While the reasons for the patterns of asthma prevalence worldwide are unclear, increases have been linked to a number of environmental factors, such as industrialization, urbanization, air pollution and tobacco use.1, 2
The increases in morbidity, and mortality in some countries, can also be attributed to social or cultural barriers, such as poverty, poor education and poor infrastructure.1, 3 Previous increases in mortality have also been attributed to the regular use of two non-selective β2-agonists at high doses.2 Their use was linked to worsening asthma control and an increased risk of death due to adverse cardiac events in the presence of severe hypoxia.2 Less reliance on β2-agonists and closer medical supervision have been advocated as methods for reducing asthma mortality, with the use of oral steroids during an exacerbation reported as reducing the risk of death by 90%.4
Other barriers preventing better control of asthma, as identified in the GINA Global Burden of Asthma report, include lack of symptom-based approaches to the management of asthma, and limited availability and use of medications.3 A further look at the regional data in this report emphasizes a lack of utilization of ICS.3 Furthermore, GINA guidelines indicate that long-acting β2-agonists (LABAs) should only be used in combination with ICS and are not a substitute for ICS or oral corticosteroids.5
The limited availability and use of medications, whether due to omission from national drug lists or cultural attitudes, hampers effective management of the disease. The Global Asthma Physician and Patient (GAPP) survey has highlighted the impact of asthma globally, and identified areas for improved management of the disease, including physician–patient communication, especially with regard to medication side effects.6 The GAPP survey, which spanned 16 nations and more than 5000 patients and physicians, revealed that there is a direct relationship between physician–patient communication and treatment compliance.6
Two major areas of potential improvement are in the diagnosis and treatment of asthma. Inadequate ICS use is one of the major factors that impact the failure of long-term management.3 Also, following a general trend throughout the world, a more practical, symptom-based approach to diagnosis is warranted at the primary care level.3
References:
1. Masoli M, Fabian D, Holt S, Beasley R. The global burden of asthma: executive summary of the GINA Dissemination Committee report. Allergy 2004;59:469–478.
2. Beasley R. The burden of asthma with specific reference to the United States. J Allergy Clin Immunol 2002;109:S482–S489.
3. Masoli M, Fabian D, Holt S, Beasley R. Global Burden of Asthma. Developed for the Global Initiative for Asthma (GINA). 2005.
4. Abramson MJ, Bailey MJ, Couper FJ, Driver JS, Drummer OH, Forbes AB, et al. Are asthma medications and management related to deaths from asthma? Am J Respir Crit Care Med 2001;163:12–18.
5. GINA. Global Initiative for Asthma.www.ginasthma.com. Revised Guidelines 2006.
6. Global asthma physician and patient (GAPP) survey www.gappsurvey.org. 2006.