AJTCCM VOL. 28 NO. 4 2022 148
EDITORIAL
Asthma is one of the most common chronic respiratory conditions,
and its prevalence is increasing worldwide.[1] It is estimated that
approximately 300million people in the world currently have asthma.[2]
e prevalence rate of asthma is increasing as communities are adopting
a more Western lifestyle and become urbanised. With the projected
increase in the proportion of the world’s urban population, that is, from
45% to 59% in 2025, a marked increase in the number of asthmatics
worldwide over the next two decades is likely. It is further estimated
that there may be an additional 100million people living with asthma
by 2025.[3,4] Epidemiological data from Southern African Development
Community (SADC) and South Africa (SA) are lacking. e only robust
data from SA is from the ISAAC study published in 2007.[4] SA has
the fourth-highest asthma mortality in the general population (1.5 per
100000) and the h-highest asthma mortality among 5 - 35-year-old
asthmatics (18.5 per 100000).[5] Despite progressive reductions over the
past few decades, asthma mortality remains high within the southern
African region. For example, in SA, among 5 - 34-year-olds, the asthma
mortality rate has decreased by 0.13deaths per 100000 per year over
recent decades. However, at 1.5, it still represents a relatively high rate
internationally, and is associated with the h-highest case fatality rate
in the world.[3]
With the updated asthma definition by the Global Asthma for
Initiative (GINA) and the paradigm change in our approach to the
management of chronic asthma, new data are mandatory. Asthma is
now understood to be a heterogeneous condition that is characterised
by frequent acute episodic exacerbations. ese frequent exacerbations
against the background of chronic persistent inammation have led to
a major revision in the management of the neglected asthma population
– the ‘mild intermittent and mild persistent asthmatic’. One of the major
drivers for this change has been the documentation of progressive
decline in measurements of lung spirometry in uncontrolled asthmatics,
irrespective of the severity of the illness.[6] is is supported by data
from landmark clinical trials published in leading journals indicating
that continuous inhaled corticosteroid steroid (ICS) treatment leads to
improved symptom control and a signicant reduction in the risk of
exacerbations with a reduction in airway inammation.[7-9]
In this edition of the journal, Smith et al.[x] present the ndings of
the SA cohort of patients from the multicentred SABA use In Asthma
(SABINA) III study. These data confirm previous data published
on asthmatic patients, and this is not unique to our region. Within
the SA population, there is a significant over-reliance on short-
acting β2‑agonists (SABA) usage. Smith et al. report that 74.9% of
the patients interviewed were prescribed ≥3 SABA canisters in the
previous 12months, and 56.5% were prescribed ≥10 SABA canisters.
Additionally, 27.1% of patients reported purchasing SABA canisters
over the counter. Among patients with both SABA purchase and
prescriptions, 75.4% and 51.5% had already received prescriptions for
≥3 and ≥10 SABA canisters, respectively, in the preceding 12months.
ese data are extremely concerning, as there is mounting evidence that
SABA overuse, and in particular >3canisters per year, is associated with
an increased risk of exacerbations, hospitalisations and mortality.[10,11]
is study further highlights the plight of the mild asthmatic, and
the mismanagement of these patients locally. In this population of
patients with mild asthma, symptoms remain uncontrolled in >50%
of patients.[12] One of the major reasons postulated for the poor control
documented in this group of patients is the lack of patient compliance
with maintenance treatment.[13] Of the 501patients analysed in the
SABINA subpopulation, asthma was partly controlled/uncontrolled
in 60.3% of patients, with 46.1% experiencing ≥1 severe exacerbations
in the 12months before the study visit. ese data reinforce the need
for the use of ICS at all opportunities in the management algorithm
for step-up therapy in patients with asthma. e adoption of the new
GINA guidelines, which have been endorsed by our local SA asthma
guidelines, advocate for the use of the maintenance and reliver therapy
approach.[14] We as the advocates and custodians of respiratory
healthcare in SA need use this data to engage with clinicians and
policy-makers to make sustainable changes that will impact asthma
outcomes. We now have the data to support the implementation of
our local asthma guidelines and to prioritise the incorporation of ICS/
long-acting β2-agonists into the essential drug list as a therapeutic
option that should be available to all citizens of the country.
