Section 15 Pulmonology Chapter 103 Therapeutic Options for Uncontrolled Asthma Agam Vora and appropriate medical therapy.3 However, many factors in-between ABSTRACT may precipitate suboptimal asthma control, for instance, suboptimal treatment adherence, persistently high treatment cost, limited access Asthma is globally relevant and globally prevalent. Uncontrolled asthma to care-diagnosis-medicines, psychosocial and comorbid factors, etc. is a serious challenge wherein one-third patients currently may not obtain desired degree of asthma control. The objective of this paper is It is, therefore, important to identify all such factors in-entirety, and to review the significance of various factors (i.e. barriers) that may affect evaluate the degree of their role in optimizing better control of asthma the control of asthma and putative solutions. Many factors related to and its symptoms. The objective of this paper is to review the role of patients (e.g. adherence, environmental and lack of optimal education), various factors (barriers) that may affect the control of asthma and practitioners (lack of following guidelines, lack of educating patients, putative solutions. In clinical practice this might improve day-to-day lack of proactive approach in management, suboptimal interpretation patient management. of severity and control, etc.), public agencies (inability to make available inexpensive, affordable and guideline-required medications), researchers (lack of more objective composite approach that can be DEFINITION equally applied in practice set-ups of developed and resource-poor The control of asthma is said to be achieved if, aspects related (REP) countries, promoting one-size-fits-all approach etc.) are noted. to impairment and risk are reduced or optimally controlled. For This indicates that a collaborative composite approach is necessary instance, firstly asthma symptoms, exacerbations, unscheduled involving all stakeholders for achieving optimal asthma control. hospital visits and hospitalizations are optimally prevented and Particularly practitioners need to partner with the patients in defining personalized therapy goals and empower them to negotiate their own secondly normal (or near-normal) pulmonary function is maintained. care by self-monitoring and self-management. Practitioners should also This should be achieved with minimal burden from treatment side think to go beyond their personal beliefs (preferences, choices) and be effects. The treatment decisions (nature, type and degree) should proactive in the asthma management (management of comorbidities, ideally be based on these parameters. Patients may have their own barriers, etc.). These factors in fact indicate that the control is not solely interpretation about asthma control and should be correlated to related to severity of the underlying disease but how it is managed. clinical parameters (Table 1). Uncontrolled asthma characterizes Hence, it is likely that solving these barriers can help good proportion of that the asthma does not respond optimally to maximum guideline- those who are currently suboptimally controlled. Evaluation of asthma control in practice set-ups needs to be objectively and comprehensively directed management (Table 2). defined. BURDEN FROM POOR CONTROL The gaining optimal asthma control (GOAL) study showed that, after BACKGROUND 1 year high frequency of asthma control was achieved both with Asthma is globally prevalent and globally relevant. Prevalence is not just high and persistently rising in developed countries; but is also high TABLE 1 │ Perspectives of asthma control in REP countries, although for different reasons. For instance, changing patterns of air, occupational, and indoor pollution, unplanned No exacerbations No need for steroids urbanization, packed cohabitation, etc. are important factors for No fear of getting a cold or forgetting 1 Oral steroids ≤ 1 time/year REP-specific settings. Achieving optimal control is the central aim of inhaler therapy yet there are considerable proportions of patients who fail to respond optimally to treatment.2 This remains the case despite ever- No exercise limitations I can exercise increasing knowledge on asthma and its management. The number of No nocturnal awakening I can sleep through the night treatment options has increased to which patients generally respond No school/work absences I can go to school/work every day well. Its diagnosis does not require any sophisticated tools as well. No unscheduled hospital visits Despite this uncontrolled asthma continues to increase both in Can meet friends or hospitalization severity and prevalence. When poorly controlled, asthma can impair No uncontrolled upper airway all aspects of daily functioning and can be fatal. Ideally, optimal