Abstracts
OBJECTIVE:
To assess asthma patients in Brazil in terms of the level of asthma control, compliance with maintenance treatment, and the use of rescue medication.
METHODS:
We used data from a Latin American survey of a total of 400 asthma patients in four Brazilian state capitals, all of whom completed a questionnaire regarding asthma control and treatment.
RESULTS:
In that sample, the prevalence of asthma was 8.8%. Among the 400 patients studied, asthma was classified, in accordance with the Global Initiative for Asthma criteria, as controlled, partially controlled, and uncontrolled in 37 (9.3%), 226 (56.5%), and 137 (34.3%), respectively. In those three groups, the proportion of patients on maintenance therapy in the past four weeks was 5.4%, 19.9%, and 41.6%, respectively. The use of rescue medication was significantly more common in the uncontrolled asthma group (86.9%; p < 0.001).
CONCLUSIONS:
Our findings suggest that, in accordance with the established international criteria, asthma is uncontrolled in the vast majority of asthma patients in Brazil. Maintenance medications are still underutilized in Brazil, and patients with partially controlled or uncontrolled asthma are more likely to use rescue medications and oral corticosteroids.
Asthma/therapy; Asthma/prevention and control; Medication adherence
OBJETIVO:
Avaliar pacientes asmáticos no Brasil em relação ao grau de controle da asma, a aderência ao tratamento de manutenção e o uso de medicação de alivio em pacientes asmáticos.
MÉTODOS:
Foram utilizados os dados de um inquérito latino-americano, obtidos em quatro capitais brasileiras, de 400 pacientes com asma através de um questionário sobre o controle e o tratamento da doença.
RESULTADOS:
A prevalência de asma nesta amostra foi de 8,8%. Dos 400 pacientes estudados, 37 (9,3%), 226 (56,5%) e 137 (34,3%), respectivamente, foram classificados, segundo critérios da Global Initiative for Asthma, como tendo asma controlada, parcialmente controlada e não controlada. A proporção de pacientes em terapia de manutenção nas últimas quatro semanas naqueles três grupos, respectivamente, foi de 5,4%, 19,9% e 41,6%. O uso de medicação de alivio foi significativamente mais comum nos pacientes com asma não controlada (86,9%; p < 0,001).
CONCLUSÕES:
Nossos achados sugerem que a grande maioria dos pacientes com asma no Brasil não apresenta sua doença controlada segundo critérios internacionais. As medicações de manutenção ainda são subutilizadas no Brasil, e o uso de medicações de alívio e corticoide oral é mais frequente em pacientes com asma parcialmente controlada ou não controlada.
Asma/terapia; Asma/prevenção e controle; Adesão à medicação
Introduction
Asthma is a worldwide, common chronic disease that affects individuals of all ages and
has a great influence on patient quality of life. (
11. Murphy KR, Meltzer EO, Blaiss MS, Nathan RA, Stoloff SW, Doherty DE.
Asthma management and control in the United States: results of the 2009 Asthma
Insight and Management survey. Allergy Asthma Proc. 2012;
33(1):54-64.
,
22. Sociedade Brasileira de Pneumologia e Tisiologia. Diretrizes da
Sociedade Brasileira de Pneumologia e Tisiologia para o Manejo da Asma 2012. J Bras
Pneumol. 2012;38(Suppl 1) S1-S46.
) In 2006, the International Study of Asthma and Allergies in Childhood
reported that, in Brazil, the prevalence of asthma was 24.3% in schoolchildren and 19.0%
in adolescents,(
33. Asher MI, Montefort S, Björkstén B, Lai CK, Strachan DP, Weiland SK,
et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic
rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat
multicountry cross-sectional surveys. Lancet. 2006;368(9537):733-43.
http://dx.doi.org/10.1016/S0140-6736(06)69283-0
http://dx.doi.org/10.1016/S0140-6736(06)...
