Rate of severe exacerbations, healthcare resource utilisation and clinical outcomes in patients with COPD in low-income and middle-income countries: results from the EXACOS International Study.

INTRODUCTION: The EXAcerbations of Chronic obstructive lung disease (COPD) and their OutcomeS (EXACOS) International Study aimed to quantify the rate of severe exacerbations and examine healthcare resource utilisation (HCRU) and clinical outcomes in patients with COPD from low-income and middle-income countries. METHODS: EXACOS International was an observational, cross-sectional study with retrospective data collection from medical records for a period of up to 5 years. Data were collected from 12 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Guatemala, Hong Kong, Mexico, Panama, Russia and Taiwan. The study population comprised patients ≥40 years of age with COPD. Outcomes/variables included the prevalence of severe exacerbations, the annual rate of severe exacerbations and time between severe exacerbations; change in lung function over time (measured by the forced expiratory volume in 1 s (FEV1)); peripheral blood eosinophil counts (BECs) and the prevalence of comorbidities; treatment patterns; and HCRU. RESULTS: In total, 1702 patients were included in the study. The study population had a mean age of 69.7 years, with 69.4% males, and a mean body mass index of 26.4 kg/m2. The mean annual prevalence of severe exacerbations was 20.1%, and 48.4% of patients experienced ≥1 severe exacerbation during the 5-year study period. As the number of severe exacerbations increased, the interval between successive exacerbations decreased. A statistically significant decrease in mean (SD) FEV1 from baseline to post-baseline was observed in patients with ≥1 severe exacerbation (1.23 (0.51) to 1.13 (0.52) L; p=0.0000). Mean BEC was 0.198 x109 cells/L, with 64.7% of patients having a BEC ≥0.1 x109 cells/L and 21.3% having a BEC ≥0.3 x109 cells/L. The most common comorbidity was hypertension (58.3%). An increasing number of severe exacerbations per year was associated with greater HCRU. DISCUSSION: The findings presented here indicate that effective treatment strategies to prevent severe exacerbations in patients with COPD remain a significant unmet need in low-income and middle-income countries.

Greenhouse Gas Emissions from Respiratory Treatments: Results from the SABA CARBON International Study.

INTRODUCTION: Healthcare systems are looking to reduce their carbon impact. Short-acting ß2-agonist (SABA) overuse (≥ 3 canisters/year) is common in asthma and linked to poor outcomes; however, its environmental impact remains unknown. As part of the CARBON programme, this study retrospectively quantified the carbon footprint of SABA and controller inhalers across all respiratory indications and SABA overuse in asthma in lower-middle-income countries (LMICs), upper-middle-income countries and high-income countries across Africa, Asia Pacific, Latin America and the Middle East. METHODS: Two data sources were utilised to evaluate the carbon contribution of inhalers to respiratory care. To quantify greenhouse gas (GHG) emissions associated with total inhaler use across all respiratory indications, inhaler sales data were obtained from IQVIA MIDAS® (Q4/2018-Q3/2019) and compared by dose to prevent confounding from differences in canister actuation counts. GHG emissions associated with SABA overuse in asthma were evaluated using prescription and self-reported over-the-counter purchase data from the SABA use IN Asthma (SABINA) III study (2019-2020). Inhaler-related GHG emissions were quantified using published data and product life cycle assessments. RESULTS: SABA accounted for > 50% of total inhaler use and inhaler-related emissions in most countries analysed. The total SABA-related emissions were estimated at 2.7 million tonnes carbon dioxide equivalents, accounting for 70% of total inhaler-related emissions. Among the countries, regions and economies analysed, per capita SABA use and associated emissions were higher in Australia, the Middle East and high-income countries. Most SABA prescriptions for asthma (> 90%) were given to patients already overusing SABA. CONCLUSIONS: Globally, SABA use/overuse is widespread and is the greatest contributor to the carbon footprint of respiratory treatment, regardless of the economic status of countries. Implementing evidence-based treatment recommendations, personalising treatment and reducing healthcare inequities, especially in LMICs, may improve disease control and patient outcomes, thereby reducing SABA overuse and associated carbon emissions beyond SABA use alone.

