Asthma has long lagged behind other inflammatory conditions in terms of political attention and progress on patient outcomes. This may be partly because many people think of asthma as a generally mild condition, when in fact its severe form is a serious condition that can have a major impact on people’s quality of life. Action on severe asthma would not only relieve a significant burden for patients, health systems and society, it would also help advance other urgent policy priorities, including tackling the links between health and climate change, strengthening health system sustainability and reducing health inequalities.
Severe asthma: a distinct and serious condition
Severe asthma is defined as asthma that remains uncontrolled despite people receiving optimal inhaled therapy.1 Periodic inflammation of the airways results in potentially life-threatening exacerbations (attacks) which, over time, may gradually impair people’s lung function.1 Having frequent, unpredictable exacerbations — and the fear of one occurring — can have a detrimental impact on people’s quality of life,2,3 limiting their ability to work4 and lead a normal, active and socially-engaged life.5 This impact can be nothing short of crippling.
A significant toll on people, health systems and society
Severe asthma makes up 3-10 percent of all asthma cases,1,6 but it accounts for at least 50 percent of the total costs of asthma.7,8 The human toll of this serious condition translates into considerable costs for health systems and society in general. Asthma is one of the main contributors to increased health expenditure among noncommunicable diseases, and much of this cost is due to emergency hospital admissions and treatment of exacerbations.8 The cost of severe asthma is 10 times that of mild asthma, based on a Canadian study.9 Beyond the impact on health systems, its societal cost is even greater in terms of lost productivity and associated earnings, premature disability and death.10
The devastating and far-reaching impact of not being able to breathe was made clear to all of us during the COVID pandemic — and yet ensuring the millions of people living with severe asthma are relieved from this risk is still not given sufficient priority or urgency.’ (Tonya Winders)
Gaps between what should be done, and what happens in practice
We know what to do, yet somehow recommendations do not translate into clinical practice and patient care: globally, approximately 57 percent of patients with severe asthma remain poorly controlled despite treatment. (Professor Giorgio Walter Canonica)
Clear, consistent guidelines, quality standards and recommendations exist for the management of severe asthma, and much of the burden of this condition could be prevented by adhering to them.11,12 We need to work collectively with governments to drive real change. Below are three important areas that need attention:
1. Ensure rapid referral to specialist care and timely treatment for all patients
The first step is to acknowledge severe asthma as a distinct, serious condition requiring rapid referral to specialists for diagnosis and care. Access to a multidisciplinary, specialist team is key to optimise patient outcomes and achieve long-term control of exacerbations. Appropriate training and referral pathways are needed to help primary care and emergency room physicians recognise patients at risk of having severe asthma and refer them rapidly.
Enabling timely access to the appropriate medication is also essential to achieve long-term control of severe asthma. We know that long-term use of oral corticosteroid therapy is associated with significant side effects including weight gain, diabetes, osteoporosis, cataracts, hypertension, adrenal suppression, depression and anxiety.13,14,15 This high level of co-morbidity has led experts to call for greater adoption of oral corticosteroid sparing and stewardship strategies, and to also consider alternative targeted therapy options (i.e. biologics), where possible.16,17 Despite this, overreliance on OCS remains commonplace,18,19 and too many people with severe asthma incur significant adverse effects from long-term OCS use, at significant cost20 and even at potentially increased risk of death.15,21
2. Achieving better asthma control in the face of climate change
The interconnection between asthma and climate change adds further impetus for change. Air pollution and extreme weather conditions (e.g. heat waves), are known risk factors for asthma and can exacerbate its severity.22,23 At the same time, uncontrolled asthma can have a significant carbon footprint,24 particularly due to the greenhouse gas emissions from certain types of inhalers.24,25 Efforts to achieve greater asthma control will thus translate into environmental as well as clinical benefits, helping governments fulfil their commitments to limit the environmental impact of their health systems.
3. Addressing underlying social inequalities
Finally, the need to address underlying social determinants of health that exacerbate the risk of asthma is key, as well as existing disparities in care. Low socioeconomic position, urbanisation, poor air quality and limited health literacy are all associated with worse outcomes from asthma.26,27,28 Disparities in access and quality of care abound, with people from racial and ethnic minorities particularly affected.26 Inequities are also apparent globally, with access to even basic asthma inhaled reliever medicines compromised in some of the world’s poorest countries, leading to significant premature death and disability. 29 Mapping these disparities and developing targeted interventions to address them must be prioritised, based on the local epidemiology in each country.
A duty of care and a societal imperative
In summary, achieving freedom from exacerbations should be the goal for every person with severe asthma. In addition to the transformative impact on thousands of people’s lives across Europe, this would also help decrease the strain on overly stretched health systems, reduce the carbon footprint of care and relieve society from the cost of lost productivity and disability.Governments are uniquely positioned to drive this change by building concrete goals focused on severe asthma into comprehensive national respiratory strategies, with clear accountability measures in place to monitor and ensure continual progress over time.
