Backgrounder: Asthma Control

The theme of World Asthma Day 2013, an awareness-raising event organized by

the Global Initiative for Asthma (GINA), is You Can Control Your Asthma. The
GINA Board of Directors has chosen this theme to emphasize that effective
asthma treatments exist and, with proper diagnosis, education, and treatment,
the great majority of asthma patients can achieve and maintain good control of
their disease. When asthma is under control, patients can live full and active lives
and can prevent visits to the emergency department and hospital.
According to the GINA Global Strategy for Asthma Management and Prevention
(2012), asthma control means that a person with asthma has:
No (or minimal) asthma symptoms.
No waking at night due to asthma.
No (or minimal) need to use reliever medication.
The ability to do normal physical activity and exercise.
Normal (or near-normal) lung function test results (PEF and FEV 1).
No (or very infrequent) asthma attacks.
More than 300 million people around the world have asthma 1, and the disease
imposes a heavy burden on individuals, families, and societies. The Global
Burden of Asthma Report, a compilation of published data on the prevalence and
impact of asthma around the world that was launched on World Asthma Day
2004, indicates that asthma control often falls short and there are many barriers
to asthma control around the world.
Lack of Asthma Control
Proper long-term management of asthma will permit most patients to achieve
good control of their disease. Yet the Global Burden of Asthma Report

Unless otherwise noted, all information in this backgrounder comes from the Global Burden of
Asthma Report. The Report was commissioned by GINA and written by Richard Beasley,
Matthew Masoli, Denise Fabian, and Shaun Holt, of the Medical Research Institute of New
Zealand and the University of Southampton in the UK. For more information about the unmet
needs of asthma, and an explanation of the regions mentioned in this backgrounder, download
the full Report from www.ginasthma.org.
1

documents ample evidence that, in many regions around the world, this goal is
often not met:

Hospitalizations, emergency room visits, and other urgent care occur

when a persons asthma is not under control. Although the rates of these
medical visits generally increase as the prevalence of asthma rises, the
very high proportions of people with asthma who require such care in
many countries is an indication that lack of control is widespread.
o In Western Europe, for example, one in four people with asthma
required an emergency room visit or unscheduled urgent care in
the previous year.
o One in five Israeli children with asthma visits the emergency room
per year, and one in ten requires hospitalization.
o In the China/Taiwan/Mongolia region, one-third of people with
asthma require urgent care, emergency room visits, or hospital
admission for asthma.
o In North America, 40 percent of people with asthma required such
care in the previous year.
The above facts indicate that there is a major opportunity to reduce
hospitalizations by improving asthma control, and on World Asthma Day
2010 GINA launched an initiative encouraging governments and health
departments around the world to improve asthma control and reduce
asthma hospitalization 50% over 5 years. On World Asthma Day 2011,
GINA began the next phase of the Asthma Control Challenge with an
online data collection system for countries around the world to track their
progress in reducing hospitalizations.
Poor asthma control is also seen in the lifestyle limitations experienced
by some people with asthma. In Egypt, for example, up to one in four
children with asthma is unable to attend school regularly because of poor
asthma control.
Asthma deaths are the ultimate, tragic evidence of uncontrolled asthma.
According to the Global Burden of Asthma Report, the majority of asthma
deaths in some regions of the world are preventable.

What are the Barriers to Asthma Control?

Although the barriers to asthma control vary from country to country and from
region to region around the world, the Global Burden of Asthma Report identifies
several patterns:

Diagnosis. Some people with asthma symptoms may never receive a

diagnosis of asthma, and thus do not have the opportunity for good
asthma treatment and control. Various factors such as poor access to
medical care, underrecognition by health professionals, lack of awareness
among patients, and overlap of asthma symptoms with those of other

