low-dose inhaled corticosteroid (ICS) formoterol therapy as needed, regardless of asthma disease severity.4 This combination inhaler contains an anti-inflammatory agent which reduces inflammation of the airways and provides controlled relief.”

Despite the new way of treating asthma, the SABINA III results indicate a slow uptake of the new guidelines. Nearly 75% of the study patients used more than three SABA canisters in the previous 12 months and over 55% were prescribed more than 10 SABA canisters.

“These figures are extremely concerning, as there is increasing evidence that SABA overuse, and in particular the use of more than three pumps a year, is associated with an increased risk of asthma attacks, hospitalisations and death5,6,” explains Prof Kalla.[10,11] “Patients who are using this many blue pumps in a year should speak to their doctor immediately to re-examine and revise their asthma treatment plan.”

Prof Kalla goes on to explain that chronic control relies on anti-inflammatory maintenance7 and this applies to all asthma patients - whether their illness has been classified as mild, moderate or severe7. He adds that the approach to treatment and management of asthma is almost identical and reducing inflammation is at the heart of it8.

“What’s more, patients with mild asthma must recognise that their disease severity doesn’t preclude them from having an asthma attack9,10. The risk is equally as high regardless of disease severity, adherence to treatment, or level of control11,12,13,” warns Prof Kalla.

Congruently, the SABINA III study found that more than 50% of mild asthmatic patients have uncontrolled symptoms. Not taking maintenance medication as prescribed is believed to be the reason for continued poor control. Of these 501 patients analysed, 60% were uncontrolled or only partly controlled. Nearly 50% had experienced more than one severe asthma attack in the 12 months before the study.

Prof Kalla says that this is significant because mild asthmatic patients are regarded as the silent majority of asthmatics. “One could say labelling asthma as mild is a misnomer because you are still equally at risk of attacks.”

When it comes to childhood asthma the same treatment recommendations apply. Moreover, in children, mild asthma is more frequent, symptomatic, and less controlled than in adults14,15. But, as with adults, everything boils down to reducing inflammation and the overuse of their SABA inhaler also increases their risk of an attack. If inflammation and swelling are not treated, over time the airway walls may thicken permanently, preventing them from working efficiently.

“While there’s no cure for asthma it can be controlled and it’s important that asthmatics partner with their doctor to develop a solid asthma treatment plan that prioritises reducing inflammation safely. Asthma causes permanent inflammation of the airways and as such if you reduce your inflammation you reduce your risks,” says Prof Kalla. “To illustrate how dangerous this inflammation can be for those who live with asthma, a global study reports that excessive inflammation causes 176-million asthma attacks annually16. These attacks can be frightening, dangerous, and can be costly for the patients.”

To educate people living with asthma, and to help them reduce their risk of attacks, AstraZeneca is running the Break Over-Reliance campaign. Asthma patients can assess their levels of over-reliance through a digital assessment tool, known as the Reliever Reliance Test. This evidence-based questionnaire empowers patients to assess their over-reliance on their blue reliever inhaler, SABA17, by answering five short questions.

Prof Kalla says, “I strongly urge that everyone living with asthma take the test – it’s easy to navigate and will help them understand whether they are relying too heavily on their SABA. If the results indicate over-reliance, then that information can facilitate conversations with their health care professional about their asthma management.

“Recognising that the use of a SABA blue inhaler to control asthma symptoms actually masks symptoms and increases the risk of asthma attacks1,10,11 – action to correct asthmatic compliance has never been more important. When you consider that South Africa’s prevalence of asthma is among the highest in the world, the case for better control is urgently needed,” concludes Kalla.

For more information about the Break Over-Reliance campaign and to take the Reliever Reliance Test, visit: https://bit.ly/CheckSABAOveruse

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References;

1. The Global Asthma Report 2018. http://globalasthmareport.org/Global%20 Asthma%20Report%202018.pdf (accessed 26 October 2022)

2. The Global Asthma report south Africa. Available at http://globalasthmareport.org/management/southafrica.php. Accessed August 2021.

3. The Global Asthma report south Africa. Available at http://globalasthmareport.org/management/southafrica.php. Accessed August 2021.

4. Global strategy for Asthma Management and prevention. Global initiative for Asthma (GINA)2021. Available from https://ginasthma.org/wp-content uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf. Accessed August 2021.

5. Nwaru BI, Ekström M, Hasvold P, Wiklund F, Telg G, Janson C. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: A nationwide cohort study of the global SABINA programme. Eur Respir J 2020;55(4):1901872. https://doi.org/10.1183%2F13993003.01872-2019

6. Bloom CI, Cabrera C, Arnetorp S, et al. Asthma-related health outcomes associated with short-acting β2-agonist inhaler use: An observational UK study as part of the SABINA Global Program. Adv Ther 2020;37(10):4190-4208.

7. P.M. O Byrne. How much is too much? The treatment of mild asthma. EUR RESPIR J. 2007(30):403-406.

8. Global strategy for Asthma Management and prevention. Global initiative for Asthma (GINA)2021. Available from https://ginasthma.org/wp-content uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf. Accessed August 2021.

9. Papi A et al. J Allergy Clin Immunol Pract. 2018;6:1989-1998.

10. Price D et al. NPJ Prim Care Respir Med. 2014;24:14009.

11. Papi A et al. J Allergy Clin Immunol Pract. 2018;6:1989-1998.

12. Price D et al. NPJ Prim Care Respir Med. 2014;24:14009.

13. Fitzgerald J, Branes J, Ghipps E, et al. The burden of exacerbations in mild asthma: a systematic review. ERJ Open Res. 2020;6:00359-2019.

14. Dusser D, Montani D, Chanez P, et al. Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations. Allergy.2007;62:591–604.

15. O'Byrne. Daily inhaled corticosteroid treatment should be prescribed for mild persistent asthma. Am J Respir crit care med. 2005;172:410-416.

16. Sastre J et al. World Allergy Organ J. 2016;9:13.

17. International Primary Care Respiratory Group. Blue Reliever Reliance Test. Available at: https://www.ipcrg.org/resources/search-resources/blue-reliever-reliance-test-english [Last accessed: July 2020]

18. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2020 Update. Available at: https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020- report_20_06_04-1-wms.pdf Last accessed July 2020.

19. Price D, et al. Asthma control and management in 8,000 European patients: the Recognise Asthma and Link to Symptoms and Experience (REALISE) survey. NPJ Prim Care Respir Med. 2014; 24: 14009.

20. Pavord ID, Beasley R, Agusti A, et al. After asthma: redefining airways diseases. Lancet. 2017; 391: 350-400.

21. Smith C et al. Afr J Thoracic Crit Care Med 2022;28(4):172-180

AstraZeneca

AstraZeneca (South Africa) is a global, science-led biopharmaceutical company that focuses on the discovery, development and commercialisation of prescription medicines, primarily for the treatment of diseases in three therapy areas - Oncology, Cardiovascular, Renal and Metabolism, and Respiratory & Immunology. AstraZeneca operates in over 100 countries and its innovative medicines are used by millions of patients worldwide. For more information, please visit astrazeneca.co.za.

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