asthma No problem with sinus care needs systematic management plan, self-management support symptoms Section 15 Chapter 103 Therapeutic Options for Uncontrolled Asthma randomized trials have addressed this although only one study has TABLE 2 │ Features defining uncontrolled asthma shown improvement in peak expiratory flow (PEF)16 while other studies have shown reduction in asthma exacerbations and the use Daily daytime symptoms of rescue beta-2 agonists. Improvement in quality of life (QOL)17 and • Limitation in performing day-to-day activities a trend towards improvement of symptom score is also reported.18 • Weekly nocturnal symptoms and awakening Thus, exercises may have some relevance in asthma management especially since it allows patients to take charge of management • More need for rescue medications (self-management) of their asthma to some extent. • Lung function (FEV1) < 80% • Three or more exacerbations per year Difficult Devices Inhalation is the mainstay of treatment since it facilitates high bronchial concentration of drug without high systemic bioavailability but with reduced side effects. Optimal use of device is extremely inhaled corticosteroid and polytherapy of inhaled corticosteroid crucial for optimal drug delivery, compliance, treatment efficacy and and long-acting beta-2 agonist. However, about one-third of cases resultantly optimal control. Pressurized metered-dose inhalers are remained devoid of this control.2 Subsequent studies such as, most commonly used inhalation device. Many studies report their Asthma Insights and Reality in Europe (AIRE)4 and Asthma Insights inappropriate use in 14–90% of cases.19 This reduces drug delivery and Reality (AIR)5 also showed underwhelming results. For instance, by 13%20 and 30% reduction in 1-second forced expiratory volume AIRE study had 48% cases with regular day-time and 30% with (FEV).21 These results indicate that suboptimal use leads to asthma nocturnal symptoms, and only 50% of those with severe persistent instability from reduced availability and clinical efficacy of drug asthma had well control over their asthma. High frequency of which in turn ends up into impaired asthma control. Inappropriate unscheduled hospital visits and hospitalization was reported.4 AIR use is more important for old-age patients due to higher chances of study also reported low frequency (< 45%) of those who had good coordination error. Other factors such as suboptimal knowledge and control of their asthma.5 The epidemiology and natural history of teaching about inhalation technique22 are also pertinent. Suboptimal asthma: outcomes and treatment regimens (TENOR) study6 showed use of other devices such as dry powder inhalers is reported to be less that 83% cases with severe asthma were consistently uncontrolled on than metered-dose and is also low cost, equally efficacious,23 easier the usual asthma therapy. High burden from off-days, unscheduled to handle and have lesser side-effects from its use such as discomfort, hospitalization and hospital visits, use of steroids and twofold high vocal performance, shimmer score, etc.24 Patient-partnership is cost was observed. of paramount importance in choosing the right device. One may choose the best possible device, but if it is not liked by the patient, it RELEVANT FACTORS FOR MODIFICATION might be difficult to achieve an optimal use of that device and thus OF CONTROL optimal asthma control in the same manner. Adherence Environmental Asthma is a dynamic disorder with on-and-off exacerbations and Exposure to environmental irritants not only increases the risk high variability, thus maintaining optimal adherence is important. for development of asthma but also increase its morbidity for This is more so in children who need support from their peers. instance severity,25 exacerbations, unscheduled hospital visits and Not maintaining this increases the risk for morbidity, mortality hospitalization.26 For these cases positive parental perceptions might and treatment cost.7,8 Despite this the adherence is suboptimally also play an important role in achieving an optimal asthma control.27 achieved for minority of asthma cases, for example, from less than Pollutants produce strong inflammatory responses that in turn 30 to 70%. Less than 50% of children remain adherent to prescribed worsen the asthma symptoms, lung function, respiratory distress, medications.9 Underwhelming situation is observed in this regard increased medication use that all end up into asthma instability.28 in five large states of India.10 Those who are nonadherent are at an These factors may also pose risk by inducing genetic variation in increased risk for asthma instability and long-term poor outcome oxidative stress pathway. Living in traffic dense surroundings,