The healthcare sector is a large emitter of greenhouse gases (GHGs); therefore, healthcare systems will need to reduce their carbon footprint to meet their carbon reduction targets. In respiratory care, the environmental impact of controller inhalers has received considerable attention due to the global warming potential of the propellants used in metered-dose inhalers. In contrast, little is known about the contribution made by short-acting ß₂-agonist (SABA) relievers globally, which are often the only inhaled medication used by many patients with milder asthma. The SABA use IN Asthma (SABINA) programme reported that SABA overuse (3 or more SABA canisters/year) is common and associated with an increased risk of asthma attacks. Since all inhalers have a carbon footprint, SABA overuse may result in an avoidable excess carbon footprint. Therefore, to provide a complete picture of the carbon footprint of respiratory care, we examined the contribution of SABA relievers and their potential overuse. The total SABA-related GHG emissions accounted for 70% of total inhaler-related GHG emissions, and > 90% of prescriptions for SABA relievers for asthma were given to patients who were already overusing their SABA. Overall, SABA use/overuse is commonly observed worldwide and is likely a significant contributor to the carbon footprint of respiratory treatment. Therefore, there is an urgent need for healthcare providers to follow the latest international treatment guidelines to reduce high SABA use in respiratory care and improve patient outcomes. This, in turn, will enable healthcare systems to reduce their carbon footprint from both treatment and patient interactions.

The use of systemic corticosteroids in asthma management in Latin American countries.

The stepwise treatment approach recommended by the Global Initiative for Asthma (GINA) includes systemic corticosteroids (SCS) suggested as a final step if asthma is severe and/or difficult to treat. Yet, despite the effectiveness of SCS, they are also associated with potentially irreversible adverse outcomes such as type 2 diabetes, adrenal suppression, and cardiovascular disease. Based on recent data indicating that the risk of developing these conditions can increase after as few as 4 short-term (burst) courses of SCS, even patients with mild asthma who receive SCS occasionally for exacerbations are also at risk of these events. As a result, recent updates by GINA and the Latin American Thoracic Society recommend decreasing SCS use by optimizing administration of non-SCS therapies and/or increasing the use of alternatives, such as biologic agents. Recent and ongoing studies characterizing treatment patterns among patients with asthma have revealed alarming trends suggesting the widespread overuse of SCS around the world. In Latin America, asthma prevalence is approximately 17%, and data suggest that the majority of patients have uncontrolled disease. In this review, we summarize currently available data on asthma treatment patterns in Latin America, which indicate that SCS are prescribed to 20-40% of patients with asthma considered to be well controlled and over 50% of patients with uncontrolled disease. We also offer potential strategies to help reduce SCS use for asthma in everyday clinical practice.

Short-acting ß2-agonist prescription patterns for asthma management in the SABINA III primary care cohort.

Short-acting ß2-agonist (SABA) prescriptions and associated outcomes were assessed in 1440 patients with asthma from the SABA use IN Asthma (SABINA) III study treated in primary care. Data on asthma medications were collected, and multivariable regression models analysed the association of SABA prescriptions with clinical outcomes. Patients (mean age, 47.9 years) were mostly female (68.6%); 58.3% had uncontrolled/partly controlled asthma and 38.8% experienced ≥1 severe exacerbation (reported in 39% of patients with mild asthma). Overall, 44.9% of patients were prescribed ≥3 SABA canisters (over-prescription) and 21.5% purchased SABA over-the-counter. Higher SABA prescriptions (vs 1-2 canisters) were associated with significantly decreased odds of having at least partly controlled asthma (6-9 and 10-12 canisters) and an increased incidence rate of severe exacerbations (10-12 and ≥13 canisters). Findings revealed a high disease burden, even in patients with 'mild' asthma, emphasising the need for local primary care guidelines based on international recommendations.

Over-prescription of short-acting ß2-agonists and asthma management in the Gulf region: a multicountry observational study.

