(Focus-India)
In India, November month is marked by the onset of the season that involves changes in weather conditions, which brings unique challenges for individuals battling respiratory ailments. One of such ailments is Asthma, which is a chronic lung disease that affects people of all ages. The Global Burden of Disease (GBD) study has estimated that India is home to over 30 million asthmatics, accounting for 13.09% of the global burden. These numbers underscore the magnitude of the issue and the pressing need for effective management and care.
To learn more about the management of Asthma, we connected with Dr. Ashok K. Rajput, a renowned Pulmonologist from India, who highlighted the importance of regular inhaled medication and the use of appropriate protective measures, in the effective asthma management, especially for patients residing in highly polluted areas, Dr Ashok also discussed the necessity of maintaining strict medication compliance and a strong doctor-patient relationship to ensure effective asthma control.
Dr. Ashok K. Rajput is a Senior Consultant, Pulmonary Medicine currently serving at CK Birla Hospital, Delhi, India.
We usually prescribe inhalers like ICS (inhaled corticosteroids) to manage asthma symptoms. Another helpful measure is wearing a mask, particularly an N95 mask, when the air quality is poor. It can provide some protection against certain pollutants.
According to the Annual World Air Quality Report released by Swiss air quality technology company, IQAir, India has ranked eighth in the list of countries with the worst air quality index and 12 of the 15 most polluted cities in Central and South Asia are in India [1],[2]. How does the exposure to pollutants, specifically fine particulate matter, in heavily polluted Indian cities impact asthma outcomes?
Dr. Rajput - Asthma is a condition where tiny particles like dust, pollen, fumes, and smoke enter your body and cause your airways to react. They become narrow and inflamed, leading to symptoms like coughing, wheezing, and sneezing. To treat this, doctors usually prescribe inhaled medications like steroids and bronchodilators to reduce inflammation and improve symptoms. The quality of the air you breathe plays a significant role too, whether you're indoors or outdoors. Indoor pollution from things like incense, mosquito coils, or smoking can trigger inflammation and worsen asthma symptoms. Similarly, when the air quality is poor, especially during winter in North India with smog and fog, asthma flare-ups tend to be more common. This is why cities like Delhi, which are crowded and less clean, have a higher incidence of asthma.
What preventive measures are recommended for asthma patients residing in highly polluted areas?
Dr. Rajput - It would be best if people with asthma could move to a better and cleaner environment, a place with cleaner air. But if that's not possible, they should make sure to take their regular inhaled medication. We usually prescribe inhalers like ICS (inhaled corticosteroids) to manage asthma symptoms. Another helpful measure is wearing a mask, particularly an N95 mask, when the air quality is poor. It can provide some protection against certain pollutants.
I understand that asthma exacerbations or flare-ups can vary in severity, ranging from mild to life-threatening. What are the current strategies and guidelines that you follow for the prevention and management of asthma exacerbations/flare-ups?
Dr. Rajput - Yeah, these flare-ups can be really dangerous. Sometimes they even require hospitalization and intensive care, and in severe cases, the person may need to be put on a ventilator. The risk of mortality in asthma is directly related to these severe flare-ups and exacerbations. In fact, in some cases, severe exacerbation can be fatal. That's why it's crucial to control asthma effectively.
One of the key ways to prevent severe exacerbations is by using regular inhaled medication, such as ICS (inhaled corticosteroids) and LABA (long-acting beta-agonists). When a person consistently takes their inhaler medication as prescribed, follows the correct technique, and stays compliant with the treatment, they are less likely to experience severe exacerbations. They may still have mild flare-ups from time to time, but those can be managed effectively. To prevent these severe exacerbations, it's essential to establish a strong partnership between the patient and their doctor. Compliance with medication should be ensured, and the correct inhaler technique should be practiced. Additionally, it's important to avoid environments with dust, fumes, and smoke, and strive for a cleaner living space. Measures like using air purifiers can be helpful too.
More than 50 to 60 percent of patients with frequent exacerbations have type-2 inflammation or eosinophilic inflammation. To determine this, doctors may assess the eosinophilic count, the fraction of exhaled nitric oxide, and immunoglobulin E (IgE) levels. If a patient has allergic or eosinophilic asthma and despite regular inhaler use, they still experience exacerbations, requiring oral or injectable steroids, frequent hospital visits, or ER trips, it indicates that their asthma is not well controlled. For such patients, there are biologics available these days. Depending on the type of inflammation they have, doctors may prescribe anti-IL-5 drugs for eosinophilic inflammation and anti-IgE biologics for allergic asthma. These medications are usually given through injections once a month or so. By utilizing these biologic treatments, asthma exacerbations can be drastically reduced or even eliminated, and the need for oral or injectable steroids diminishes.
The key is to properly select patients who have frequent exacerbations and determine whether they have eosinophilic inflammation or allergic asthma. For these biologic drugs to work, the patient's eosinophil levels need to be quantified, with a count of more than 300 per microliter or between 150 and 300 at least two to three times, along with a requirement for steroids and frequent exacerbations. Once eosinophilic inflammation is confirmed, these medications can be effective in managing asthma.
The use of biologics has shown significant improvements in asthma control, reduction in exacerbations, cessation of oral steroid requirements, decreased reliance on inhaled steroids, and even improvement in lung function. It's a highly effective approach, but it's crucial to carefully select the patients who will benefit the most from these treatments.
For severe refractory asthma, what is the role of anti-IL-4 and anti-IL-5, doctor?
Dr. Rajput - So, when we talk about refractory asthma, we are referring to those who are already on high doses of inhaled corticosteroids and still need frequent oral steroids. They often end up in the hospital due to frequent exacerbations, despite being compliant with their treatment and having good inhaler technique. Now, if their asthma is characterized by a high eosinophil count, indicating type 2 inflammation, they become suitable candidates for biologic treatments like anti-IL-5 drugs. These biologics have been available in our country, and I have personally used them in about 20 to 25 cases with excellent results.
