Inadequate antiasthma drug use in the north of Italy

The Danish National Database for Asthma: establishing clinical quality indicators

Asthma is one of the most common chronic diseases worldwide affecting more than 300 million people. Symptoms are often non-specific and include coughing, wheezing, chest tightness, and shortness of breath. Asthma may be highly variable within the same individual over time. Although asthma results in death only in extreme cases, the disease is associated with significant morbidity, reduced quality of life, increased absenteeism, and large costs for society. Asthma can be diagnosed based on report of characteristic symptoms and/or the use of several different diagnostic tests. However, there is currently no gold standard for making a diagnosis, and some degree of misclassification and inter-observer variation can be expected. This may lead to local and regional differences in the treatment, monitoring, and follow-up of the patients. The Danish National Database for Asthma (DNDA) is slated to be established with the overall aim of collecting data on all patients treated for asthma in Denmark and systematically monitoring the treatment quality and disease management in both primary and secondary care facilities across the country. The DNDA links information from population-based disease registers in Denmark, including the National Patient Register, the National Prescription Registry, and the National Health Insurance Services register, and potentially includes all asthma patients in Denmark. The following quality indicators have been selected to monitor trends: first, conduction of annual asthma control visits, appropriate pharmacological treatment, measurement of lung function, and asthma challenge testing; second, tools used for diagnosis in new cases; and third, annual assessment of smoking status, height, and weight measurements, and the proportion of patients with acute hospital treatment. The DNDA will be launched in 2016 and will initially include patients treated in secondary care facilities in Denmark. In the nearby future, the database aims to include asthma diagnosis codes and clinical data registered by general practitioners and specialised practitioners as well.

The impact of allergic rhinitis on the management of asthma in a working population

Background

Currently, little data is available about the management of asthma in the working population. The aim of this study was to describe asthma control and severity among workers according to current or previous allergic rhinitis comorbidity.

Methods

A network of occupational physicians participated in this pilot study on a voluntary basis. They included a random sample of salaried workers during their systematic occupational medical check-up. All subjects completed a self-administered questionnaire based on the European Community Respiratory Health Survey screening questionnaire, and if they reported any respiratory symptoms including allergic rhinitis, the physician filled in a medical questionnaire. Current asthma control and severity were evaluated according to 2006 Global Initiative for Asthma guidelines.

Results

A total of 110 occupational physicians from two French regions participated. Out of the 6906 employees screened, 3102 identified respiratory symptoms and completed the medical questionnaire and performed spirometry. Overall, 374 were identified as current asthmatics, including 271 (72.5 %) with allergic rhinitis. Among current asthmatics with current allergic rhinitis (n = 95), 68.8 % had partially controlled asthma or uncontrolled asthma, including 51.6 % who received insufficient anti-asthmatic treatment. Partly or no control asthma was not associated with current rhinitis (OR = 1.4; 95 % CI: 0.8-2.7). Current asthmatics with current or previous allergic rhinitis had a significantly lower risk of emergency department visits than current asthmatics without allergic rhinitis (respectively 11.6, 17.1 and 29.1 %; P = 0.002).

Conclusions

Most current asthmatics both with and without allergic rhinitis had uncontrolled asthma, with inappropriate treatment. Future intervention strategies need to be developed for effective control and prevention of asthma in the workplace.

Pattern of asthma medication use among children from a large urban center in Brazil

PURPOSE

Despite the advances in asthma therapeutics, there are few data on the use and determinants of anti-asthmatic drugs in the general population of children. This study describes the use of asthma medications among children in the general population and in children with current asthma, living in a large urban center in Brazil.

METHODS

A population-based cross-sectional survey, aimed at analyzing asthma determinants, was conducted with 1,382 children aged 4-11 years, between February and May 2006, in Salvador, Brazil. At baseline, an extensive questionnaire was applied, including questions about the use of asthma medications in the last 12 months.

RESULTS

In all studied children (n = 1,382) aged 4-11 years, oral beta2-agonists were the drugs most frequently used (9.8%), followed by short-acting inhaled beta2-agonists (4.3%) and systemic corticosteroids (1.6%). Anti-asthmatic drug use was higher among males than females, and it significantly decreased with age in both genders. A total of 312 children (22.6%) reported current asthma, and 62% of them were not being treated with any anti-asthmatic drugs. Of all those who reported following a certain type of treatment, 20% used oral beta2-agonists alone; 6.1%, short-acting inhaled beta2-agonists alone; and 4.8%, a combination of both drugs. Anti-asthmatic drug use did not differ according to socioeconomic status, except for the use of inhaled beta2-agonists and systemic corticosteroids.