,
44. Sole D, Wandalsen GF, Camelo-Nunes IC, Naspitz CK; ISAAC - Brazilian
Group. Prevalence of symptoms of asthma, rhinitis, and atopic eczema among Brazilian
children and adolescents identified by the International Study of Asthma and
Allergies in Childhood (ISAAC) - Phase 3. J Pediatr (Rio J). 2006;82(5):341-6.
http://dx.doi.org/10.1590/S0021-75572006000600006
https://doi.org/10.1590/S0021-7557200600...
) whereas the prevalence of physician-diagnosed asthma was approximately 10%.
Because of its high prevalence, asthma has a major socioeconomic impact,(
55. Amaral LM, Palma PV, Leite IC. Evolution of public policies and
programs for asthma control in Brazil from the perspective of consensus guidelines. J
Bras Pneumol. 2012;38(4):518-25.
http://dx.doi.org/10.1590/S1806-37132012000400015
https://doi.org/10.1590/S1806-3713201200...
) given that, when it is uncontrolled, it can lead to hospitalizations and
school/work absenteeism, as well as being life threatening during attacks.(
66. Neffen H, Baena-Cagnani CE, Malka S, Solé D, Sepúlveda R, Caraballo
L, et al. Asthma mortality in Latin America. J Investig Allergol Clin Immunol.
1997;7(4):249-53.
7. Pereira ED, Cavalcante AG, Pereira EN, Lucas P, Holanda MA. Asthma
control and quality of life in patients with moderate or severe asthma. J Bras
Pneumol. 2011;37(6):705-11.
8. Global Initiative for Asthma (GINA) [homepage on the Internet].
Bethesda: National Heart, Lung and Blood Institute. National Institutes of Health, US
Department of Health and Human Services. [cited 2014 Mar 24]. Guidelines - GINA
Report, Global Strategy for Asthma Management and Prevention. Available from:
http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60
http://www.ginasthma.com/Guidelineitem.a...
-
99. Blaiss MS, Nathan RA, Stoloff SW, Meltzer EO, Murphy KR, Doherty DE.
Patient and physician asthma deterioration terminology: results from the 2009 Asthma
Insight and Management survey. Allergy Asthma Proc.
2012;33(1):47-53.
)
Although there have been effective medications for the treatment of asthma since the
1980s, complete symptom control is not achieved in most patients.(
1010. Szefler SJ. Advancing asthma care: the glass is only half full! J
Allergy Clin Immunol. 2011;128(3):485-94.
http://dx.doi.org/10.1016/j.jaci.2011.07.010
http://dx.doi.org/10.1016/j.jaci.2011.07...
,
1111. Nathan RA, Meltzer EO, Blaiss MS, Murphy KR, Doherty DE, Stoloff SW.
Comparison of the Asthma in America and Asthma Insight and Management surveys: did
asthma burden and care improve in the United States between 1998 and 2009? Allergy
Asthma Proc. 2012;33(1):65-76.
) Because of their anti-inflammatory activity, inhaled corticosteroids are
the therapy of choice in asthma. Maintenance treatment with an inhaled corticosteroid
reduces the frequency and severity of exacerbations and the number of hospitalizations
and emergency room visits, as well as improving quality of life, pulmonary function, and
bronchial hyperresponsiveness and decreasing exercise-induced
bronchoconstriction.(
22. Sociedade Brasileira de Pneumologia e Tisiologia. Diretrizes da
Sociedade Brasileira de Pneumologia e Tisiologia para o Manejo da Asma 2012. J Bras
Pneumol. 2012;38(Suppl 1) S1-S46.
) Despite all the known benefits of this treatment, the Asthma Insights and
Reality in Latin America (AIRLA) survey reported that only 6% of the asthma patients
were using an inhaled corticosteroid.(
1212. Neffen H, Fritscher C, Schacht FC, Levy G, Chiarella P, Soriano JB,
et al. Asthma control in Latin America: the Asthma Insights and Reality in Latin
America (AIRLA) survey. Rev Panam Salud Publica. 2005;17(3):191-7.
http://dx.doi.org/10.1590/S1020-49892005000300007
https://doi.org/10.1590/S1020-4989200500...