The use of biologics has shown significant improvements in asthma control, reduction in exacerbations, cessation of oral steroid requirements, decreased reliance on inhaled steroids, and even improvement in lung function. It's a highly effective approach, but it's crucial to carefully select the patients who will benefit the most from these treatments. I have even witnessed cases where patients have achieved remission with the help of these biologics. It's quite remarkable to see them gradually reduce their medication and eventually forget about their asthma symptoms altogether. So, biologics can truly make a significant difference in the lives of asthma patients, but the key lies in selecting the right patients for these treatments.
Precision medicine aims to improve asthma treatment outcomes by utilizing genetic testing, biomarker analysis, targeted therapies, and environmental control measures [3],[4]. So, how does personalized precision therapy based on clinical characteristics and laboratory biomarkers contribute to the future of asthma treatment?
Dr. Rajput - As I mentioned before, it's important to select patients based on whether they have allergic or eosinophilic inflammation. Patients who have comorbid conditions like allergic rhinitis or sinusitis tend to respond well to anti-IL-5 drugs. On the other hand, patients with high levels of allergic IgE do better with anti-IgE medication. It all depends on which pathway, whether it's the IgE pathway or the IL-5 pathway, is the dominant one in their case. So, the treatment becomes personalized based on targeting that specific pathway.
It's important to note that these biologic treatments are add on top of the basic treatment, which includes ICS (inhaled corticosteroids) and LABA (long-acting beta-agonists). The use of biologics is personalized and focused only on those patients for whom we have identified the specific pathway and target it accordingly. That's how these treatments work.
Are there any barriers and challenges in implementing precision medicine approach for asthma, doctor?
Dr. Rajput - Actually, the biologic treatments I mentioned earlier can be quite expensive. The injections can cost around 50,000 rupees per month or even up to 1 lakh rupees per month. So, the main obstacle here is the cost. However, in terms of the treatment itself, these injections are relatively small and usually well-tolerated without any major side effects. They have been shown to be effective and safe in achieving positive results. It's just that the high-cost acts as a barrier for many people to access these treatments.
Do you believe patient education and training can contribute to enhancing adherence to treatment for moderate to severe asthma in India?
Dr. Rajput - Absolutely! Education plays a crucial role in ensuring patient compliance and regular use of inhaled medication. As I mentioned earlier, when patients are compliant and consistently use their inhalers with the correct technique, the frequency and severity of exacerbations significantly decrease. In fact, in many cases, exacerbations can be completely avoided. On the other hand, when patients stop taking their medication, reduce their dosage, or make mistakes in their inhalation technique, that's when exacerbations tend to occur.
That's why it's important to educate patients about proper inhaler techniques and emphasize the importance of compliance during every visit. It's not just the responsibility of the doctor, but also respiratory technicians, healthcare workers, and even the media to spread this knowledge. Whether it's through television, radio, or mobile messages, all these mediums can contribute to educating people about the correct use of inhalers and the significance of staying compliant with their asthma treatment.
One common mindset among patients is that they only need to take their inhaler when they experience symptoms. They believe that as long as they can breathe fine, there's no need for the inhaler. It's a different mindset compared to patients with conditions like hypertension or diabetes, who understand the importance of taking medication even when they feel well to prevent complications.
You mentioned that compliance is a significant challenge in asthma management. What is your opinion on using digital health technologies such as mobile apps or wearables to enhance compliance and improve the management of asthma?
Dr. Rajput - In theory, utilizing digital health technologies like mobile apps or wearables for asthma management sounds great. However, in reality, many patients don't actively engage with these tools as much as we would hope. They tend to be more focused on social media, messaging apps like WhatsApp, games, and other forms of entertainment on their mobile devices. When it comes to health-related applications, patients often don't utilize them optimally. It seems that the psychology of patients leans more towards using mobiles and social media for entertainment rather than for health purposes. So, while the concept of using these technologies appears promising on paper, it ultimately depends on whether patients are willing to actively utilize them for their healthcare.
Is there any mobile apps or wearable devices available in India especially for managing asthma?
Dr. Rajput - There are indeed some companies developing devices that utilize Bluetooth technology to track inhaler usage and provide reminders for the next dose. However, despite these advancements, these devices are not always user-friendly, and patients often lack interest in using them. One common mindset among patients is that they only need to take their inhaler when they experience symptoms. They believe that as long as they can breathe fine, there's no need for the inhaler. It's a different mindset compared to patients with conditions like hypertension or diabetes, who understand the importance of taking medication even when they feel well to prevent complications.
In the case of asthma, patients may not have the same level of concern or fear. They need to be educated about the necessity of taking their inhaler regularly, regardless of their current symptom status. It's crucial to help them understand that consistent medication usage is essential for managing their asthma effectively.
What advice would you give to individuals with asthma to help them better manage their condition and improve their quality of life?
Dr. Rajput - Asthma can be effectively controlled and treated with the right approach. The key is to establish a strong partnership between the patient and the doctor. Regular visits to the doctor, whether monthly, every three months, or every six months, are important. This allows for monitoring and adjustment of treatment as needed. The principle of step-up and step-down therapy with inhalers is followed, and the treatment plan can be shared with the patient. Patients can also be empowered to make adjustments themselves, stepping up or stepping down their medication under the guidance of their doctor. It's crucial to seek medical advice early if there are any concerns or worsening symptoms. Ultimately, compliance with regular inhaler use is essential. It can make a significant difference in controlling asthma, preventing exacerbations, and achieving better overall asthma management.
Thank you so much, doctor. This discussion was insightful.
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