CONCLUSIONS

An overwhelming majority of asthmatic children were not using long-term medications for asthma, in particular inhaled corticosteroids, regardless of the severity of their disease. This result points to the deficiencies of the Brazilian public health system in recognizing this important pharmacological need for child care and thereby limiting the access of these children to a group of efficacious, available, and low risk therapeutic medications.

Severe asthma patients in Korea overestimate their adherence to inhaled corticosteroids

Good adherence to inhaled corticosteroid (ICS) therapy is essential for effective asthma control. The factors affecting ICS therapy adherence vary among individuals and countries. As few data on adherence have been reported in Korea, the factors influencing such adherence, and the clinical implications thereof, were evaluated in Korean asthma patients. A total of 185 asthma patients who had taken ICS regularly for over 1 year were randomly selected from the recently established domestic adult asthma cohort, COREA (Cohort for Reality and Evolution of Adult Asthma Korea). To obtain adherence to ICS, both prescription refill adherence and self-reported adherence over 1 year (these are objective and subjective measurements respectively) were assessed without any interventions that might affect patients' adherence to ICS. Patients' information such as age, sex, smoking history and number of medication taken, was collected. Assessment of asthma severity, pulmonary function tests, and asthma symptom score were performed to evaluate the possible clinical implication of adherence to ICS. Approximately half of the patients (50.9%) showed less than 80% of prescription refill adherence. There was a considerable discrepancy between prescription refill adherence and self-reported adherence especially in the patients whose refill adherence was under than 50%. Younger asthma patients showed lower adherence to ICS than did older (> or = 60 years old) patients. Higher asthma severity was significantly associated with lower refill adherence to ICS. However, asthma symptom scores and forced expiratory volume in 1 second (FEV(1)) values were not directly related with refill adherence. To improve asthma control in Korea, enhancement of adherence to ICS is critical: our findings emphasize the need to use objective measurements when adherence to asthma medication is to be assessed in clinical practice.

The socio-economic burden of asthma is substantial in Europe

BACKGROUND

Few data are available on the asthma burden in the general population. We evaluated the level and the factors associated with the asthma burden in Europe.

METHODS

In 1999-2002, 1152 adult asthmatics were identified in the European Community Respiratory Health Survey (ECRHS)-II and the socio-economic burden (reduced activity days and hospital services utilization in the past 12 months) was assessed.

RESULTS

The asthmatics with a light burden (only a few reduced activity days) were 13.2% (95% CI: 11.4-15.3%), whereas those with a heavy burden (many reduced activity days and/or hospital services utilization) were 14.0% (95% CI: 12.1-16.1%). The burden was strongly associated with disease severity and a lower quality of life. Obese asthmatics had a significantly increased risk of a light [relative risk ratio (RRR) = 2.17; 95% CI: 1.18-4.00] or a heavy burden (RRR = 2.77; 95% CI: 1.52-5.05) compared with normal/underweight subjects. The asthmatics with frequent respiratory symptoms showed a threefold (RRR = 2.74; 95% CI: 1.63-4.61) and sixfold (RRR = 5.76; 95% CI: 3.25-10.20) increased risk of a light or a heavy burden compared with asymptomatic asthmatics, respectively. Moreover, the lower the forced expiratory volume in 1 s % predicted, the higher the risk of a heavy burden. The coexistence with chronic cough/phlegm only increased the risk of a heavy burden (RRR = 1.88; 95% CI: 1.16-3.06). An interaction was found between gender and IgE sensitization, with nonatopic asthmatic females showing the highest risk of a heavy burden (21.6%; 95% CI: 16.9-27.1%).

CONCLUSIONS

The asthma burden is substantial in Europe. A heavy burden is more common in asthmatics with obesity, frequent respiratory symptoms, low lung function, chronic cough/phlegm and in nonatopic females.

Respiratory symptoms/diseases, impaired lung function, and drug use in two Italian general population samples

BACKGROUND

Research and practice indicate that a sizeable amount of prescribed drugs is never used.

AIM

To assess the habitual up-take of medicines in subjects with respiratory symptoms/diseases or impaired lung function in general population samples.

