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Publications Foracort Forum - Issue - 1

Despite significant advances in knowledge about asthma and the availability of more effective therapy, under-treatment and poor asthma control are common.1 Patients underestimate their asthma control, have low expectations of control and over-rely on bronchodilators, while under-using controller medications such as inhaled corticosteroids (ICS).2 Asthma treatment regimens are complex and confusing for many patients who need to use multiple inhalers several times a day. The availability of ICS and a bronchodilator in a single inhaler (FORACORT) provides a convenient, simple and effective way of treating asthma.

Reality Check
Asthma affects up to 150 million adults and children worldwide, with an estimated 50% jump in prevalence every decade.3 The economic burden of asthma is huge. In the US , the total cost of asthma was almost US$ 10.7 billion in 1994.4 The patient and the society have to bear loss of productive time at work and in school. Patients are forced to cut down participation in activities. There is also a tremendous impact on other family members.
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The Indian Scene
India has an estimated 15 to 20 million asthmatics. Rough estimates indicate a prevalence of between 10% and 15% in children in the age range of five to eleven.3
GOALS of Asthma Care
Prevent both chronic and troublesome symptoms Maintain near-normal pulmonary function Provide optimal pharmacotherapy with minimal or no adverse effects Maintain normal activity levels Prevent recurrent exacerbations and minimise need for emergency-department visits and hospitalization Satisfaction with asthma care.
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Asthma in America (AIA) Survey5
This survey was carried out to assess the level of asthma control with current medications Figure 1: Percentage of patients using an inhaler at least once daily for quick relief in the Asthma in America Survey The above study reflects the reality that asthma is poorly managed in a large number of patients. Figure 2: Percentage of Patients Reporting Activity Restriction in the Asthma in America Survey One of the goals of asthma care is to maintain normal activity level. However the above graph shows that this goal was not met.
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AIRE study2
The Asthma Insights & Reality in Europe (AIRE) Survey a patient survey carried out in seven European countries, illustrates the gap between clinical practice guidelines and the reality of treatment for patients with asthma. The AIRE survey reveals that the treatment of asthma is falling far short of the GINA Treatment Guidelines: The GINA Treatment Guidelines say that one of the goals of asthma management is no or minimal need for emergency room visits or hospitalization. AIRE survey shows that in the past one year: • 7% of asthma patients were hospitalized overnight for asthma. • 10% of asthma patients had to go to the emergency room for asthma. • 25% of asthma patients had other unscheduled asthma-related emergency visits to a doctor's clinic because of asthma Another goal of asthma management is no missed school or work due to asthma. The guidelines also state that no sleep disruption should occur. • 25% of asthma patients missed school or work in the past 12 months because of their asthma • 30% of asthma patients awoke with breathing problems at least once a week during the past four weeks The GINA Treatment Guidelines say that people with asthma should be able to maintain their normal activity levels. • 42% of asthma patients say their asthma limits their ability to take part in sports or recreation • One third (32%) say it limits their normal physical exertion • 23% say it limits their choice of job or career • 29% say it limits them in their lifestyle, while 22% say it limits their social activities. Both the surveys clearly show that all the goals are not being met in spite of effective treatment available.
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Good Asthma Control
Patient adherence to the prescribed medication is the key to good asthma control.
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What is adherence?
Compliance does not necessarily mean adherence. Compliance implies a passive role. The patient takes his medication religiously as prescribed by the physician. But does he willingly adhere to such treatments? Is he motivated? Adherence implies an active role. It is a self-motivated decision to adhere to treatment advice.
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Why is adherence important?
Good adherence plus the right medicines yield effective control of disease. In other words, the equation that leads to good control can be complete only with adherence. Non-adherence can lead to: • Missed appointments • Failure in following instructions • Delay in seeking medical care Unmet needs of asthma patient reflect in attitudes to the disease and its treatment. This indifferent or negative approach gives rise to non-adherence.
