Asthma control: a challenge in care
Cano-Salas, María del Carmen1
2022, Number 3
2022; 81 (3)
ABSTRACT
KEYWORDS
.Asthma is one of the most common chronic noncommunicable diseases worldwide, affecting about 339 million people in the world.1 The global prevalence in children and adolescents is estimated at about 10.5%2 and in adults it is between 6-7%;3 with regional variations in which low- and middle-income countries show a continuous increase, while in high-income countries it seems to be stabilizing.
Asthma is a disease with a heterogeneous behavior, with mild to severe levels; despite this variability, two domains should always be considered in the evaluation of patients that are very useful for therapeutic decision-making: current control (e.g., symptoms, use of rescue medication and lung function) and future risk (e.g., exacerbations and decreased lung function).
Asthma control refers to the degree to which the manifestations of asthma have been eliminated or diminished due to treatment, according to the control achieved we can speak of the suitability and compliance with the treatment objectives.4 In recent years, the great advances that have been made in the treatment of asthma, especially in severe asthma with the use of biologic drugs, have led to better control of the disease; however, it is still a challenge to achieve and maintain it.
Factors that may contribute to poor asthma control include: treatment barriers (poor adherence, poor inhaler technique or poor access to medications), comorbidities (e.g., allergic rhinitis, dysfunctional breathing, obesity, vocal cord dysfunction, gastroesophageal reflux disease, chronic rhinosinusitis with nasal polyposis, psychosocial factors, among others), exposure to triggers (e.g. allergens, viruses, tobacco smoke, pollution) and certain inflammatory features such as T2 inflammation and within this, eosinophilia and allergic sensitization.
Around poor asthma control there are several issues that need to be addressed in the same patient, so that multidisciplinary and collaborative care is essential to identify and treat the factors involved.
This issue of NCT includes the work of Lugo-González IV et al., Relación entre percepción de enfermedad, tratamiento, adherencia y control del asma: un análisis de mediación;5 this is a novel work because it includes a model that evaluates disease perception, medication beliefs, adherence to treatment and asthma control through tools validated in the Mexican population. The authors found that psychological factors are predictors of adherence and asthma control; this reinforces that the approach to patients is multidisciplinary and that psychological interventions are indispensable in the treatment of the disease.
Adherence is, among the treatment barriers, a great challenge to overcome; despite having had an effective pharmacological treatment for most patients for several decades, I am referring to inhaled corticosteroids, only 25-30% of patients are adherent. On the other hand, it is well known that there may be discordance between the data provided by patients and what we find when applying objective adherence measurement tests; however, in this study the self-report of adherence to treatment was high, related to patients with a positive perception of the disease and treatment; however, more than 60% were evaluated as non-adherent. This is reflected in the fact that only 51% of patients had control according to the Asthma Control Questionnaire (ACT).
Lack of adherence implies a worse control of the disease and, therefore, a greater impact on the quality of life of patients, as well as on direct and indirect health costs. In addition, it is evident that the causes of poor control are multiple in most patients, which is why addressing the clinical aspects of the condition (symptoms, lung function, etc.) are not sufficient in patients with uncontrolled asthma and we must investigate individually the causes that favor poor symptom control.
Another aspect that should be highlighted from the findings of the study is that patients with greater adherence to treatment are those who have a positive perception of treatment; with a high need for treatment and moderate concern for adverse events of the control drugs, this, from my point of view, may be a reflection of the education that patients receive about the disease and at the same time of the confidence in the drugs to improve their health conditions. In this sense, it is important to dedicate exclusive time to inquire about patients' preferences, beliefs and knowledge, so that treatment can be individualized by covering pharmacological and non-pharmacological aspects, including emotional aspects within these.
Asthma is a complex entity that must be approached from different perspectives, which requires the collaborative work of several specialists in the search for and treatment of the factors associated with uncontrolled asthma; likewise, it is necessary that as physicians we strive to provide space for patient education, which is undoubtedly a debt that contributes significantly to the barriers to treatment. At present, we are obliged to seek the best comprehensive strategy for each patient with asthma to achieve control of the disease and reduce the risks associated with this condition.
AFILIACIONES
1Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico.REFERENCES
García-Marcos L, Asher MI, Pearce N, Ellwood E, Bissell K, Chiang CY, et al; Global Asthma Network Phase I Study Group. The burden of asthma, hay fever and eczema in children in 25 countries: GAN Phase I study. Eur Respir J. 2022;60(3):2102866. Available in: https://doi.org/10.1183/13993003.02866-2021
2022, Number 3
2022; 81 (3)