METHODS

Data regard 4010 subjects (8-88 years) from the rural area of Po River Delta (North Italy) and the urban area of Pisa (North-Central Italy). Analyses concern the habitual use of any or specific medicines (broncho-pulmonary, anti-allergic, cardio-vascular, diuretic) in subjects with asthma, chronic bronchitis/emphysema (COPD), COPD or chronic cough/phlegm (COPDsx), and airways obstruction (AO, FEV(1)/FVC<70%).

RESULTS

Asthma, COPD, COPDsx, and AO were present in 6%, 5%, 21%, and 13% of cases, respectively. Only 37% and 21% of subjects with respiratory symptoms/diseases used any or specific medicines, respectively. The subjects with COPD exhibited the highest prevalence of assumption (59% for any drug, 38% for specific medicines), followed by asthmatics (42% and 30%), and subjects with AO (40% and 25%). After accounting for sex, age, residence area, smoking habit, education, and presence of comorbidity, the conditions significantly related to any medicine up-take were COPD (OR 1.65, 95% CI 1.08-2.53) and asthma (OR 1.47, 95% CI 1.01-2.12). Only asthma resulted significantly associated with the use of specific drugs (OR 3.11, 95% CI 1.94-4.97). Drug use was higher in the urban than in the rural area.

CONCLUSION

The results indicate that most people in the general population do not use drugs, in spite of reported respiratory disorders. The underuse of medicines seems lower in the urban area.

Cost analysis of GER-induced asthma: a controlled study vs. atopic asthma of comparable severity

Bronchial asthma is a costly disease: while the role of pharmaceutical strategies was greatly emphasised in order to alleviate its economic burden, the aetiological approach to asthma has received much less attention from this point of view. The impact of gastro-oesophageal reflux (GER)-related asthma was assessed in comparison to atopic asthma in 262 matched patients, and the corresponding direct and indirect annual costs calculated. All subjects were screened by means of a 95-item self-questionnaire. The overall resource utilisation was calculated for the last 12 months. Drug-induced annual costs were euro 290.4 (interquartile range-iqr 32.8) in atopic and euro 438.4 (iqr 27.8) in GER-related asthma (p<0.001); expenditure for medical consultations and diagnostics were euro 166.1 (iqr 14.8) vs. euro 71.6 (iqr 11.0) (p<0.001), and euro 338.4 (20.0) vs. 186.9 (iqr 26.5) (p<0.001), respectively. Direct costs due to hospital admissions and indirect costs due to absenteeism were also higher in GER-related asthmatics: 2.201.7+/-90.0 vs. euro 567.1+/-11.0 (p<0.001), and euro 748.7+/-94.7 vs. euro 103.6+/-33.9 (p<0.001), respectively. The total annual cost per patient was euro 1246.7 (iqr 1979.6) in atopic and euro 3967.1 (iqr 3751.5) in GER-related asthma, p<0.001. In conclusion, GER-induced asthma has a more relevant economic impact on healthcare resources than atopic asthma. Although further studies are needed, present data tend to demonstrate that when facing difficult asthma (GER-related asthma in this case), the aetiological assessment of the disease plays a critical role in optimising the approach to patients' needs.

Chronic outpatient management of asthmatics attending the emergency department: a survey from a country with low income

PURPOSE

Little is known about compliance with international guidelines of asthma management in developing countries where some medications are prohibitively expensive.

METHODS

A survey was conducted in asthmatic patients attending the emergency department for acute asthma. Asthma severity was evaluated and conformity of chronic treatment with international guidelines was assessed. Additional features of asthmatic education were also evaluated.

RESULTS

A total of 127 consecutive patients (mean age 34 +/- 14 years) answered the questionnaire. Mild asthma was present in 19.7% patients, 56.7% had moderate asthma and 23.6% had severe asthma. Of the 124 known asthmatic patients, 33% had no treatment for chronic asthma. In the remaining, treatment adhered to international guidelines in 44% patients. The major cause of treatment inadequacy was the lack of inhaled corticosteroids (64%) or suboptimal dosage of corticosteroids (13%). Conformity to guidelines according to favorable or unfavorable economic conditions was 59% and 33%, respectively (P = 0.036). Treating physicians provided an 'action plan' for managing acute symptoms to 19% patients. Forty percent of asthmatic patients performed correctly the five components of metered dose inhaler use.

CONCLUSION

Our study reveals an important proportion of non-treated asthmatic patients. In most asthmatic patients, treatment did not conform with guidelines because of an underutilization of corticosteroids, mainly because of economic obstacles.