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Factors that influence adherence
Related to medicine Satisfaction with the medication is of utmost importance to patient. This also happens to be the prime factor that encourages adherence. Patient characteristics Acceptors are those patients who will follow treatment and adhere to it. Distancers (who are not in tune with their physician in managing their asthma) will not adhere to treatment.6 Increase in the number of acceptors indicates that adherence towards treatment has improved. Treatment characteristics Complexity in the treatment regimen is a major hindrance.2 Multiple, large doses and the need to juggle separate inhalers-all these discourage adherence. Patient-provider relationship The patient's faith in the provider has a major influence on adherence to treatment.7 The clinical setting and the features of the disease are other factors that have a bearing on adherence.
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How to encourage adherence?
Treatment characteristics can be changed to a great extent by implementing adjustable dosing. This can positively modify the patient's perception to treatment. When combinations became available in a single inhaler, fixed dosing regimen was introduced. This improved compliance but adherence remained a challenge. The following strategies can help to improve patient satisfaction and adherence: • Tailor-made medication scheduled according to patient's routine • Doctor maintains agreement with the patient on the goals of the treatment • Regular review of the self-management plan • Regular sharing of specific reassuring information to allay fears • Addressing the patient's and the family's underlying concerns about asthma Simplification of the health-care regimen is directly associated with better adherence to preventive treatment. Thus, the doctor should work towards: • Reducing the frequency of daily doses • Limiting the total number of different medications (e.g. prescribing a combination inhaler rather than two separate inhalers) • Sticking to the same type of inhaler for different medication types (e.g. dry powder inhaler for relievers as well as preventers - together these are coined as controllers). These steps can help convert most of the distancers into acceptors.
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AMD: Asthma care at its simplest
Advances in our understanding of the disease and steady development in drugs and devices have seen a progressive evolution of asthma control. Now Adjustable Maintenance Dosing (AMD) provides an excellent level of disease control and, equally importantly, helps reduce the impact of asthma on patients' lives. Earlier, these relievers and preventers used to be available as separate components. Then came the fixed-dose combinations that put the two classes of medicine in the same inhaler. However, fixed-dose regimens with controller medications do not take into account the variability of asthma. Inevitably there are times when patients are receiving either more medication than required during periods of control, or less than is necessary to control symptoms during periods of worsening.2
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What is today's requirement?
The aim of current asthma management is to achieve early control of asthma and then maintain control with the minimum effective medication dose.
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How AMD works?
AMD that combines budesonide and formoterol efficiently meets the patient's need for optimal asthma control using fewer inhalers and less drug. This is sure to have a major impact on the patient's adherence to treatment. The availability of an inhaled corticosteroid (budesonide) and a bronchodilator (formoterol) in a single inhaler (FORACORT) provides a convenient, simple and effective way to treat asthma. AMD should be considered an option for asthma patients who are symptomatic on a low dose of ICS and would like to control their asthma more effectively. Once asthma control is maintained, patients can step down to the lowest effective dose. This approach is in line with the current international guidelines for asthma management. As a consequence of the unique pharmacological properties and the dose-response effect of formoterol and budesonide, the combination of these two drugs in a single inhaler (FORACORT) is the only combination available for asthma that is ideally suited for AMD. FORACORT flexible dosing takes the variable nature of asthma into account, and by dose adjustments at the onset of worsening, initiates disease control. Patients can maintain control of their asthma simply by increasing or decreasing the number of inhalations from the single inhaler - increased to prevent symptoms worsening into exacerbations, and then reduced to a minimal level again when control is re-established. References 1. Eur Respir J 2000; 16: 802-807 2. Expert Opin Pharmacother 2003; 4(8): 1393-1406. 3. World Health Organisation (WHO): Bronchial asthma. Geneva , Switzerland 2000. 4. J Allergy Clin Immunol 2000; 106: 493-499 5. Advanced Studies in Medicine 2002; 2(14): 499-503 6. International Journal for Quality in Health Care 2001; 13(5): 375-383. 7. Resp Med 2000; 94: 2-9 8. J Allergy Clin Immunol 1998; 101: 457-463 9. Resp Med 1998; 92: 1017-1021.
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