BACKGROUND: The overuse of short-acting ß2-agonists (SABA) is associated with poor asthma control. However, data on SABA use in the Gulf region are limited. Herein, we describe SABA prescription practices and clinical outcomes in patients with asthma from the Gulf cohort of the SABA use IN Asthma (SABINA) III study. METHODS: In this cross-sectional study conducted at 16 sites across Kuwait, Oman, and the United Arab Emirates, eligible patients (aged ≥ 12 years) with asthma were classified based on investigator-defined disease severity guided by the 2017 Global Initiative for Asthma report and by practice type, i.e., respiratory specialist or primary care physician. Data on demographics, disease characteristics, and prescribed asthma treatments, including SABA, in the 12 months prior to a single, prospective, study visit were transcribed onto electronic case report forms (eCRFs). All analyses were descriptive in nature. Continuous variables were summarized by the number of non-missing values, given as mean (standard deviation [SD]) and median (range). Categorical variables were summarized by frequency counts and percentages. RESULTS: This study analyzed data from 301 patients with asthma, 54.5% of whom were treated by respiratory specialists. Most patients were female (61.8%), with a mean age of 43.9 years, and 84.4% were classified with moderate-to-severe disease, with a mean (SD) asthma duration of 14.8 (10.8) years. Asthma was partly controlled or uncontrolled in 51.2% of patients, with 41.9% experiencing ≥ 1 severe exacerbation in the 12 months preceding their study visit. Overall, 58.5% of patients were prescribed ≥ 3 SABA canisters, 19.3% were prescribed ≥ 10 canisters, and 13.3% purchased SABA over-the-counter (OTC) in the 12 months before the study visit. Most patients who purchased OTC SABA (92.5%) also received SABA prescriptions. Inhaled corticosteroid/long-acting ß2-agonist combinations and oral corticosteroid bursts were prescribed to 87.7% and 22.6% of patients, respectively. CONCLUSIONS: SABA over-prescription was highly prevalent in the Gulf region, compounded by purchases of nonprescription SABA and suboptimal asthma-related outcomes. Increased awareness among policymakers and healthcare practitioners is needed to ensure implementation of current, evidence-based, treatment recommendations to optimize asthma management in this region. TRIAL REGISTRATION: NCT03857178 (ClinicalTrials.gov).

Severe asthma treatment patterns: A multicenter observational study in the Gulf region.

Background: While crucial to the assessment and improvement of asthma control, insights on treatment practices in patients with severe diseases across Gulf nations are lacking. This observational study describes the treatment patterns of adolescents and adults with severe asthma across four countries of the Gulf region and evaluates current levels of asthma control; quality of life (QoL); exacerbation frequency; and the application of cellular, protein, and respiratory biomarkers in assessing asthma severity and inflammation. Methods: Patients (aged >12 years, body weight ≥40 kg) with clinician-diagnosed, severe asthma (guided by the 2018 Global Initiative for Asthma definition) were included in this cross-sectional, multicenter, observational study conducted in the four Gulf countries of Kuwait, Oman, Qatar, and the United Arab Emirates. Data on demographics, treatment patterns, and laboratory parameters (blood eosinophil count [BEC], levels of serum immunoglobulin E [IgE], and fractional exhaled nitric oxide [FeNO]) were extracted from the medical records of patients during a 12-month retrospective period and transcribed onto case report forms. At the Enrollment visit, patients assessed their asthma control and QoL with the self-administered Asthma Control Questionnaire (ACQ) and a standardized version of the Asthma Quality of Life Questionnaire (AQLQ(S)), respectively. Results: Among the 243 patients analyzed, (mean [standard deviation (SD)] age, 48.4 [13.9] years; female, 67.5%), the inhaled corticosteroid (ICS)/long-acting ß2 agonist (LABA) combination was the most prescribed asthma medication (n = 240; 98.8%). Most patients were classified as "uncontrolled," (n = 173; 71.2%) and the majority (n = 206; 84.8%) experienced ≥1 exacerbation(s) in the preceding 12 months. The mean (SD) ACQ score was 2.1 (1.2), which indicated uncontrolled asthma, and the mean (SD) total AQLQ(S) score was 4.7 (1.4), suggesting "some limitation" in overall QoL. BECs during the 12-month period were elevated in most patients (>300 cells/µL [n = 183; 41.7%], 150-300 cells/µL [n = 138; 31.4%], <150 cells/µL [n = 118; 26.9%]), suggesting an eosinophilic asthma phenotype, although no standardized threshold by which to define eosinophilia has yet been confirmed. This study revealed that the biomarkers BEC, serum IgE, and FeNO concentrations were obtained inconsistently by the participating centers. Conclusions: Despite recommended ICS/LABA therapy being prescribed to most patients for their severe disease, the majority experienced uncontrolled asthma and exhibited elevated BECs. These findings indicate the need for enhanced treatment strategies to improve and sustain asthma control in the Gulf region.

