CNS: You can manage your asthma!

(In the lead up to World Asthma Day 2012)
“The suffering and waste of resources caused by not managing asthma effectively are much greater than the cost of effective action.” Dr Nils E Billo, MD, MPH, Executive Director, International Union Against Tuberculosis and Lung Disease (The Union). 42 years old Raashid Ali (name changed), a former TB patient, has been living with asthma since 2004, when he first developed symptoms of breathlessness. Raashid comes from a middle class family and is engaged in his business of 'zardozi' (embroidery with golden threads), the famous work of Lucknow. He underwent an 18 months anti TB treatment in 1990. His uncle died of TB a few years ago and his mother was also suspected of it when he was a kid. “I am okay and fit now, but am in constant touch with the doctor. He has given me an inhaler which I now use intermittently— may be once a week or less. I do not take any oral medication. I spend around Rs 150 (3 US $) per month on my treatment. I do not have any problems in my daily routine. I am indebted to my doctor who has helped me manage the disease and keep it under control.”

Raashid is one of the 235 million people around the world who are affected by asthma which accounts for 1 in every 250 deaths worldwide. India contributes to 10% of the global burden of asthma, with around 3% to 5% of its population being asthmatic. Childhood asthma incidence in India ranges from 2.1% to 11.8%.

The word ‘asthma’ comes from a Greek word meaning ‘panting’ or ‘breathless’. It is a disease of the bronchial tubes (called the airways) that typically presents with “wheezing”, shortness of breath and/or coughing, particularly in children, which are caused by the allergic reaction between a trigger allergen that enters the body and the antibody called the IgE (Immunoglobulin E). This leads on to inflammation and narrowing of the airways, causing spasm difficulty in breathing.

As symptoms of asthma mimic those of other lung diseases it is often difficult to distinguish asthma from other chronic lung diseases like TB, particularly in settings where diagnostic facilities are sub-optimal. So it often goes undiagnosed, or is misdiagnosed, especially in children. According to Dr BP Singh, a renowned chest specialist, “If a child has recurrent cough and upper respiratory tract infection the doctors often misdiagnose this as primary complex and start giving Anti Tuberculosis Treatment. This is a serious concern—you are misdiagnosing the disease and misusing the drug.”

Professor (Dr) Surya Kant, Head of the Pulmonary Medicine Department, Chhatrapati Shahuji Maharaj Medical University (CSMMU), and Chairperson of Indian Chest Society (North) says that, “Usually asthma has a clinical diagnosis. In children, nocturnal or early morning cough is an alarm for asthma, and so is breathlessness during playing. In adults it is episodic breathlessness—not continuous. But a word of caution here— all breathlessness is not asthma, just like all that glitters is not gold.”

Asthma is not curable, but it can be controlled and managed with existing medicines. Hence patient education is essential to help them lead a normal and healthy life. They need to learn how to manage their asthma: how and when to take their medicines and when to seek help from health care facilities. According to Dr BP Singh, “The problem is that most people neither have awareness about the disease nor access to healthcare facilities where they can seek proper treatment. A study conducted in Mumbai found that many clinical physicians themselves were not aware of the exact management of the patients. This is probably one of the biggest hindrances.”

The ideal treatment for controlling asthma is the inhalation therapy. Inhaled corticosteroids are non- addictive and free from side effects even in the long term. Dr Chiang Chen Yuan, Director, Department of Lung Health and NCDs, at the The Union, says that, “By using inhaled corticosteroids, most asthma patients can control their asthma: they will have no symptoms (or very mild symptoms), no asthma attacks, no unplanned emergency hospital visits, no limitation of activities, no airflow limitation and minimal bronchodilator use (2 times per week). Unfortunately, the majority of asthma patients do not use inhaled corticosteroid. The global Asthma Insights and Reality surveys reported that less than 20% of patients with moderate-severe asthma use inhaled corticosteroid. This could be related to, apart from poor affordability, clinicians’ practice, and patients’ preference. However, clinicians are in a position to influence patients’ preference.”

In India also more than 70% asthma patients depend on oral medication. Dr Singh feels that, “In India, people are using less of this drug due to poor prescription, poor adherence to treatment and also due to the myth or patients’ belief that if one uses them there are going to be lot of side effects.”

The truth is that properly dosed inhalers and do not cause any side effects. Inhalation therapy is a targeted delivery of the drug to the lungs and it does not go to any other body organ. In oral medication only 1% of the drug goes to bronchial mucosa and the rest goes to other parts of the body through blood system causing severe side effects. Secondly in inhalation therapy the dose is very small (in micrograms), whereas in oral medication it is of the order of milligrams.

According to Dr Surya Kant, “Inhalation therapy costs around Rs 4-5 per day, making asthma treatment one of the cheapest treatments available in India. Inhalers are just like spectacles. If your bronchial tubes are weak, use an inhaler in the same way as you would use specs if your eyes are weak. As one brushes the teeth daily, so also an asthma patient needs to take the inhaler daily in the morning and evening. This will help control asthma very effectively.”

The Union has worked with the International Study of Asthma and Allergies in Childhood (ISAAC), a research network established more than 20 years ago. It has also established the Asthma Drug Facility (ADF) as a procurement mechanism to provide quality-assured essential aerosol medicines, used routinely in the treatment of asthma, at reduced costs. Since 2010, the ADF has successfully delivered inhaled corticosteroids at low prices to countries in Latin America, the Middle East, South-East Asia and Africa.

Professor Nadia Ait Khaled, The Union's Advisor on Asthma, avers that, “Asthma is under diagnosed and under treated in the world, particularly in resource limited settings. With adequate diagnosis and long term management of asthma, patients could have a normal social and professional life. The number of emergency room visits and hospitalizations will decrease dramatically and consequently decrease the economic and disability burden of patients, families and governments.”

Shobha Shukla - CNS

(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)