Are the asthma guideline goals achieved in daily practice? A population-based study on treatment adequacy and the control of asthma

BACKGROUND

The guidelines for asthma recommend that the use of anti-inflammatory therapy should be adapted to the severity of the disease. However, few data are available to assess the adequacy of the use of drugs and its influence on the control of asthma in 'real life'.

METHODS

The adequacy of the current use of anti-asthmatic medication according to the Global Initiative for Asthma (GINA) guidelines was assessed in a random sample of 400 asthmatics identified in the frame of the Italian Study on Asthma in Young Adults. Asthma severity was assessed using the GINA criteria; accordingly, a patient was classified as receiving inadequate treatment if his/her current use of drugs was lower than that suggested by the guidelines for the corresponding severity level. The absence of asthma attacks in the last 3 months was used as an indicator of the disease control.

RESULTS

Fifty-five percent of the patients had persistent asthma. Overall, 48% (95% CI 41.2-54.8) of persistent asthmatics were receiving inadequate treatment, and 66% (95% CI 59.5-72.4) had not used their medication daily over the past 3 months. Persistent asthmatics who were inadequately treated had a significantly greater frequency of asthma attacks (geometric mean ratio 3.7; 95% CI 2.1-6.6) than those using an adequate dose of medication. Mild and moderate persistent asthmatics using an adequate medication regimen reported a low number of asthma attacks (median 0). At the multivariate analysis, a good control of the disease was positively associated with an adequate dose of anti-inflammatory medication (OR = 2.2; 95% CI 1.1-4.5) and was negatively associated with a later onset of asthma (OR = 0.96; 95% CI 0.93-0.99) and severe asthma (OR = 0.37; 95% CI 0.17-0.81).

CONCLUSIONS

Despite the increase in the use of inhaled corticosteroids, half of the persistent asthmatics from the general population are using a medication regimen below their severity level. When the use of drugs follows the GINA guideline recommendations, a good control of asthma is also achievable in the daily management of the disease, particularly in the case of mild and moderate asthmatics.

An Internet survey of asthma treatment

The aim of this investigation was to study pharmacological treatment in relation to asthma severity among patients visiting an asthma web site on the Internet. The study comprised 650 subjects from 30 countries with self-reported asthma that participated in an Internet based patient survey. The survey was posted on the web site Asthma Information Centre (www.mdnet.de). Moderate or severe night cough or wheezing was reported by 43% and activity limitation by 55% of the asthmatics. Short-acting beta-agonists were used by 67% and inhaled steroids by 59%. The use of short-acting beta-agonists decreased with age, whereas the use of inhaled steroids, long-acting beta-agonists and antileukotrienes was lowest in the youngest (0-20 years) and highest age groups (> 60 years). The use of short-acting beta-agonists increased, and the use of inhaled steroids decreased with the severity of nocturnal symptoms (p < 0.01). Side effects were most often reported for oral beta-agonists (42%) and least often for antileukotrienes (9%). We conclude that despite problems with selection and external validity, an online asthma survey produces results that agree highly with more resource-demanding surveys. We find that many asthmatics have a low level of asthma control, and the survey indicates that underuse of inhaled steroids is one of the reasons why the goals set up in asthma guidelines so far have not been reached.

Predictors of poor asthma control in European adults

Asthmatics in the community suffer morbidity due to poor asthma control. The Global Initiative for Asthma (GINA) guidelines established minimum goals for the management of asthma. Our objective was to quantify the demographic and clinical factors associated with asthma control in adult asthmatics. A population sample of asthmatics 16 years and older was obtained by random digit dialing in seven European countries (France, Germany, Italy, The Netherlands, Spain, Sweden, and United Kingdom), and asthma control was quantified according to daytime and nighttime symptoms, severe episodes, and limits on daily activities due to asthma. Among the 2050 adult current asthmatics surveyed, 35% had good asthma control (0 or 1 GINA goals failed), 40% had moderate asthma control (2 or 3 GINA goals failed), and 25% had poor asthma control (4 or 5 GINA goals failed). Fewer subjects with poor than those with good asthma control had ever received a lung function test, and significantly fewer patients with poor asthma control had been taught by a doctor or nurse how to use their peak flow meter. When questioned about the underlying cause of asthma, only 7.8% of asthmatics mentioned airway inflammation, and only 17.6% stated that inhaled corticosteroids were the most effective medication for reducing airway inflammation. There was more use of quick relief bronchodilator medications in the past 4 weeks among patients with poor asthma control. Asthma management practices and the knowledge, attitudes, and behavior of adult asthmatics in the general population are associated with the degree of asthma control.

