Although asthma is a condition which can be managed with proper care and precautions, lack of adherence or compliance with treatment often results in poor asthma outcomes. This is mainly seen in cases of severe asthma such as brittle asthma. Experts are of the opinion that this situation poses a major challenge to healthcare providers and patients due to the lack of awareness amongst asthma patients and medical practitioners on the same. In relation to this, the Global Asthma Physician and Patient (GAPP) survey revealed a direct relationship between the quality of physician-patient communication, the level of treatment side effects and the extent of patient compliance highlighting a clear need for improved patient—focused care in asthma. Dr Agam Vora, Asst Hon & In charge, Department of Chest & TB, Dr RN Cooper Municipal General Hospital, Mumbai, in conversation with Raelene Kambli, provides further valuable insights on brittle asthma and ways to manage it
What is brittle asthma? What are its causes?
| Dr Agam Vora |
Brittle asthma, also known as difficult asthma, is a variant of asthma which is difficult to treat. It’s a condition which arises due to failure in achieving asthma control when maximally recommended doses of inhaled therapy are prescribed for at least 6 -12 months, under the care of an asthma specialist. Most patients of brittle asthma are essentially under-treated asthmatics who will benefit by proper guidance and adherence to treatment. It can be unstable and unpredictable with frequent severe attacks and hospital admissions. Often no consistent trigger factors can be identified, hence, there is lack of awareness amongst sufferers of this severe form of asthma. Few common causes of brittle asthma are atopy, food allergy, psychological factors, allergic cold and steroids resistance.
How fatal is this condition? Does it lead to any other respiratory disorders?
General asthma is often diagnosed under normal cases and is usually considered curable. However this severe type of asthma, if undiagnosed, can even prove to be fatal. In absence of proper treatment given it can lead to 100 per cent mortality rate. In my opinion, about 30 to 40 per cent of the difficult asthma patients die inspite of being in the best possible centres. Asthma can also lead to respiratory failure and eventually respiratory arrest. Initially, they may have low oxygenation which eventually results into elevated carbon dioxide levels.
What is the prevalence of brittle asthma in India? Can you give us some statistics?
With the present Indian population estimated to be one billion plus, the disease still remains under-recognised, underestimated and under treated in India. Approximately, about three per cent of the Indian population suffers from asthma, out of which 0.05 per cent of all asthmatics are difficult asthma patients. Despite varied therapeutic options available, many asthmatic patients with moderate – severe persistent asthma continue to experience symptoms even after therapy with inhaled or systemic corticosteroids. In fact, these account for 217000 emergency room visits and 10.5 million physician office visits every year. In India, asthma is a low public health priority and a significant proportion of patients receive only basic care and are not able to benefit from therapeutic advances. There is a dire need for asthma patients in India to identify the symptoms of this severe disease and inform their physicians at the earliest.
Are medical practitioners in India well informed about this fatal type of asthma?
Unfortunately, there is much written information about the disease but very little is available on the seriousness of brittle asthma or difficult asthma. A lot of practitioners are unaware of this condition and may not diagnose it. It may even lead to deaths. We need to make our patients and medical colleagues aware of this type of asthma. Regular continuing medical education (CME) activities and articles on the disease can help spread awareness amongst medical practitioners and the patients. There is a dire need for patients to understand the seriousness of the disease and the need for regular therapy.
What kind of awareness should the medical practitioners provide about brittle asthma to their patients?
If you thought lack of sleep, uneasiness, persistent breathing difficulties, multiple hospitalisations and faster consumption of inhalers in spite of consuming regular asthma medication was part of your disease, you’re wrong. You could be suffering from difficult asthma which can be fatal. Two of the major challenges witnessed in the treatment of difficult asthma in India are the lack of previous treatment records of the patients while getting treated by a new doctor and the lack of fear amongst patients as it’s considered to be controllable. Lack of adherence or compliance with treatment is the most common cause of poor asthma outcomes. India is best equipped with medication for the treatment of asthma; the treatment only needs to be taken seriously by the patients.
Which is the best way to manage such kind of asthma? What are the ways to prevent it?
Lack of adherence or compliance with treatment is the most common cause of poor asthma outcomes. In the treatment of asthma it is essential that at the outset, an accurate diagnosis is established by performing a pulmonary function test (PFT). Treatment should be in the step ladder manner outlined by Global Initiative for Asthma (GINA). Subsequent visits should monitor the progress of the patient along with accurate assessment of asthma control as outlined by the GINA guidelines. If at the completion of three to six months of therapy the patient achieves good control, the treatment can be continued. In the event of sub optimal control a systematic protocol should be adopted to exclude the above causes of poor control. Hygiene measures in lifestyle, food intake and exercise can cut down the risk of brittle asthma drastically. If a patient is diagnosed with asthma, one should avoid eating food with preservatives as that aggravates asthma; always opt for food with greater shelf life. Alternate therapy such as yoga has proven to be very beneficial to prevent as well as keep asthma in control.
What are the other causes of brittle asthma?
Other causes of brittle asthma are
- Asthma mimics such as COPD, hiatal hernia, ABPA, heart failure, vocal cord dysfunction syndrome
- Presence of co morbidities – allergic rhinitis, GERD, psychiatric illnesses, sleep apnea
- Unidentified exacerbating factors – rare causes such as mutations in the beta 2 receptor gene or mutations in the steroid receptor gene.