) Inadequate maintenance treatment has a direct influence on the rate of
disease control. Many studies have shown that, even in the 2000s, only one third of the
asthma patients had totally controlled asthma.(
1313. Adams RJ, Fuhlbrigge A, Guilbert T, Lozano P, Martinez F. Inadequate
use of asthma medication in the United States: results of the asthma in America
national population survey. J Allergy Clin Immunol. 2002;110(1):58-64.
http://dx.doi.org/10.1067/mai.2002.125489
https://doi.org/10.1067/mai.2002.125489...
,
1414. Navarro RP, Schaecher KL, Rice GK. Asthma management guidelines:
updates, advances, and new options. J Manag Care Pharm. 2007;13(6 Suppl D):S3-11;
quiz S12-3.
) In the AIRLA survey, only 2.6% of the patients had well-controlled
asthma.(
1212. Neffen H, Fritscher C, Schacht FC, Levy G, Chiarella P, Soriano JB,
et al. Asthma control in Latin America: the Asthma Insights and Reality in Latin
America (AIRLA) survey. Rev Panam Salud Publica. 2005;17(3):191-7.
http://dx.doi.org/10.1590/S1020-49892005000300007
https://doi.org/10.1590/S1020-4989200500...
)
Several guidelines have been published to disseminate the appropriate management of
asthma, on the basis of current clinical evidence.(
22. Sociedade Brasileira de Pneumologia e Tisiologia. Diretrizes da
Sociedade Brasileira de Pneumologia e Tisiologia para o Manejo da Asma 2012. J Bras
Pneumol. 2012;38(Suppl 1) S1-S46.
,
88. Global Initiative for Asthma (GINA) [homepage on the Internet].
Bethesda: National Heart, Lung and Blood Institute. National Institutes of Health, US
Department of Health and Human Services. [cited 2014 Mar 24]. Guidelines - GINA
Report, Global Strategy for Asthma Management and Prevention. Available from:
http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60
http://www.ginasthma.com/Guidelineitem.a...
) They contain objective strategies for assessing and measuring asthma
control, as well as therapeutic recommendations and plans for asthma-related education.
Those guidelines are expected to make it possible to reduce the impact of asthma on the
lives of patients and to achieve complete asthma control.
In 2011, the Latin America Asthma Insight and Management (LA AIM) survey(
1515. Maspero JF, Jardim JR, Aranda A, Tassinari C P, Gonzalez-Diaz SN,
Sansores RH, et al. Insights, attitudes, and perceptions about asthma and its
treatment: findings from a multinational survey of patients from Latin America. World
Allergy Organ J. 2013;6(1):19.
) was designed to assess the impact of asthma on the lives of patients, their
perception of their symptoms, and the prescribed treatment for the disease. The results
of that survey made it possible to assess asthma control in those patients in accordance
with the Global Initiative for Asthma (GINA) guidelines.(
88. Global Initiative for Asthma (GINA) [homepage on the Internet].
Bethesda: National Heart, Lung and Blood Institute. National Institutes of Health, US
Department of Health and Human Services. [cited 2014 Mar 24]. Guidelines - GINA
Report, Global Strategy for Asthma Management and Prevention. Available from:
http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60
http://www.ginasthma.com/Guidelineitem.a...
)
The present study analyzed the data collected by the LA AIM survey in Brazil in order to determine the medications used (maintenance and rescue medications) and compliance with treatment, as well as to relate these variables to the level of asthma control.
Methods
In 2011, the LA AIM survey, conducted in five Latin American countries (Argentina, Brazil, Mexico, Venezuela, and Puerto Rico), was designed using the same methods as the Asthma Insight and Management Study (AIM) conducted in the United States.( 1616. Meltzer EO, Blaiss MS, Nathan RA, Doherty DE, Murphy KR, Stoloff SW. Asthma burden in the United States: results of the 2009 Asthma Insight and Management survey. Allergy Asthma Proc. 2012;33(1):36-46. ) The present study is based on the analysis of the Brazilian data from the LA AIM survey.