A comparison of primary care physicians and pneumologists in the management of asthma in Spain: ASES study

The purpose of the ASES study is to determine the clinical characteristics of Spanish asthmatic patients seen in primary care (PC) and in pneumology (P) departments, comparing the availability of diagnostic methods, morbidity, the type of treatment and follow-up between the two health care settings. ASES is a multicenter, descriptive, cross-sectional study. The physicians were selected by random sampling. The data were collected by the participating physicians using three questionnaires. Data were collected on 2349 asthmatic patients (1298 from hospitals and 1051 from PC). Smokers predominated in the PC setting (P = 0.000). The spirometry was performed at least once a year in 87.2% of the patients seen in P and 39.8% in PC (P = 0.000). Morbidity was high in both groups (P and PC), more than two nighttime awakenings per month (25.5% versus 29%) and emergency visits in previous year (26% versus 21%). A high percent of asthmatic patients was using both inhaled corticoids and long-acting beta2-agonists (49.5% versus 32%). The 30% of PC patients could not be classified into any step of the treatment. In Spain, the morbidity of disease is high, despite the large use of drugs. Objective monitoring tests have very limited use in PC.

The control of asthma in Italy. A multicentre descriptive study on young adults with doctor diagnosed current asthma

BACKGROUND

Few data are available on the management of asthma in the general population. The aim of this study was to evaluate the level of asthma control in Italian patients, a decade after the publication of the international guidelines.

MATERIALS AND METHODS

Within the framework of a multicentre, population-based study on people aged 20-44 years, 18 873 subjects replied to a postal screening questionnaire (response rate = 72.7%) on the presence of asthma symptoms and exacerbations, and their impact on daily life. All subjects reporting having ever had a doctor diagnosis of asthma and either taking medicine for asthma when interviewed or having had an asthma attack in the last 12 months, were considered current asthmatics.

RESULTS

Of the screened subjects, 649 (3.4%) were current asthmatics. Of these, only 14% did not report exacerbations or had been symptom-free in the last 12 months. More than 20% of current asthmatics had their daily life activities seriously impaired and 54 patients (8%) had at least one hospital/emergency department admission as a result of asthma exacerbation in the last 12 months. The life impairment and the rates of hospitalization significantly increased as the control of the symptoms worsened. The use of asthma drugs was quite common in current asthmatics: 586 (90.2%) reported having been under pharmacological treatment in the last 12 months. Only 63 patients (10%) had the disease under control (neither symptoms nor life impairment): they had a significantly higher percentage of drug use (100%vs 89%) and of daily use prescriptions (50%vs 36%) than non/moderately controlled asthmatics. Poorly controlled asthmatics had a significantly higher percentage of women (63%vs 44%), of patients with the coexistence of chronic cough and phlegm (47%vs 30%) than moderately/well-controlled asthmatics. The comparison between our data and similar data collected in 1991 in Italy showed that the use of asthma drugs increased by about 12%, while the control of symptoms did not improve in the last decade.

CONCLUSION

Despite the high percentage of drug users, the control of symptoms and exacerbations was overall poor in Italy and resulted in a heavy individual and social burden, pointing out that the guideline goals have far from been reached in Italy.

Health-care resource use by asthmatics in Croatia

We report a survey of the impact of asthma on daily life and on health-care resource use by adult asthma patients in four counties in Croatia. Over a 1-year period beginning November 1998, 185 general practitioners recruited 504 asthma patients, who completed a questionnaire about their drug therapy, health-care resource use, symptoms, limitations in daily activities, and work loss due to asthma. Over a 2-week period, inhaled corticosteroids were used by 51.5% of patients, short-acting and long-acting beta-agonists by 70.8% and 53.5%, respectively, and oral extended-release theophyllines by 29.8%. Nocturnal awakenings were experienced by 58.7% of patients, 75.5% experienced daytime symptoms, and 42.5% were limited in their daily activities. In the previous year, 12.5% of the patients were hospitalized, 33% missed work, and 70% reported reduced effectiveness in the workplace. In the previous 6 months, 35.2% of the patients visited an emergency room due to worsening of asthma symptoms. The human and socioeconomic burden of asthma in Croatia is considerable. These results can help guide the development of asthma policy in Croatia and raise awareness of asthma as a public health issue.

