A focus on symptom control over exacerbation risk in asthma may hinder uptake of GINA guidance featuring ICS/formoterol as the preferred asthma reliever treatment, even in mild asthma, and as maintenance and reliever therapy (MART).

About 1,200 adults from Australia, Canada, China, and the Philippines responded to a 2020 online survey in the Asthma Patients’ and Physicians’ Perspectives on the Burden and Management of Asthma (APPaRENT) study.

The study, published in Respiratory Medicine, found about 43% of patients considered their asthma was well controlled or somewhat controlled. About 20% of patients in Australia and Canada and 10% of patients in China and the Philippines considered their asthma to be completely controlled.

“Despite these perceptions of reasonable control, many patients indicated that their asthma had caused them to experience shortness of breath (≥3 times/week: 37.0–47.3%) and night-time awakenings due to symptoms (≥1 time/week: 29.9–60.3%),” the study authors said.

“In addition, rescue inhaler use was generally high (≥1 use/day: 22.3–37.5%; 2–3 times per week: 19.2–40.7%).”

The study found a higher proportion of patients in China (51.7%) and the Philippines (37.3%) compared to Australia and Canada (<20% of patients) were aware of MART dosing.

“In contrast, more than half of all physicians were aware of MART; exceeding 70% in Australia, Canada, and China.”

Blue inhalers still prescribed

“Despite this relatively high awareness of MART, most physicians indicated that they prescribe a SABA in addition to a MART regimen at least some of the time. The majority of physicians (73.0–92.0%) indicated that they were aware of as-needed (PRN) dosing for patients with mild asthma.”

Physicians most frequently reported prescribing an ICS/LABA regimen (50–80%) for patients with moderate asthma, in accordance with current international recommendations.

“However, for patients with mild asthma, most physicians reported using as-needed SABA only (30–70%) or low dose ICS plus as-needed SABA (10–20%), despite the recommended shift to as-needed 263 ICS/formoterol in recently updated global recommendations.”

“This continuing use of separate controller and reliever inhalers, with controller used to suppress the need for reliever, suggests that real-world clinical practice takes some time to evolve and adopt new recommendations.”

The investigators, including Professor Sinthia Bosnic-Anticevich, said the implementation of the recommendation for as-needed ICS/formoterol merits assessment for both patients with mild asthma and patients receiving ICS/formoterol as part of MART.

They said their findings suggested a lack of patient and physician awareness and understanding of the clinical benefits of MART.

“An increase in the provision of effective and consistent education for both patients and physicians on the benefits and use of as-needed ICS/formoterol, including its use as part of the MART regimen, may serve to address current gaps and improve asthma management overall,” they wrote.

Shifting ingrained behaviours

Professor Bosnic-Anticevic, from the Woolcock Institute of Medical Research, told the limbic the issue was well ingrained perspectives and behaviours in patients and healthcare professionals.

“For the patients with mild asthma, many are used to SABA only. This study highlights that there are some behaviours that will need to shift and there needs to be a strategy that supports both patients and health care professionals shifting those.”

She said people were used to doing things in a certain way because there haven’t been many changes in the guidelines for quite a while.

“Especially if we have treatment options now that are PRN, we really need to make sure the patient is aware of where they are at and that healthcare professionals are there to support them and help them transition to something else if it is appropriate for them.”

“We’ve known for quite a while now that patients often think they are better controlled than what they actually are,” she said.

Professor Bosnic-Anticevic, a respiratory pharmacist, said healthcare professionals were also used to managing their patients in a certain way.

“The clear message is that there does need to be an implementation strategy. It can’t happen ad hoc. That strategy needs to include a proper review and work up for the patients.”

“In Australia, it’s not mandated that patients with asthma need to have a review annually but overseas in countries like the UK, that’s what happens. So it may be that there needs to be a bit more structure in the way we review these patients and then determine what is appropriate for them and then support them in whatever is the best decision for them.”

“It requires support for healthcare professionals until the shift starts to happen.”

She said the fact that a lot of behaviours were triggered by asthma symptoms rather than exacerbation risk reduction was a problem.

“We do need to change that focus to prevent those flare ups and exacerbations even in patients who have mild asthma. But that is not something we have been used to. We all need to be on the same page and promoting the same thing and supporting the patients in the same way.”