Asthma management in low and middle income countries: case for change

Abstract

Asthma is the most common noncommunicable disease in children, and among the most common in adults. The great majority of people with asthma live in low and middle income countries (LMICs), which have disproportionately high asthma-related morbidity and mortality. Essential inhaled medications, particularly those containing inhaled corticosteroids (ICS), are often unavailable or unaffordable, and this explains much of the global burden of preventable asthma morbidity and mortality. Guidelines developed for LMICs are generally based on the outdated assumption that patients with asthma symptoms <1-3 times per week do not need (or benefit from) ICS. Even when ICS are prescribed, many patients manage their asthma with oral or inhaled short-acting β₂-agonists (SABA) alone, owing to issues of availability and affordability. A single ICS-formoterol inhaler-based approach to asthma management for all severities of asthma, from mild to severe, starting at diagnosis, might overcome SABA overuse/over-reliance and reduce the burden of symptoms and severe exacerbations. However, ICS-formoterol inhalers are currently very poorly available or unaffordable in LMICs. There is a pressing need for pragmatic clinical trial evidence of the feasibility and cost-effectiveness of this and other strategies to improve asthma care in these countries. The global health inequality in asthma care that deprives so many children, adolescents and adults of healthy lives and puts them at increased risk of death, despite the availability of highly effective therapeutic approaches, is unacceptable. A World Health Assembly Resolution on universal access to affordable and effective asthma care is needed to focus attention and investment on addressing this need.

FIGURE 1

Deaths and disability due to asthma 1990–2019. a) Number of deaths and disability-adjusted life years (DALYs) due to asthma according to World Bank income category for both sexes and all ages. Between 1990 and 2019 the number of deaths and DALYs in lower middle income countries far exceeded those of other income brackets. b) Percentage of deaths and DALYs due to asthma according to World Bank income category for both sexes and all ages. In 2019, rates of asthma deaths were highest in lower middle income countries, followed by low income countries. By 2019, disease burden (DALYs) in lower middle income countries had overtaken that of high income countries. Both death rates and DALYs have been increasing in low income countries, and DALYs in lower middle income countries. In contrast, deaths and disease burden have decreased steadily in high income countries from 1990 to 2019. Adapted from [6].

FIGURE 2

Global Initiative for Asthma (GINA) recommendations for management of asthma in adolescents and adolescents. GINA treatment steps for adults and adolescents are divided into two tracks, depending on the inhaled reliever medication. Within Track 1 (preferred approach), low-dose inhaled corticosteroid (ICS)–formoterol is the reliever at all steps. Within track 2 (alternative approach), short-acting β₂-agonist (SABA) is the reliever at all steps. LAMA: long-acting muscarinic antagonist; Ig: immunoglobulin; IL: interleukin; LABA: long-acting β₂-agonist; LTRA: leukotriene receptor antagonist; HDM: house dust mite; SLIT: sublingual immunotherapy; OCS: oral corticosteroids. Reproduced from [11] with permission.