Assessment of asthma severity and treatment by GPs in Belgium: an Asthma Drug Utilization Research Study (ADUR)

A prospective study was performed between June 1996 and December 1997, to identify how general practitioners (GPs) in Belgium assess asthma severity and how they treat asthma according to their severity assessment. Three hundred and sixty-five GPs included 1376 already diagnosed and treated asthmatics. The GPs used a questionnaire providing data on patient demographics, aetiology of asthma, symptoms and medication use. The patients provided a complete diary card of day and night symptoms and morning and evening peak expiratory flow rates during a 3-week period. Asthma severity as assessed by GPs was compared with the severity according to the GINA guidelines. Along the same line, asthma treatment was evaluated according to the GPs assessment of severity and according to the GINA guidelines. Confronting the assessment of asthma severity by the GPs with the GINA criteria revealed that about 20% and 2% of the patients' asthma severity respectively were under- and over-estimated, respectively (using a discrepancy between GPs and GINA assessment of severity by 2 or more classes). Using the GINA criteria for treatment, only 37.5% of the patients seemed to be correctly treated. Taking a discrepancy between GINA assessment and treatment of two classes as an error, 2.3% and 23.4% of the asthmatics are over- and under-treated, respectively. In conclusion, this study provides evidence that GINA guidelines seem not to be adequately interpreted and implemented by GPs in Belgium. Improvement of the assessment of asthma severity is definitely needed and may lead to more appropriate use of asthma medication.

Classification methods for the identification of 'case' in epidemiological diagnosis of asthma

The identification of the asthmatic 'case' in epidemiological research is a controversial issue. This study was aimed at classifying asthmatic subjects using a statistical decision rule that minimised the misclassification rate with respect to the clinicians' diagnosis. The rule was defined by a combination of predictors that are easily observed in epidemiological studies (asthma-like questions, physiological tests) without necessarily including the clinical opinion of expert physicians. From pooled data on 1103 subjects at the three Italian centres of the European Community Respiratory Health Survey (ECRHS) a post-consensus clinicians' diagnosis of asthma was obtained, and seven predictors were selected from among 18 potential candidates (specificity ranged from 64 to 99%, but sensitivity ranged from 22 to 62%). This data set was processed with tree-structured classifier techniques (the Classification And Regression Trees, CART), classical discriminant analysis (Fisher's Linear Discriminant Function, LDF), and the neural network method (Multi-Layer Perceptron, MLP model). The results suggest that modifications of the 'classification tree' provide a more useful decision rule, sensitive (93%) and specific (85%), than either LDF or MLP. The decision tree is readily interpretable from a clinical perspective and uses five out of the seven predictors (in descending hierarchical order: ever had asthma, current asthma, shortness of breath, atopy and wheezing and breathless). The findings seem to indicate a considerable success with respect to previous epidemiological studies and await repetition in other ECHRS populations.

The European Community Respiratory Health Survey: what are the main results so far? European Community Respiratory Health Survey II

The European Community Respiratory Health Survey (ECRHS) was the first study to assess the geographical variation in asthma and allergy in adults using the same instruments and definitions. The database of the ECRHS includes information from approximately 140,000 individuals from 22 countries. The aim of this review is to summarize the results of the ECRHS to date. The ECRHS has shown that there are large geographical differences in the prevalence of asthma, atopy and bronchial responsiveness, with high prevalence rates in English speaking countries and low prevalence rates in the Mediterranean region and Eastern Europe. Analyses of risk factors have highlighted the importance of occupational exposure for asthma in adulthood. The association between sensitization to individual allergens and bronchial responsiveness was strongest for indoor allergens (mite and cat). Analysis of treatment practices has confirmed that the treatment of asthma varies widely between countries and that asthma is often undertreated. In conclusion, the European Community Respiratory Health Survey has shown that the prevalence of asthma varies widely. The fact that the geographical pattern is consistent with the distribution of atopy and bronchial responsiveness supports the conclusion that the geographical variations in the prevalence of asthma are true and most likely due to environmental factors.

The use of anti-asthmatic drugs in children: results of a community-based survey in Germany

PURPOSE

To describe the use of anti-asthma drugs in children in the general population and in children with asthma using data from two large surveys in Germany.