diseases contribute to underdiagnosis of asthma in regions including the

Baltic states, the Middle East, Southern Asia, China/Taiwan/Mongolia, and
East, West, and Southern Africa.
Treatment. Barriers relating to treatment are the most commonly cited in
the Global Burden of Asthma Report, occurring in one form or another in
almost all regions around the world:
o The high cost of medicines means that many people with asthma
in the Baltic states, the Balkans/Turkey/Caucasus/Mediterranean
Islands region, the Middle East, Central and South America, East
and West Africa, and other areas may not receive sufficient
medication to control their disease. In Turkey, the cost of a year of
treatment for a person with moderate persistent asthma is about
half the monthly salary of a nurse; in Syria, it is greater than a
nurses monthly salary.
o Asthma medications are not available in some areas, such as
parts of the Middle East, Southern Asia, Central America, and
North, West, and East Africa.
o Treatment that is not consistent with evidence-based guidelines
may hamper asthma control in, for example, the UK/Republic of
Ireland, Western Europe, China/Taiwan/Mongolia, Central America,
the Caribbean, and West and East Africa. There are wide
variations in prescribing practices in different areas of the world,
and even when cost is not a barrier undertreatment may still occur.
o The underuse of inhaled corticosteroids for long-term
management of asthma is a particular problem in many regions,
including the Middle East, the Caribbean, and West Africa. These
medications diminish chronic inflammation in the lungs of asthma
patients, and are a key to controlling the disease.
o A general lack of access to medical care limits asthma treatment
and control in areas such as the
Balkans/Turkey/Caucasus/Mediterranean Islands region, Eastern
Europe, Russia, Central Asia and Pakistan, Southern Asia,
Southern Africa, and China. This lack of access may arise from
socioeconomic factors, or may be a matter of scarce infrastructure
and poor transport, especially in rural areas.
Education. People with asthma may not understand how to use their
medications properly, or may not understand concepts such as asthma
control and when to seek help for worsening asthma that would help them
manage their disease effectively. Misconceptions about asthma and its
treatment represent are widespread in regions including Southeast Asia,
Central Asia and Pakistan, Eastern Europe, the UK/Republic of Ireland,
Northeast Asia, and Russia.
Environmental Health. Avoiding risk factors that cause asthma symptoms
is an important strategy for improving control. However, in many regions
of the world, people with asthma may be exposed to conditions such as

outdoor or indoor air pollution, cigarette smoke, or chemicals on the job

that make their asthma worse.
Improving Control
The Global Burden of Asthma Report also details a number of instances where
improving asthma control has reduced the burden of this disease. For example:

Declining asthma mortality rates over the last 10 years have been
attributed to the increased use of inhaled corticosteroid therapy in
areas including Scandinavia, the UK/Republic of Ireland, Western Europe,
and Argentina. In Northeast Asia, increased use of inhaled
glucocorticosteroids has led to a reduction in asthma severity.
National asthma campaigns in Finland and other Scandinavian
countries, the UK, Australia, New Zealand, and elsewhere have reduced
asthma morbidity and mortality. These programs often include
educational components for both health professionals and the general
public.

A strategy for achieving and maintaining asthma control is set out in the GINA
Global Strategy for Asthma Management and Prevention. The strategy requires
four interrelated components of therapy:

Develop patient/doctor partnership.

Identify and reduce exposure to risk factors.
Assess, treat, and monitor asthma.
Manage asthma exacerbations.

Under this strategy, asthma is treated in a stepwise manner to achieve and

maintain control of the disease. Medication is increasedstepped upwhen
asthma is not controlled, and gradually stepped down once good control is
achieved and maintained for a period of time.
www.ginasthma.org/.../AsthmaControlBkgrdr13.d...

What to do if you think your medication is not

working?
If you notice any of the following, it could be an indication that your asthma medication
is not working:

wakingatnightwithcoughing,wheezing,shortnessofbreathoratightchest
increasedshortnessofbreathonwakingupinthemorning

needingmoreandmorerelievertreatmentoriftherelieverdoesnotseemtobe
workingwelloritseffectislastinglessthanfourhours
youcannotkeepupwithyourusuallevelofactivityorexercise.

