As many as 40 per cent of patients with uncontrolled severe asthma rely on traditional oral corticosteroids – a therapy that can have harmful consequences with overuse.
A lot of us take our breathing for granted. But if you’ve got asthma, there are times when breathing is anything but normal. An asthma attack can bring on wheezing, coughing, chest tightness and the panicked feeling of having the air sucked out of your lungs.
There are 3.8 million Canadians who suffer from asthma, and new research shows more than 70 per cent of people with uncontrolled severe asthma are not able to access modern treatments that improve symptoms and quality of life. Equally concerning, 40 per cent of patients with uncontrolled severe asthma relied on traditional oral corticosteroids – a therapy that can have harmful consequences with overuse.
The study, titled Characterizing uncontrolled severe asthma in Canada (ALERT), was conducted by pharmaceutical company GSK in collaboration with Asthma Canada, and recently presented at physician conferences. It highlights the importance of educating healthcare providers and patients on alternative treatments like injectable biologics that can shut down lung inflammation for better symptom control and reduce oral corticosteroid dependency.
An abstract of the study will be published in the European Respiratory Journal in November.
“One of the indications of poor asthma control is how much oral steroid is being used,” says Dr. Susan Waserman, report contributor and leading allergy and asthma expert based at St. Joseph’s Hospital in Hamilton, Ontario where she is also a professor of medicine at McMaster University.
“Given the current landscape, patients may not have family doctors and have to rely on an emergency room,” she says of people with uncontrolled severe asthma symptoms looking for help. “Often when the emergency room is your first stop, you’re given oral corticosteroids, which is a very common five-day course of therapy. There’s no question that corticosteroids work. They will take care of the inflammation. But this is a temporary fix.”
The ALERT study stresses the need for better identification of uncontrolled patients and easier access to optimal treatment as a priority for patient care.
How many people are impacted? According to the study, about 7.5 per cent of Canadians with asthma have severe asthma which is linked to increased mortality and hospitalization. Of those, 12.7 per cent were classified as having uncontrolled severe asthma. The study also revealed that 72 per cent of patients with uncontrolled severe asthma were not using available biologic therapy.
Often, when these uncontrolled severe asthma patients leave urgent care, they are not going to a doctor for follow-up, assessment and then referred to an asthma specialist for treatment – a “care pathway” that should be accessible to everyone, Waserman explains.
“Clearly, if somebody’s going to an emergency department and getting two courses of oral corticosteroids, they need to be assessed to make sure that everything else has been corrected and they need a specialist.”
Oral corticosteroids along with inhaled medications on a puffer have long been an important treatment option for managing severe asthma. However, oral corticosteroids are known to increase the risk of short and long-term adverse effects, even at low doses.
And for patients without a specialist to direct their treatment, there’s the danger of returning to the ER repeatedly for oral corticosteroids.
“People don’t realize that you don’t need a huge amount of oral corticosteroids to cause trouble. So, what do we worry about? In children, they will interfere with growth,” Waserman says. “In older adults, they will cause weakening of the bones, so people can get osteoporosis and increased risk of fracture.” Some people deal with mood and sleep disturbance, diabetes and blood pressure problems can get worse, and oral corticosteroids can lead to cataracts and glaucoma in the eyes.
“There’s all sorts of things that may arise in the context of overuse of steroids.”
Basically, oral corticosteroids are referred to as “rescue medication.”
“The science has exploded in the past few decades. We have better medications than ever to treat certain allergic diseases, asthma especially. We have guidelines on treatment for asthma. We have five different biologics available for treatment which have changed the course of how people manage,” Waserman says.
The results of biologic therapy for her patients have been life-changing. “These are people who may be on oral corticosteroids either daily or intermittently, and many of them are able to completely cut out oral corticosteroids. They no longer have asthma attacks, and they have a normal quality of life, which is really what we’re looking for.”
Children aged six and older can also receive the therapy.
Not every person with uncontrolled severe asthma requires biologic therapy, but they should be assessed by a specialist for appropriate intervention for better asthma control.
The problem, as the ALERT study has brought to light, is that there are barriers at every step of the way for patients. Waserman talks about visits to family doctors, for people who have them, as not always successful. They may not be aware of the patient red flags for referral, despite efforts to inform GPs about asthma treatment guidelines and new treatments. Further, many family doctors don’t feel there is ready access to specialists, who are the ones who prescribe biologics. Specialists like respirologists and other asthma experts also have long wait times of several months or more.
Then there’s affordability, because government funding requires very specific criteria for patients to qualify and many people can’t afford them out of pocket.
“All of these things do need to be met before somebody is able to start biologics,” adds Waserman. She hopes the ALERT study messaging is widely heard for better identification of uncontrolled severe asthma in patients and access to improved care.