METHODS

Community-based random sample of 5-7 and 9-11-year-old children in Dresden and Munich were studied in 1995/96 by parental questionnaires using the Phase II protocol of the International Study of Asthma and Allergies in Childhood (ISAAC). A total of 11,094 children participated in the surveys (response rate 83%).

RESULTS

In all children, inhaled beta 2-agonists were used most frequently during the last 12 months (2.6%), followed by inhaled cromolyns (2.5%), oral beta 2-agonists (1.5%), and inhaled steroids (0.9%). Drug use was significantly higher among boys than girls and in older children compared to younger ones (P < 0.05 for both). Among children with current asthma, 47% had used inhaled beta 2-agonists, 43% inhaled cromolyns, 22% oral beta 2-agonists, and 16% inhaled steroids. Inhaled steroids were used significantly more often in Dresden (21.7%) than in Munich (11.2%) (P < 0.05).

CONCLUSIONS

Among anti-asthma drugs, agents used for symptomatic relief were the most frequently reported followed by inhaled anti-inflammatory agents. Most of the anti-inflammatory drugs used were SCG, which may indicate under-treatment with inhaled steroids.

Prescribing patterns for asthma by general practitioners in six European countries

To assess the level of concordance with international consensus on asthma management, we compared primary care prescribing patterns for asthma in different European countries. A prospective study of prescription items with an associated diagnostic label of asthma in patient consultations with a total of 235 general practitioners (GPs) from Belgium, England, Ireland, Italy, Northern Ireland, Portugal, Scotland and Spain was performed. A total of 101,544 consecutive consultations were recorded in autumns 1994 and 1995 of which 3595 (3.5%) were for patients with asthma and 3243 (3.2%) were for patients receiving a prescription for asthma. Overall, asthma consultations varied from 1.8% in Italy to 5.8% in Ireland (mean 3.4%, SD 1.6). Prescribed inhaled medications for children varied from 72% of the total asthma prescriptions in Ireland and Portugal to 82% in Northern Ireland (mean 79%, SD 8.1) and for adults 55% in Italy to 85% in Spain (mean 70%, SD 10). Inhaled corticosteroid usage for adults varied from 14% in Italy to 31% in Northern Ireland (mean 24%, SD 6.4). For children, beta2-agonist use varied from 24% in Italy to 67% in Spain (mean 45%, SD 13). Despite publication of international guidelines for the management of asthma, inter-country prescribing practices vary considerably and could be improved. The frequency of use of asthma as a diagnostic label also varies markedly.

Characteristics of users of inhaled long-acting beta 2-agonists in a southern European population

We characterized the population of users of inhaled long-acting beta 2-agonists in the region of Friuli-Venezia Giulia, in Italy, and assessed changes in asthma treatment and control after initiating long-acting beta 2-agonists. All residents using formoterol or salmeterol between 1992 and 1996 were identified in the regional Health Databases. Utilization rates of asthma medications and hospitalization rates for asthma were computed for the year before and after the date of the first long-acting beta 2-agonist prescription. There were 3803 users of formoterol and 20,054 users of salmeterol. Overall, 65% of users were older than 54 years of age. All formoterol users and 86% of salmeterol users received their first prescription for the respective drug during the study period (new users). Among these new users, 50% had not received any asthma drug during the 4 months preceding the start of long-acting beta 2-agonist administration. Prior 1 yr utilization rates of asthma medications and hospitalization rates for asthma were greater among new users of long-acting beta 2-agonists than among new users of salbutamol and xanthines. In addition, formoterol new users had higher prior use of asthma drugs than new users of salmeterol. One year prior hospitalization rates for asthma were also higher among formoterol than salmeterol new users with rate ratios of 1.7 (95% CI 1.3-2.2) for patients younger than 45 and 1.5 (1.2-1.9) for older patients. Use of short-acting beta 2-agonists, oral steroids and xanthines significantly declined after starting formoterol, whereas the use of inhaled steroids increased after the start of either formoterol or salmeterol. Asthma hospitalizations decreased by 32% in patients under age 45, by 43% in older patients, during the year following the start of formoterol, and by 15% and 24%, respectively, after the start of salmeterol. We conclude that long-acting beta 2-agonists were mainly prescribed to middle-aged and elderly patients and that formoterol appeared to be preferentially prescribed to patients with more severe asthma than salmeterol. Changes in asthma treatment and reduction in hospitalization rates for asthma after starting formoterol and salmeterol are compatible with an improvement in the control of asthma.