If you experience any of these symptoms, then you should see your doctor or asthma
nurse.
Readmore:
http://www.netdoctor.co.uk/diseases/facts/asthmamedication.htm#ixzz2wT0a4Q5Z

Asthma Medication Misuage Rampant: Good Health Insurance Is No

Guarantee of Proper Use
Misuseofasthmadrugsamongpeoplewithgoodhealthinsuranceismoreprevalentthan
previouslythought,accordingtoanewstudybyJohnsHopkinsresearchers.
"Contrary to what many people believe, asthma is not just a problem for people in inner
cities and the uninsured," says Albert Wu, M.D., associate professor of health policy and
management in the Hopkins School of Public Health.
The study, published in the Dec. 13 issue of Archives of Internal Medicine, found that 16
percent of insured individuals who use inhaled beta-agonists for short-term asthma relief
overuse their medication. Sixty-three percent of insured individuals who use inhaled
corticosteroids for long-term asthma relief underuse their medication.
"The magnitude of corticosteroid underuse is huge, and this is a missed opportunity to
control asthma," says Gregory Diette, M.D., an instructor in the Hopkins School of
Medicine's division of pulmonary and critical care medicine and lead author of the study.
"Those who overuse beta-agonists need their treatment regimen intensified or need to pay
more attention to whatever triggers their symptoms."
The new study also found that medication misuse has a gender bias. Women are
significantly more likely to underuse inhaled corticosteroids, while men are significantly
more likely to overuse inhaled beta-agonists. "Only 25 percent of moderately or severely
symptomatic female patients, for example, were using at least a modest, regular dose,"
says Diette.
Inhaled beta-agonists are generally used as asthma-rescue drugs to relieve coughing,
wheezing and shortness of breath. They work by opening up the lungs' air passages and
increasing air flow. Overusing beta-agonists speeds up heart rate, causes jittery behavior
and has been linked to higher than expected death rates. "We don't know whether the
overuse is causing harm or whether it is just a marker for people who are very sick," said

Diette. "One way or the other, however, the people who are overusing it need more
attention."
Inhaled corticosteroids, taken one or two times daily, quiet the inflammation of the lungs,
reduce the likelihood of an asthma attack before it begins and help change the course of
the disease. Underuse of these drugs increases the chances that you will have an attack if
you encounter an asthmatic trigger such as dust, cockroaches, pets, perfume or pollution.
For years, researchers have known that asthmatics misuse their drugs, but they haven't
known which people were more apt to do so. Investigators assumed, however, that those
with quality health care would be more likely to use medications properly.
To fill the knowledge gap, Diette and his colleagues launched the Managed Health Care
Association Outcomes Management System Asthma Project. The doctors gathered and
analyzed information from 6,612 sicker-than-average asthmatic individuals on their
gender, race, education, asthma symptom severity, medication usage, health care access
and satisfaction, and physician speciality. These individuals, employees and dependents
of some of the largest U.S. companies, had health insurance coverage through managed
care.
The researchers weren't too surprised at the overuse statistics, but they were shocked,
they said, at the amount of underuse. "We now know that the magnitude of corticosteroid
underuse is huge," says Diette. In addition to being male, overusers of beta-agonists were
more likely to have frequent symptoms, use inhaled corticosteroids or visit a doctor other
than an allergist. In addition to being female, underusers of corticosteroids were more
likely to be younger, nonwhite or getting care from a nonspecialist.
The researchers say doctors need to question their patients, especially those most at risk,
about their medication usage. In addition, the findings could have implications for doctor
choice or training. "Where there are advantages to specialists, the question is how do you
narrow the gap between specialist and generalist physicians," said Diette. "It may be
worth considering referring more patients to specialists for evaluation and management."
Between 12 million and 15 million people, including close to 5 million children, in the
United States have asthma. Asthma is a chronic disease through which airflow in and out
of the lungs may be blocked by muscle squeezing, swelling and excess mucus. In 1997,
more than 30.5 million prescriptions were filled for asthma medication, and patients had
approximately 1.2 million emergency room visits and 445,000 hospitalization days.
Other authors include Albert Wu, Elizabeth Skinner, Rebecca Clark, Michael Huber and
Donald Steinwachs from Johns Hopkins; Leona Markson from Merck & Company;
Robert McDonald from Anthem Blue Cross and Blue Shield and the Indiana University
School of Medicine; and Joseph Healy from Harvard Pilgrim Health Plan. The study was
funded by the Managed Health Care Association and Merck & Co., Inc.
http://esgweb1.nts.jhu.edu/press/1999/DEC99/991213.HTM