In Brazil, 4,545 households were randomly selected from a national probability sample in four cities: São Paulo; Rio de Janeiro; Curitiba; and Salvador. The population surveyed consisted of adults over 18 years of age and parents/caregivers of adolescents between 12 and 17 years of age; the individuals selected should have physician-diagnosed asthma. After the households that were initially selected were contacted by phone, 400 asthma patients were selected to be interviewed in person. The interviews lasted a maximum of 35 min. The questionnaire consisted of 53 questions that addressed five asthma topics: symptoms; impact of asthma on daily activities; perception of asthma control; exacerbations; and treatment and medications.
The questions about symptoms covered daytime and nighttime symptom frequency in the past four weeks, symptom frequency during the worst month of the past 12 months, the most bothersome symptom, triggering symptoms, symptom seasonality, and the frequency of symptom worsening. Respondents were asked whether they or their children had sought medical attention during exacerbations, symptom worsening, or severe acute episodes in the past year.
Regarding treatment, respondents were asked about the use of maintenance and rescue medications in the past four weeks and whether their physician had provided a written action plan for asthma management. Patients were investigated as to whether they used maintenance medication every day, whether that medication was necessary when the symptoms were not present, and whether rescue medication could be used every day, if necessary.
The present study was approved by the Research Ethics Committee of the Federal University of São Paulo Hospital São Paulo (Ruling no. 250155).
Statistical analysis
Categorical data are presented as absolute values and percentages, and continuous data are presented as mean and standard deviation. The chi square test was used for the comparison of categorical data among the groups studied (controlled, partially controlled, and uncontrolled asthma), and ANOVA was used for the comparison of means. Tukey's post hoc test was used. A value of p < 0.05 was considered statistically significant.
Results
The characteristics of the asthma patients in Brazil are shown in Table 1, by groups determined by GINA classification. In that Brazilian sample, the proportion of asthma patients was 8.8%. In accordance with the GINA criteria for asthma control, asthma was classified as controlled in 37 patients (9.3%), as partially controlled in 226 (56.5%), and as uncontrolled in 137 (34.3%).
The mean age was lower in the controlled asthma group than in the uncontrolled asthma group (31.1 ± 9.9 years vs. 39.3 ± 16.6 years; p = 0.03). In all groups, females predominated, especially in the uncontrolled asthma group (76.6%; p = 0.02). Most patients had pets, regardless of the group. In the controlled asthma group, 75.6% of the patients were never smokers. The presence or absence of smokers in the household did not affect asthma control (Table 1).
The medications used in the treatment of asthma are shown in Table 2. Regarding the use of maintenance medication in the past four weeks, 94.6% of the patients with controlled asthma reported that they were not using any maintenance medication regularly, whereas 80.1% of those with partially controlled asthma and 58.4% of those with uncontrolled asthma stated the same (p < 0.001). The use of rescue medication (short-acting β2 agonists) progressively increased as a function of poor asthma control, with 86.9% of the patients with uncontrolled asthma reporting their use (p < 0.001).
Oral corticosteroid use during an asthma attack was assessed in the past 12 months. The rates of oral corticosteroid use during an asthma attack were 45.9%, 40.7%, and 56.2%, respectively, in the controlled, partially controlled, and uncontrolled asthma groups, without significant difference (p = 0.06).
During the personal interview, participants reported what medications they had used for maintenance treatment of asthma and relief of symptoms in the past four weeks. Subsequently, a list of trade names of medications was presented to participants so that they could indicate the one(s) that they were using for maintenance treatment. The exact same list was presented to patients so that they could then identify the medication(s) used for relief of symptoms.
Most patients in the controlled asthma group reported that they were not using maintenance medication (55.6%), whereas among those in the partially controlled and uncontrolled asthma groups, the most commonly used medication was a short-acting bronchodilator (35.8% and 53.3%, respectively). Only 2.8% of the individuals in the controlled asthma group were using an inhaled corticosteroid, either alone or in combination with a long-acting β2 agonist. The rate of inhaled corticosteroid use was also very low in the partially controlled and uncontrolled asthma groups (12.9% and 24.1%, respectively). The use of a long-acting β2 agonist alone was reported by 5.6% and 3.5% of the patients in the controlled and partially controlled asthma groups, respectively. Only one patient in the partially controlled asthma group reported using tiotropium (Table 3).