I S Kalla
Department of Pulmonology and Department of Critical Care Medicine,
Charlotte Maxeke Johannesburg Academic Hospital, University of the
Witwatersrand, Johannesburg, South Africa
iskalla786@gmail.com
1. Kroegel C. Global Initiative for Asthma (GINA) guidelines: 15 years of application.
Expert Rev Clin Immunol 2009;5(3):239-249. https://doi.org/10.1586/eci.09.1
2. GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and national
deaths, prevalence, disability-adjusted life years, and years lived with disability for
chronic obstructive pulmonary disease and asthma, 1990 - 2015: A systematic analysis
for the Global Burden of Disease Study 2015. Lancet Respir Med 2017;5(9):691.
https://doi.org/10.1016/S2213-2600(17)30293-X
3. Masoli M, Fabian D, Holt S, Beasley R, Global Initiative for Asthma Programme.
e global burden of asthma: Executive summary of the GINA Dissemination
Committee report. Allergy 2004;59(5):469-478. https://doi.org/10.1111/j.1398-
9995.2004.00526.x
4. Pearce N, Aït-Khaled N, Beasley R, et al. Worldwide trends in the prevalence of
asthma symptoms: Phase III of the International Study of Asthma and Allergies
in Childhood (ISAAC). Thorax 2007;62(9):758-766. https://doi.org/10.1136/
thx.2006.070169
5. Cazzoletti L, Marcon A, Corsico A, et al. Asthma severity according to Global
Initiative for Asthma and its determinants: An international study. Int Arch Allergy
Immunol 2010;151(1):70-79. https://doi.org/10.1159/000232572
6. Coumou H, Westerhof GA, De Nijs SB, Zwinderman AH, Bel EH. Predictors
of accelerated decline in lung function in adult-onset asthma. Eur Respi J
2018;51(2):1701785. https://doi.org/10.1183/13993003.01785-2017
7. Bateman ED, Reddel HK, O’Byrne PM, et al. As-needed budesonide-formoterol
versus maintenance budesonide in mild asthma. New Eng J Med 2018;378(20):1877-
1887. https://doi.org/10.1056/NEJMoa1715275
8. O’Byrne PM, Mejza F. Advances in the treatment of mild asthma: Recent evidence.
Polish Arch Int Medi 2018;128(9):545-549. https://doi.org/10.20452/pamw.4341
9. O’Byrne PM, FitzGerald JM, Bateman ED, et al. Inhaled combined budesonide-
formoterol as needed in mild asthma. New Eng J Med 2018;378(20):1865-1876.
https://doi.org/10.1056/NEJMoa1715274
e plight of the ‘asthmatic patient’ in South Africa – a subgroup
analysis of the SABINA III study
149 AJTCCM VOL. 28 NO. 4 2022
EDITORIAL
10. Nwaru BI, Ekström M, Hasvold P, Wiklund F, Telg G, Janson C. Overuse of short-
acting β2-agonists in asthma is associated with increased risk of exacerbation and
mortality: A nationwide cohort study of the global SABINA programme. Eur Respir J
2020;55(4):1901872. https://doi.org/10.1183%2F13993003.01872-2019
11. Bloom CI, Cabrera C, Arnetorp S, et al. Asthma-related health outcomes associated
with short-acting β2-agonist inhaler use: An observational UK study as part of the
SABINA Global Program. Adv er 2020;37(10):4190-4208.
12. Braido F, Brusselle G, Guastalla D, et al. Determinants and impact of suboptimal
asthma control in Europe: The International Cross-Sectional and Longitudinal
Assessment on Asthma Control (LIAISON) study. Respir Res 2016;17(1):1-10.
13. Gillissen A. Patients’ adherence in asthma. J Physiology Pharmacol 2007;58(5):205-222.
14. Lalloo U, Kalla I, Abdool-Gaar S, et al. Guidelines for the management of asthma
in adults and adolescents: Position statement of the South African oracic Society –
2021 update. Afr J oracic Crit Care Med 2021;27(4):30-43. https://doi.org/10.7196/
AJTCCM.2021.v27i4.189
Afr J Thoracic Crit Care Med 2022;24(2):148-149. https://doi.
org/10.7196/AJTCCM.2022.v28i4.298