Prevalence of asthma and allergies among children in the United Arab Emirates: A cross-sectional study.

BACKGROUND: Asthma, allergic rhinitis, and atopic dermatitis are the most common chronic inflammatory disorders in children worldwide. These conditions place a significant burden on the healthcare system due to their multiple related complications and the necessity of hospital visits. This study aimed to evaluate the prevalence and severity of asthma and allergic diseases among school children aged 6-7 years and 13-14 years in Dubai and the Northern Emirates, United Arab Emirates (UAE). PATIENTS AND METHODS: This was a multicenter, cross-sectional study that recruited children from March to June 2019 via school class registers in Dubai and the Northern Emirates, UAE. The Arabic and English versions of the International Study of Asthma and Allergies in Childhood (ISAAC) core questionnaires on asthma, allergic rhinitis, and atopic dermatitis were completed by parents or legal guardians of children aged 6-7 years, and by the children themselves in those aged 13-14 years. RESULTS: In this study, we included 3436 children (1944 children aged 6-7 years and 1793 children aged 13-14 years). We estimated the prevalence of asthma (11.9%), wheezing (44.2%), allergic rhinitis (46.5%), hay fever (22.1%), and atopic dermatitis (12.9%) in the 6- to 7-year-old group. In the 13- to 14-year-old group, the prevalence was 9.8%, 33.1%, 51.3%, 19.9%, and 14.6%, respectively. The prevalence of any history of asthma was higher in boys than girls in the 6- to 7-year-old group (13.9% vs. 10%) and in the 13- to 14-year-old group (11.2% vs. 8.7%). In the 6- to 7-year-old group, the highest prevalence of asthma, sneezing, and atopic dermatitis was observed in Dubai, Ajman, and Umm Al Quwain, respectively. In the 13- to 14-year-old group, the highest prevalence of asthma was observed in Ras Al Khaimah, and the highest prevalence of sneezing and atopic dermatitis was observed in Sharjah. CONCLUSION: We found that the prevalence of asthma, allergic rhinitis, and atopic dermatitis in the UAE is comparable to that in neighboring countries; the prevalence of asthma, wheezing, and hay fever was higher in the 6- to 7-year-old group, while in the 13- to 14-year-old group, the prevalence of allergic rhinitis and atopic dermatitis was higher. Overall, the prevalence of any history of asthma was highest in Ras Al Khaimah, followed by Dubai, and lowest in Ajman. Our findings suggest that allergic disorders represent a healthcare burden in the UAE and more efforts are needed to organize nationwide campaigns to detect undiagnosed children to overcome the burden caused by these conditions.

Adherence to medication among adult asthma patients in the Middle East and North Africa: results from the ESMAA study.

BACKGROUND: Low levels of adherence to asthma medication is reported in many countries worldwide. Improved knowledge of adherence in the Middle East and North Africa (MENA) is needed to address this major public healthcare burden. OBJECTIVE: Assess the level of adherence in patients attending a routine consultation and the relationship between adherence, patient/disease characteristics, disease control, and quality of life. METHODS: A large-scale cross-sectional epidemiological study was performed on adults suffering from asthma for at least 1 year and without an acute asthma episode within 4 weeks. Adherence was assessed using the MMAS-4 questionnaire©. Predictive factors of adherence were analyzed with logistic regressions. RESULTS: Overall 7203 eligible patients were included in 577 sites. Mean age was 45.4 years (±14.7), 57.2% were female, mean BMI was 28.5 kg/m2 (±6.0), and 11% were active smokers. Good adherence was observed in 23.6% with a country effect (p < 0.001). Higher age, higher SF-8 Mental component score, and high level of control were associated with good adherence (p < 0.001). Patients treated with a fixed combination (ICS + LABA) have better adherence and patients treated with short-acting beta agonist alone have a lower adherence. Good adherence has been noted in 528 uncontrolled patients suggesting the existence of a subgroup difficult to treat and who have severe asthma. CONCLUSIONS: Asthma adherence in the MENA is unsatisfactory with less than one quarter of asthma patients having good adherence. This finding highlights the need to improve access to treatment, ensure better control follow-up and improved education among healthcare providers and patients.