Regarding rescue medications, 12.1% and 10.9% of the individuals in the controlled and partially controlled asthma groups, respectively, reported that they were not using any rescue medication. In contrast, all patients in the uncontrolled asthma group used at least one medication they referred to as rescue medication. The vast majority of patients in the three groups used a short-acting bronchodilator (66.7%, 71.5%, and 80.6% in the controlled, partially controlled, and uncontrolled asthma groups, respectively). An inhaled corticosteroid was considered rescue medication by some patients (3.0%, 2.3%, and 4.5% in the same groups, respectively), as were the combination of an inhaled corticosteroid and a long-acting β2 agonist (0.0%, 3.2%, and 9.0%, respectively) and a long-acting β2 agonist alone (9.1%, 2.7%, and 0.0%, respectively; Table 4).
Those patients who had asthma attacks in the past 12 months were asked whether, during an attack, their use of rescue medication was higher than, lower than, or equal to their daily use. All groups reported an increased need to use rescue medication (30.0%, 64.9%, and 57.1% of the patients in the controlled, partially controlled, and uncontrolled asthma groups, respectively), although the increase was more pronounced in the partially controlled and uncontrolled asthma groups (p = 0.002 in relation to the controlled asthma group; data not shown in tables).
In the sample as a whole, 42.0% of the asthma patients reported that their physician had provided a written treatment action plan, explaining the need for maintenance treatment and when to use the rescue medication.
In addition, 41% of the patients reported that they fully or partially agreed with the idea that the rescue medication should be used daily, regardless of the presence of symptoms. Regarding continuous inhaled corticosteroid use, 62.3% of the patients said that it was a cause for concern, and, when categorized into groups, 51.3%, 57.5%, and 73.0% of the patients in the controlled, partially controlled, and uncontrolled asthma groups, respectively, reported that concern. The reasons given by patients for their fear of using an inhaled corticosteroid were its side effects, concern about its safety and long-term effects, and concern about dependence.
Discussion
The present study has shown that, in accordance with GINA criteria,(
88. Global Initiative for Asthma (GINA) [homepage on the Internet].
Bethesda: National Heart, Lung and Blood Institute. National Institutes of Health, US
Department of Health and Human Services. [cited 2014 Mar 24]. Guidelines - GINA
Report, Global Strategy for Asthma Management and Prevention. Available from:
http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60
http://www.ginasthma.com/Guidelineitem.a...
) asthma is uncontrolled in the vast majority of asthma patients in Brazil. A
small proportion of patients in the uncontrolled and partially controlled asthma groups
used maintenance medication, and, consequently, they were the ones who used oral
corticosteroids and rescue medication the most often in the past 12 months.
Because the inclusion criterion for the present study was having received a physician
diagnosis of asthma, the observed proportion of asthma patients was 8.8%, which is very
similar to the prevalence of physician-diagnosed asthma in Brazil, according to the
International Study of Asthma and Allergies in Childhood.(
1717. Worldwide variations in the prevalence of asthma symptoms: the
International Study of Asthma and Allergies in Childhood (ISAAC). Eur Respir J.
1998;12(2):315-35. http://dx.doi.org/10.1183/09031936.98.12020315
https://doi.org/10.1183/09031936.98.1202...
) Therefore, it is possible that our results reflect the national situation
regarding asthma control. Nevertheless, the objective of the present study was not to
assess the prevalence of asthma in Brazil, but rather to assess patient's use of
medications.
The poor control of asthma in Latin America has been known since 2003, when the AIRLA
survey showed that asthma was totally controlled in only 2.6% of the adult patients with
asthma and in 2.4% of the children with asthma.(
1212. Neffen H, Fritscher C, Schacht FC, Levy G, Chiarella P, Soriano JB,
et al. Asthma control in Latin America: the Asthma Insights and Reality in Latin
America (AIRLA) survey. Rev Panam Salud Publica. 2005;17(3):191-7.
http://dx.doi.org/10.1590/S1020-49892005000300007
https://doi.org/10.1590/S1020-4989200500...