HighCostofAsthmaMedsPuttingLivesatRiskPriceReviewNeeded

Asthma Foundation NSW is calling on the Federal Government to review the cost
of asthma medications following the publication of a new survey. It shows that
many consumers are struggling with the cost of vital asthma medication, having
to reduce or go without medication, resulting in asthma attacks that need urgent
medical treatment.
Our survey not only confirms that price is a major barrier to the control of
asthma, but directly results in people either skimping on medication to make it go
further or skipping prescriptions altogether, said Michele Goldman, CEO of
Asthma Foundation NSW.
This will come as no surprise to the government as a 2009/10 report by the
Council of Australian Governments (COAG) Reform Council revealed that more
than a million people were put off buying their prescribed medicine because of the
price.
Over 400 Australian asthmatics die each year and there has been a recent spike in
the number of child deaths, so asthma control can be, literally, a matter of life and
death.
A review of the PBS system, with a view to reducing the disparity between the
cost of asthma reliever and preventer medication for non-concession card holders,
is clearly needed.
The on-line survey, conducted by Asthma Foundation NSW during April 2012
collected information about 859 adults with asthma. The survey asked if the cost
of medications affected them and if they had experienced any medical
emergencies as a result. The headline results showed:

o
o
o

85%ofrespondentshadanissuewiththecostoftheirmedication,with
38%findingitisusuallyoralwaysanissue.
49%ofrespondentsadmittedtotakinglessmedication,orgoingwithout
entirely,becauseofthecost.
Whenpeoplewereskippingmedications,81%werenottakingpreventer
medication,26%nottakingrelieverand7%nottakingrespiratorymeds
suchasoralsteroids.

Over75%ofpeoplewhosaidtheyalwaysorusuallywentwithout
medicationsduetocostreportedthattherehadbeenanasthmaattackasa
result.Inmorethanhalfofthesecases,urgentmedicalhelp(GPor
hospital)wasrequired.

Comments left by those surveyed vividly illustrated the key issues:

o

itisahugestruggleandIdeliberatelyputmyselflastsomychildren
getwhattheyneed.Iendeduphavingamajorasthmaattackandwas
rushedtohospitaltheyclaimedmylungshadclosedupsomuchifIhad
leftitanylongertheywouldnothavebeenabletoreopentheairways,I
spent6daysinhospitalandseveralweeksaftertogetbacktonormal
health.
Consideringweneedthismedicationtobe'healthy'andsurvive,Idon't
seewhyweshouldhavetopaysomuchforthemedication.Especially
whentherearethe3ofusin1familyneedingthemedicationtostayalive.
It'snotfair.
Ifthepreventermedicationsforasthmawerecheaperthenmorepeople
wouldtakethemandtherewouldbelesschanceofpeoplehavingattacks.
Iknowofmanyasthmaticswhoonlytakepreventersseasonallywhenthey
shouldbetakingthemallyearroundduetothecost.Itcostsme$72a
monthjustformypreventermedication.Thenontopofthatisthecostof
Ventolinandallergymedications.

Chronic conditions like asthma cant be cured, you have it for life. Drug therapy
is the cornerstone of asthma treatment, enabling people to prevent and reverse
inflammation of the airways, said Ms Goldman.
We believe that having asthma is stressful enough and making medications more
affordable will enable people to better control their asthma and stay well, reduce
pressure on the health system and result in less days off work and school.
Its clear that some sort of relief is needed and we believe that either a stepped
reduction in co-payments or giving people with a chronic condition, who need
regular medications, a concession card would provide that.
It is a proposal not without precedent. Currently, prescription medications are free
in Northern Ireland, Scotland and Wales.
Claims that free or cheaper prescription medication would lead to a blow-out in
PBS costs is not been supported by figures from Wales where the use of
medications has increased by 3.9 to 6% year on year, said Ms. Goldman.

Five years into the experiment the Welsh Minister for Health and Social Services
has reported a reduction in the financial burden on consumers and the health
system with a drop in the numbers being admitted to hospital.
Are you having trouble controlling your asthma? Sign up for Asthma Assist today.
Call 1800 645 130 or register here.
Media Enquiries: Nick Bleszynski 0403 931 291