Asthma control and use of short-acting beta-2-agonists for symptom relief in Africa – A narrative review

INTRODUCTION

Asthma is a serious global health problem estimated to affect more than 226 million people worldwide and over 119 million people on the African continent.^[1] Inhaled corticosteroids (ICS), taken regularly or as needed when combined with short-acting beta-2-agonists (SABAs) (anti-inflammatory reliever therapy or AIR), represent the cornerstone of asthma management across all severities, while SABAs only provide rapid symptom relief.^[2] SABAs have no inherent anti-inflammatory activity, and their overuse (≥3 canisters/year) is associated with an increased incidence of exacerbations, mortality, and healthcare costs.^[3-6]

ASTHMA CARE IN AFRICA

Asthma care in Africa is occurring in the background of high levels of poverty and weak health care systems. Inequities in access to healthcare care are common across Africa and are particularly severe among certain populations, such as those living in urban slums and rural communities. At present, nearly half a billion people in Africa are estimated to be living in extreme poverty.

The African region is unfortunately experiencing uneven progress toward the achievement of the United Nations 2030 target for sustainable development goal (SDG) 1, which is to end poverty in all forms.^[7] Poverty has been associated with a higher burden of asthma, including asthma deaths.^[8,9] It is, therefore, not entirely surprising that asthma control has not been achieved for a large proportion of people living with asthma in Africa. Poverty should, however, not be an excuse for the lack of optimal asthma control in Africa.^[10]

CURRENT STATE OF MANAGEMENT OF ASTHMA AND USE OF SABAs TO MANAGE ASTHMA

It is safe to state that, in general, asthma care and management in Africa is sub-optimal for adults, adolescents, and children. Of the 26,654 individuals with doctor-diagnosed asthma who participated in the global asthma network phase 1 study in which three African countries (South Africa, Cameroon, and Nigeria) contributed participants, between 29.3% and 85.3% used SABAs alone, only 12.6–51.9% used inhaled steroids (ICS), and 44.8% individuals with severe asthma were not using ICS^[11] [Table 1].

In addition, in a recent systematic review by Mphahlele et al. that included 883 children and adolescents from Nigeria, South Africa, and Uganda, the prevalence of uncontrolled asthma ranged from 30.9% to 44.5%. Regular use and adherence to ICS were poor, with less than 10% of the participants from Uganda (screening done in the community) reporting that they had used ICSs routinely in the past 12 months. Further, among the cohort of children and adolescents with uncontrolled asthma, the majority reported that they preferred to use only SABA.^[12]

Overuse of SABAs is a common global asthma care challenge.^[13] The SABA use in Asthma (SABINA) studies have provided concerning information on the use of SABAs in Africa. Three African countries (South Africa, Kenya, and Egypt) were involved in the SABINA III study, which revealed a dismal state of affairs with nearly half of all patients (46.5%) from the African cohort prescribed ≥3 SABA canisters in the past 12 months, which is considered over-prescription.^[14] In both the Kenyan and South African cohorts, over 70% (71.9% in Kenya and 75% in South Africa) of patients were prescribed 3 or more SABA canisters in 1 year.^[15,16] More than 25% purchased the SABA without a prescription in South Africa, and while the figure stood at 38.8% in Kenya, in Africa as a whole, the figure was 32.6%^[14-16] [Table 2].

Based on robust clinical trial evidence, the Global Initiative for Asthma (GINA) no longer recommends as-needed SABA without concomitant ICS for adults and children above 6 years of age^.[2] The use of SABA alone and or excessive use of SABA in the treatment of asthma has been associated with poor asthma control, higher rates of asthma exacerbations, and asthma deaths.^[6,17] Asthma exacerbations and deaths occur even when the asthma is considered to be mild by both the healthcare provider and the person with asthma.^[3] Thus, there is a major imperative to reduce the rate of asthma exacerbations and, therefore, prevent asthma deaths in all people with asthma, including those with infrequent symptoms. This was the focus of the key studies that informed the decision by GINA to recommend the change from using SABA alone for relief of asthma symptoms in persons with infrequent symptoms to using an ICS with formoterol as needed or ensuring an ICS is also taken whenever SABA is used.^[3,13,18,19] The documented overuse of SABA on the African continent is, therefore, a major cause of concern.

It is important to ask the question, “Why is there overuse of SABA in Africa?” There are multiple reasons for the overuse of SABA in Africa and elsewhere in the world. SABAs have been used for a long time and are on the minds of many healthcare providers and people with asthma with their work. Asthma symptoms rapidly resolve when these medicines are used. Because they do not prevent the next attack, used alone, these medicines are inappropriate for the long-term control of asthma. Compared with ICS, SABAs are considered affordable by people with asthma, healthcare providers, and healthcare systems. This makes these medicines more attractive to healthcare financiers, especially governments, in the low-resource settings of Africa. A myopic view of the cost of treatment of asthma based on the unit cost of medicines may be contributing to the documented poor access to ICS in Africa.^[20] The widespread myths and misconceptions about asthma and the fear of “steroids” are also likely to be contributing to the overuse of SABAs. The fact that these medicines are freely available without a prescription in the African medicine market is also likely to be contributing to their overuse [Table 3].

WHAT CAN BE DONE TO REDUCE THE OVERUSE OF SABA IN AFRICA?

Reducing SABA overuse will not be an easy task; however, efforts must be made to achieve this goal if the asthma control landscape in Africa is to change. We suggest that the following actions be undertaken in the effort to reduce SABA overuse in Africa: [Figure 1].

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Figure 1:

Steps to reducing short acting beta-2- agonist (SABA) over use in Africa. ICS: Inhaled corticosteroids.

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CONCLUSION

Asthma is a major public health concern with a rapidly increasing burden in Africa. Its treatment is currently suboptimal with overuse of SABA, which leads to poor asthma control with an increased risk of asthma exacerbations and deaths. This situation needs redress urgently through advocacy efforts, educational programs, and market shaping. We urge respiratory societies across Africa to take the lead in pushing for change so that asthma deaths are brought to zero on the continent.