) The design of our study was similar to that of the AIRLA survey, and,
although our study used other criteria for classifying asthma control (daytime and
nighttime symptoms, exercise-induced symptoms, and overall severity of symptoms), the
two studies showed similar results. The fact that the current number of patients with
controlled asthma is approximately nearly three times that of 10 years ago, according to
the AIRLA survey, should not be seen as encouraging, because, for a disease for which
treatment and treatment effectiveness are well known, 8% is a very low number.
Despite widespread knowledge that inhaled steroids are the medication of choice as asthma controllers, we found that most patients did not use them. The fact that only 5.4% of the patients with controlled asthma had used maintenance medication in the past four weeks may reflect that this group consists of patients with mild disease, not requiring continuous inhaled corticosteroid use. However, approximately half of those patients had to take an oral corticosteroid during an asthma attack, which demonstrates that, at some time in the year, asthma was uncontrolled in those patients. Only 19.9% of the patients with partially controlled asthma and 41.6% of those with uncontrolled asthma reported that they had used maintenance medication in the past month, despite the fact that they reported rescue medication use. In the AIM survey conducted in the United States in 2009,( 1818. Gold LS, Smith N, Allen-Ramey FC, Nathan RA, Sullivan SD. Associations of patient outcomes with level of asthma control. Ann Allergy Asthma Immunol. 2012;109(4):260-265.e2. ) the observed proportion of patients who used maintenance medication in the controlled asthma group in that country (32%) was higher than that in Brazil. The fact that inhaled corticosteroids were used by a higher proportion of American patients than of Brazilian patients could be the reason for the lower rate of hospital visits and admissions among American patients with asthma. Likewise, the proportion of patients who used rescue medication in the United States was lower in all groups, which reinforces the idea that asthma is better controlled in patients who use maintenance medication more often.( 1818. Gold LS, Smith N, Allen-Ramey FC, Nathan RA, Sullivan SD. Associations of patient outcomes with level of asthma control. Ann Allergy Asthma Immunol. 2012;109(4):260-265.e2. ) A study conducted at a referral center for the treatment of pediatric asthma in Brazil reported that symptoms were controlled in 45% of the patients.( 1919. Kinchoku VM, Oliveira IS, Watanabe LA, Fomin AB, Castro AP, Jacob CM, et al. Factors associated with asthma control in a pediatric reference center. Rev Paul Pediatr. 2011;29(4):591-8. ) This shows us that, even at a referral center for the treatment of asthma, although the reported rate of disease control was much higher than that found in the present study, asthma control was achieved in only half of the patients.
In 2003, the rate of inhaled corticosteroid use in Latin America was 6%.(
1212. Neffen H, Fritscher C, Schacht FC, Levy G, Chiarella P, Soriano JB,
et al. Asthma control in Latin America: the Asthma Insights and Reality in Latin
America (AIRLA) survey. Rev Panam Salud Publica. 2005;17(3):191-7.
http://dx.doi.org/10.1590/S1020-49892005000300007
https://doi.org/10.1590/S1020-4989200500...
) In the present study, 15.8% of the patients had been on maintenance therapy
in the past four weeks, when assessed by medication use. Although this rate is below
ideal, with the ideal scenario being inhaled corticosteroid use by all patients with
partially controlled or uncontrolled asthma, it is two and a half times higher than that
reported by the AIRLA survey, demonstrating a significant improvement towards meeting
the goal established in the guidelines. The low number of patients who used an inhaled
corticosteroid could reflect two situations: physicians are not prescribing controller
medication properly, which is in clear noncompliance with the Brazilian Thoracic
Association guidelines(
22. Sociedade Brasileira de Pneumologia e Tisiologia. Diretrizes da
Sociedade Brasileira de Pneumologia e Tisiologia para o Manejo da Asma 2012. J Bras
Pneumol. 2012;38(Suppl 1) S1-S46.
) and the GINA guidelines;(
88. Global Initiative for Asthma (GINA) [homepage on the Internet].
Bethesda: National Heart, Lung and Blood Institute. National Institutes of Health, US
Department of Health and Human Services. [cited 2014 Mar 24]. Guidelines - GINA
Report, Global Strategy for Asthma Management and Prevention. Available from:
http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60
http://www.ginasthma.com/Guidelineitem.a...