References
1. Chung KF, Wenzel SE, Brozek JL, et al. 2014. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J 43(2): 343-73
2. Shaw DE, Sousa AR, Fowler SJ, et al. 2015. Clinical and inflammatory characteristics of the European U-BIOPRED adult severe asthma cohort. European Respiratory Journal 46(5): 1308-21
3. Foster JM, McDonald VM, Guo M, et al. 2017. “I have lost in every facet of my life”: the hidden burden of severe asthma. Eur Respir J 50(3):
4. Ojeda P, Sanz de Burgoa V. 2013. Costs associated with workdays lost and utilization of health care resources because of asthma in daily clinical practice in Spain. J Investig Allergol Clin Immunol 23(4): 234-41
5. Nunes C, Pereira AM, Morais-Almeida M. 2017. Asthma costs and social impact. Asthma Research and Practice: 10.1186/s40733-016-0029-3:
6. Hekking PW, Wener RR, Amelink M, et al. 2015. The prevalence of severe refractory asthma. J Allergy Clin Immunol 135(4): 896-902
7. Meyers J, Yoo J, Reddel H. 2019. Difficult-to-treat and severe asthma in adults: Towards a new treatment paradigm. Australian Journal for General Practitioners 48: 188-92
8. Bahadori K, Doyle-Waters MM, Marra C, et al. 2009. Economic burden of asthma: a systematic review. BMC Pulmonary Medicine 9(1): 24
9. Sadatsafavi M, Lynd L, Marra C. 2010. Direct health care costs associated with asthma in British Columbia. Can Respir J 17(2): 74-80
10. Håkansson KEJ, Løkke A, Ibsen R, et al. 2023. Beyond direct costs: individual and societal financial burden of asthma in young adults in a Danish nationwide study. BMJ Open Respiratory Research 10(1): e001437
11. Global Initiative for Asthma (GINA). 2023. Global Strategy for Asthma Management and Prevention (2023 Update).
12. Menzies-Gow A, Jackson DJ, Al-Ahmad M, et al. 2022. A Renewed Charter: Key Principles to Improve Patient Care in Severe Asthma. Advances in Therapy 39(12): 5307-26
13. Lefebvre P, Duh MS, Lafeuille MH, et al. 2015. Acute and chronic systemic corticosteroid-related complications in patients with severe asthma. J Allergy Clin Immunol 136(6): 1488-95
14. Pavord I, Bahmer T, Braido F, et al. 2019. Severe T2-high asthma in the biologics era: European experts’ opinion. Eur Respir Rev 28(152):
15. Price DB, Trudo F, Voorham J, et al. 2018. Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study. J Asthma Allergy 11: 193-204
16. Haughney J, Winders T, Holmes S, et al. 2023. A Charter to Fundamentally Change the Role of Oral Corticosteroids in the Management of Asthma. Advances in Therapy: 10.1007/s12325-023-02479-0:
17. Lommatzsch M, Brusselle GG, Canonica WG, et al. 2022. Disease-modifying anti-asthmatic drugs. Lancet 399: 1664–68
18. Dhar R, Rhee C, Perng D. 2023. The burden of systemic corticosteroid use in asthma management in Asia. Respirology: 10.1111/resp.14533: 1-14
19. Canonica GW, Blasi F, Paggiaro P, et al. 2020. Oral CorticoSteroid sparing with biologics in severe asthma: A remark of the Severe Asthma Network in Italy (SANI). World Allergy Organ J 13(10): 100464
20. Canonica GW, Colombo GL, Bruno GM, et al. 2019. Shadow cost of oral corticosteroids-related adverse events: A pharmacoeconomic evaluation applied to real-life data from the Severe Asthma Network in Italy (SANI) registry. World Allergy Organization Journal 12(1): 100007
21. Bleecker ER, Al-Ahmad M, Bjermer L, et al. 2022. Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group. World Allergy Organization Journal 15(12): 100726
22. Wu Y, Song P, Lin S, et al. 2021. Global Burden of Respiratory Diseases Attributable to Ambient Particulate Matter Pollution: Findings From the Global Burden of Disease Study 2019. Front Public Health 9: 740800
23. Deng SZ, Jalaludin BB, Antó JM, et al. 2020. Climate change, air pollution, and allergic respiratory diseases: a call to action for health professionals. Chin Med J (Engl) 133(13): 1552-60
24. Wilkinson A, Maslova E, Janson C, et al. 2021. Greenhouse gas emissions associated with asthma care in the UK: results from SABINA CARBON
25. Wilkinson A, Woodcock A. 2022. The environmental impact of inhalers for asthma: A green challenge and a golden opportunity. Br J Clin Pharmacol 88(7): 3016-22
26. Perez MF, Coutinho MT. 2021. An Overview of Health Disparities in Asthma. Yale J Biol Med 94(3): 497-507
27. Marmot M. 2018. Inequalities in asthma mortality: a specific case of a general issue of health inequalities. Thorax 73(8): 704-05
28. Gupta RP, Mukherjee M, Sheikh A, et al. 2018. Persistent variations in national asthma mortality, hospital admissions and prevalence by socioeconomic status and region in England. Thorax 73(8): 706-12
29. Mortimer K, Reddel HK, Pitrez PM, et al. 2022. Asthma management in low and middle income countries: case for change. Eur Respir J. 2022 Sep 15;60(3):2103179.
