With 5.4 million people in the UK living with asthma2, you may suffer from it personally or know someone who has it. Our familiarity with asthma means that many refer to it as “just asthma”. However, asthma is a serious, inflammatory disease requiring regular inhaled anti-inflammatory treatment to reduce symptoms and prevent severe asthma attacks. In the UK, it is estimated that someone with asthma suffers an attack every ten seconds3 . Any severe attack is a terrifying event and can be life-threatening. With approximately 75,000 people hospitalised for severe attacks each year4, rates of hospital admission and mortality in the UK are amongst the worst in Europe1.
Fundamentally, asthma is an inflammatory disease and therefore the foundation of care is inhaled corticosteroid (ICS) treatment5. ICS-containing “preventer inhalers” (typically brown but come in many colours) reduce inflammation in the airways, preventing symptoms from worsening and reducing the risk of an attack. One of the biggest contributors to the growing burden of asthma attacks is a systematic over-reliance on “rescue” therapies – in particular, the “blue inhaler”.
Despite numerous effective preventer inhalers available, people with asthma instead primarily seek quick relief from their asthma symptoms by using their blue inhaler6. Evidence suggests that people who use blue inhalers excessively are at a greater risk of having an asthma attack7. Indeed, the use of three or more blue inhalers in a single year is associated with a two-fold increase in the risk of having a severe attack8. Disappointingly, in the UK, we dispense 15.5 million blue inhalers to asthma patients each year (~three per person on average), which is amongst the highest in the world9 and suggests a large number of people may be sub-optimally treated. Used alone, blue inhalers possess no anti-inflammatory properties and therefore do not address the cause of the disease, the inflammation6,10.
Another consequence of the over-reliance on blue inhalers beyond the associated attacks, is the over-prescribing of steroid tablets to treat them. Oral corticosteroids (OCS) may be used in short bursts as a life-saving treatment for attacks but frequent use of OCS courses may be an indicator of sub-optimal asthma care7,11.OCS tablets are associated with significant side effects12, and even short courses can have a significant impact on patients13. Side effects can include weight gain, mood changes, and the increased risk of osteoporosis, hypertension, heart attack, and stroke, amongst others14.
Furthermore, people with severe asthma, a significant form of the disease that is not controlled with high doses of inhaled medication, are frequently treated with OCS12. In light of the side-effects associated with OCS and despite numerous “precision” medicines now available to treat severe asthma, only a small proportion of approximately 200,000 people living with severe disease in the UK today are given access to these medicines2.
The over-reliance on rescue treatments in the UK is contributing to poor national asthma outcomes and is increasing the risk of asthma attacks. Furthermore a reliance on frequent OCS courses may be causing unnecessary harm to people with asthma. Given the extraordinary circumstances of recent months and the heightened need to keep high risk people out of hospital, now is the time to seek better outcomes for all people living with asthma.
It is more critical than ever that we all adopt a mindset of zero tolerance for asthma attacks – people with asthma must come to understand the cause of their disease and use the appropriate anti-inflammatory medicines to treat it. Only then, will asthma ever be “just asthma”.
Job code: GB-22177 Date of preparation: July 2020
This article originally appeared as part of a special report on asthma care in the UK. To download a PDF of the full report, please click here.
Dr Alexander de Giorgio-Miller is Vice President for Medical and Scientific Affairs at AstraZeneca.
1 – European Lung White Book. Adult asthma. European Respiratory Society Sheffield; 2019. Available from https://www.erswhitebook.org/chapters/adult-asthma/ (Accessed July 2020)
2 – Asthma UK. Slipping through the net: The reality facing patients with difficult and severe asthma. 2018. Available from: https://www.asthma.org.uk/globalassets/get-involved/external-affairs-campaigns/publications/severe-asthma-report/auk-severe-asthma-gh-final.pdf (Accessed July 2020)
3 – nhs.uk. Asthma attacks. 2018. Available at: https://www.nhs.uk/conditions/asthma/asthma-attack/ (Accessed July 2020)
4 – Asthma UK. Asthma data visualisations. 2020. Available at: https://www.asthma.org.uk/support-us/campaigns/data-visualisations/ (Accessed July 2020)
5 – National Institute for Health and Care Excellence (NICE). Asthma: diagnosis, monitoring and chronic asthma management [NG80]. 2017. Available from https://www.nice.org.uk/guidance/ng80/chapter/Recommendations#diagnostic-summary (Accessed July 2020)
6 – O’Byrne P, Jenkins C and Bateman E. The paradoxes of asthma management: time for a new approach? Eur Respir J. 2017;50:1701103. https://erj.ersjournals.com/content/50/3/1701103 (Accessed July 2020)
7 – Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths. 2014. Available at: https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills (Accessed July 2020)
8 – Stanford RH, Shah MB, D’Souza AO et al. Short-acting-sagonist use and its ability to predict future asthma-related outcomes. Ann Allergy Asthma Immunol. 2012;109(6):403– 407 https://doi.org/10.1016/j.anai.2012.08.014 (Accessed July 2020)
9 – AstraZeneca UK Ltd. Data on File. ID: REF-74617 (Accessed July 2020)
10 – Pavord ID, Beasley R, Agusti A et al. After asthma: redefining airways diseases. Lancet. 2018;391:350-400. https://pubmed.ncbi.nlm.nih.gov/28911920/ (Accessed July 2020)
11 – Global Initiative for Asthma. 2019 GINA report, Global strategy for asthma management and prevention. 2019. https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf Accessed July 2020)
12 – Asthma UK. Living in limbo: the scale of unmet need in difficult and severe asthma. 2019. Available at: https://www.asthma.org.uk/69841483/globalassets/get-involved/external-affairs-campaigns/publications/living-in-limbo/living-in-limbo—the-scale-of-unmet-need-in-difficult-and-severe-asthma.pdf (Accessed July 2020)
13 – Price et al. Short-course systemic corticosteroids in asthma: striking the balance between efficacy and safety. European Respiratory Review. 2020. 29, 190151. (Accessed July 2020)
14 – BNF National Institute of Health and Care Excellence. Prednisolone: Side Effects. Available from: https://bnf.nice.org.uk/ drug/prednisolone.html#sideEffects (Accessed July 2020)
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