) or patients are poorly compliant with maintenance therapy, which would
demonstrate their poor understanding of the disease and its treatment. When asked
whether they had some concern about using an inhaled corticosteroid continuously, 62.3%
of the patients responded affirmatively, which shows us that most patients were not
informed of or did not understand the importance of maintenance treatment of asthma.
This demonstrates that greater educational intervention is needed to resolve patient
uncertainties about the safety of the medication, its possible side effects, and its
long-term benefits. Other factors that may explain the poor treatment compliance are
poor symptom perception by the patients, difficult access to medical appointments,
medication cost, and medication dose schedule.
A study conducted at a referral center for the treatment of severe asthma in the state of Bahia,( 2020. Santos Pde M, D'Oliveira A Jr, Noblat Lde A, Machado AS, Noblat AC, Cruz AA. Predictors of adherence to treatment in patients with severe asthma treated at a referral center in Bahia, Brazil. J Bras Pneumol. 2008;34(12):995-1002 ) Brazil, in which educational strategies were used, reported high compliance with inhaled corticosteroid use (83.8%). This shows that the use of appropriate patient education strategies makes it possible to achieve optimal treatment. The factors related to patient noncompliance in that study were medication adverse effects, living far from the referral center, limited resources to pay for transportation to and from the center, and dose schedule.( 2020. Santos Pde M, D'Oliveira A Jr, Noblat Lde A, Machado AS, Noblat AC, Cruz AA. Predictors of adherence to treatment in patients with severe asthma treated at a referral center in Bahia, Brazil. J Bras Pneumol. 2008;34(12):995-1002 )
Analysis of Tables 3 and 4, which depict the medications reported by patients as being used, shows that there is clear confusion between maintenance and rescue therapy, i.e., patients have difficulty acknowledging the role of each type of therapy in the treatment of asthma. Some patients were using an inhaled corticosteroid alone for relief of symptoms. A cause for even greater concern is that there were patients (5.6% and 3.5% in the controlled and partially controlled asthma groups, respectively) who were using a long-acting β2 agonist alone, which is absolutely advised against in the treatment of asthma. Once again, the lack of understanding of the disease and its treatment on the part of patients is evident.
Rescue short-acting bronchodilator use is one of the markers of asthma severity, and, in the present study, the patients in greatest need for rescue medication use were found to be those in the partially controlled and uncontrolled asthma groups. An assessment of the medications used for relief of symptoms in the past four weeks, as indicated by the name of the medication, showed that their rate of use, in the three groups, ranged from 66% to 80% (Table 4). This is another indication of underuse of maintenance medication, because it reflects the high number of patients who used rescue medication. This high rate of rescue medication use shows that patients were still having asthma attacks, suggesting that the doses of maintenance medication were insufficient. One limitation of the administered questionnaire in terms of short-acting bronchodilator use was that patients were asked solely whether they had or had not used the medication in the past four weeks, rather than being asked about the frequency of use. This information was partially taken into account when classifying asthma control.
Oral corticosteroid use, another marker of poor asthma control, shows a trend toward being increased in the partially controlled and uncontrolled asthma groups. The need for oral corticosteroid use, in all groups, was higher in Brazil than in the United States (controlled asthma, 45.9% vs. 15%; partially controlled asthma, 40.7% vs. 40%; uncontrolled asthma, 56.2% vs. 45%). ( 1818. Gold LS, Smith N, Allen-Ramey FC, Nathan RA, Sullivan SD. Associations of patient outcomes with level of asthma control. Ann Allergy Asthma Immunol. 2012;109(4):260-265.e2. ) In 2009, a study of asthma education that was conducted in Brazil and followed patients over a two-year period reported an association between reduced oral corticosteroid use and increased compliance with maintenance treatment, emphasizing the importance of educational interventions for asthma control.( 2121. Angelini L, Robles-Ribeiro PG, Carvalho-Pinto RM, Ribeiro M, Cukier A, Stelmach R. Two-year evaluation of an educational program for adult outpatients with asthma. J Bras Pneumol. 2009;35(7):618-27. )
It is of interest that the number of patients who reported having a written treatment
plan in Brazil (41%) was higher than that in the United States (32%).(
1515. Maspero JF, Jardim JR, Aranda A, Tassinari C P, Gonzalez-Diaz SN,
Sansores RH, et al. Insights, attitudes, and perceptions about asthma and its
treatment: findings from a multinational survey of patients from Latin America. World
Allergy Organ J. 2013;6(1):19.
) In the AIRLA survey,(
1212. Neffen H, Fritscher C, Schacht FC, Levy G, Chiarella P, Soriano JB,
et al. Asthma control in Latin America: the Asthma Insights and Reality in Latin
America (AIRLA) survey. Rev Panam Salud Publica. 2005;17(3):191-7.
http://dx.doi.org/10.1590/S1020-49892005000300007
https://doi.org/10.1590/S1020-4989200500...
) in 2003, the observed proportion of adult patients who had a prepared
action plan (38%) was very similar to the current number, which demonstrates that,
despite the Brazilian Thoracic Association guidelines(
22. Sociedade Brasileira de Pneumologia e Tisiologia. Diretrizes da
Sociedade Brasileira de Pneumologia e Tisiologia para o Manejo da Asma 2012. J Bras
Pneumol. 2012;38(Suppl 1) S1-S46.
) and the GINA guidelines,(
88. Global Initiative for Asthma (GINA) [homepage on the Internet].
Bethesda: National Heart, Lung and Blood Institute. National Institutes of Health, US
Department of Health and Human Services. [cited 2014 Mar 24]. Guidelines - GINA
Report, Global Strategy for Asthma Management and Prevention. Available from:
http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60
http://www.ginasthma.com/Guidelineitem.a...
) there has been no progress on this issue.
The design of the present study was the same as that of the AIM survey(
1616. Meltzer EO, Blaiss MS, Nathan RA, Doherty DE, Murphy KR, Stoloff SW.
Asthma burden in the United States: results of the 2009 Asthma Insight and Management
survey. Allergy Asthma Proc. 2012;33(1):36-46.
) and was similar to that of the AIRLA survey.(
1212. Neffen H, Fritscher C, Schacht FC, Levy G, Chiarella P, Soriano JB,
et al. Asthma control in Latin America: the Asthma Insights and Reality in Latin
America (AIRLA) survey. Rev Panam Salud Publica. 2005;17(3):191-7.
http://dx.doi.org/10.1590/S1020-49892005000300007
https://doi.org/10.1590/S1020-4989200500...
) However, some limitations were found in our study. Only four Brazilian
cities were assessed in the study, which means that the study sample may not be
representative of the general population in Brazil. It is very difficult to cover the
entire population of a country in studies with this type of design, though.
Nevertheless, because each of the included cities is located in a different area of the
country, this limitation is mitigated. Another limitation was the fact that spirometry,
a test that is also part of the criteria for asthma control, was not performed. However,
given that the primary objective of the study was to characterize the reality of
patients and their daily routine, classification of asthma control solely on the basis
of the questionnaire responses was enough to show that the goal of attaining disease
control has yet to be achieved in asthma management. Finally, the data on the diagnosis
of asthma and the other data were obtained by self-report rather than from medical
record abstraction.
On the basis of this study, we conclude that, in accordance with GINA criteria, asthma is not adequately controlled in the vast majority of asthma patients in Brazil, and this poor control should be attributed to underuse of maintenance medication. Consequently, we found that rescue medications and oral corticosteroids are very often used by patients with partially controlled or uncontrolled asthma. Therefore, greater efforts should be made to ensure that proper asthma treatment is prescribed and that compliance with the treatment plan is achieved.
References
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*
Study carried out at the Federal University of São Paulo Paulista School of Medicine, São Paulo, Brazil
Publication Dates
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Publication in this collection
Sep-Oct 2014
History
-
Received
24 Mar 2014 -
Accepted
15 July 2014