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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 47-50

Regular use or on demand of inhaled corticosteroids for the management of asthma among Libyan patients in Tripoli


1 Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Tripoli University, Tripoli, Libya
2 Department of Respiratory, Tripoli Medical Center, Tripoli, Libya

Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Yousef A Taher
Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Tripoli University, Tripoli
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_71_18

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  Abstract 


Background: A step-wise approach for the use of inhaled corticosteroids (ICSs) in the management of bronchial asthma is recommended by all the medical guidelines. However, often, ICS are used intermittently by patients and/or recommended by physicians to be used during the onset of exacerbations. Hence, the present study was aimed to evaluate whether Libyan asthmatic patients are using ICS regularly or on demand and their outcomes.
Methods: The present study was conducted in Tripoli city, along a period of 10 months, May 2013–February 2014. Three hundred patients of either sex recruited from different areas of Tripoli City, diagnosed with asthma and received treatment at Tripoli Medical Center and Abouseta Hospital were participated in this study.
Results: The mean age of patients (±standard deviation) was 51 years (±29.1). Our results showed that 156 patients (52%) used ICS regularly (male: 35% and female: 65%), whereas 48% (144 patients) used ICS only during attack (male: 35% and female: 65%). Of the total participants, 61% of patients stated that they had asthmatic exacerbation symptoms within 1 month after discontinued ICS use (male: 32% and female: 68%). Furthermore, 39% of patients reported that they experienced the first exacerbation of symptom after 30 days of ceased ICS use (male: 38% and female: 62%). Exposure to cold, contact with dust, and inhaler misuse were the most common reported causes of exacerbations, respectively by 71% (212 patients), 12% (37 patients), and 5% (15 patients).
Conclusion: The present findings demonstrate that, practically, half of the Libyan asthmatic patients, living in Tripoli city, are using ICS on demand and few of them had experienced asthma exacerbations after ICS pause use. Hence, in order to reduce the long-term exposure to ICS and patients' cost, our present study suggests, in contrast to international standards of asthma care, the use of ICS just during attack as a new potential treatment option.

Keywords: Asthma, hospital admission, inhaled corticosteroids, oral steroids


How to cite this article:
Tarsin W, Abdulgader H, Eshmandi E, Elshamli I, Taher YA. Regular use or on demand of inhaled corticosteroids for the management of asthma among Libyan patients in Tripoli. Libyan J Med Sci 2019;3:47-50

How to cite this URL:
Tarsin W, Abdulgader H, Eshmandi E, Elshamli I, Taher YA. Regular use or on demand of inhaled corticosteroids for the management of asthma among Libyan patients in Tripoli. Libyan J Med Sci [serial online] 2019 [cited 2019 Nov 18];3:47-50. Available from: http://www.ljmsonline.com/text.asp?2019/3/2/47/261135




  Introduction Top


Asthma is two stages that can be defined as chronic inflammatory disease and bronchial hyperresponsiveness that leads to reversible airways obstruction, either spontaneously or following medication.[1] Although everyone's airway has the ability to obstruct in response to allergens, the asthmatic's airways are very sensitive. As the airways become obstructed, more effort is required to force the air through, and therefore, breathing is very difficult together with wheezing and coughing. In general, asthma cannot be cured, but it can be managed, and with a proper treatment, people with asthma can get normal and active lives.

Asthma is one of the most common chronic inflammatory diseases in the industrialized countries. Its prevalence is increasing and over the past 35 years, a dramatic increase in hospital admission rates and general practitioner consultations, for both adults and children, has occurred.[2] It is estimated to affect 5%–10% of the world's population.[3] On the international scale, the prevalence of asthma is 1%–18% of the population in different countries according to the Global Initiative for the Asthma Management Report.[1] Air pollution, allergen exposure, tobacco smoke, and diet have all been implicated with this increase, but evidence in support of these factors is conflicting.

Asthma is classified as extrinsic or intrinsic type.[4] Extrinsic asthma is triggered by identifiable external allergens. Patients with extrinsic asthma are atopic and are readily developing immunoglobulin E (IgE) antibody against trigger materials present in the environment.[5] This form of asthma is also known as allergic, episodic, or early-onset asthma and is commonly seen in children. It is believed that the allergen induces mast cell degranulation by combining with the IgE antibody present on the surface of the mast cell. This led to liberation of variety of inflammatory mediators, including histamine, prostaglandins, and leukotriene. Besides, eosinophil's, as inflammatory cells, infiltrates and became as a characteristic feature of asthmatic airways. These cells do release variety of mediators including leukotriene C4 and platelet-activating factor, and some basic proteins such as major basic protein and eosinophil cationic protein, which are toxic to airway epithelium.[6]

Intrinsic asthma, which involves late-onset asthma, is characterized by unknown or poorly defined agents but found circumstances and conditions are responsible for the attacks. In contrast to extrinsic, a patient is not atopic and usually attacks at adulthood period.[7]

During exacerbations of asthma, the inflammatory response increases the microvascular permeability and thus cellular infiltration, fibrogenesis, and smooth muscle airway wall changes.[8],[9] This leads to a spasm and more obstruction with extramucus secretion creating a constriction or complete blockage of the airways associated with a decline in the peak expiratory flow rate (PEFR) and forced expiratory volume in 1 s.

Since the initial process of asthma is bronchoconstriction, mast cell activation and inflammation process are targeted to reduce these events. A step-wise approach to the pharmacological treatment is recommended by the GINA guidelines[10] and BTS/SIGN[11] in attempt to achieve optimal asthma control. These guidelines contain a step-up process until disease control is achieved and maintained for a sufficient period of time (usually at least 3 months), then a gradual reduction of the maintenance therapy is recommended to identify the minimum therapy required to maintain control.

The goal of asthma management has been defined as no symptoms, no limitations of daily activities, and no need to reliever treatment, normal or near-normal lung function results, and no exacerbations.[10] The step-wise approach for treatment is based on the use of inhaled short-acting bronchodilators (relievers) and corticosteroids (preventers) in the mild stages of the disease, supplemented by the use of long-acting beta agonist (protectors), antimuscarinics, theophylline's, and leukotriene antagonists. Oral corticosteroids are used for more severe cases and during acute exacerbation as a short course. At the begging of this century, the concurrent use of an inhaled long-acting beta-agonist has been advocated.[12] Patients should receive a regular clinic review, be encouraged to participate in the monitoring of their condition by means of PEFR recordings and be able to tailor their therapy to their level of symptoms.

Inhaled corticosteroids (ICS) are the most effective medication currently available to treat asthma. This route limits any clinically relevant unwanted effects. They improve the physiological abnormality of variable airflow obstructions and airway hyperresponsiveness and as well as reducing the decline in lung function over time that occurs in asthmatic patients. Therefore, ICS are considered as the first-line therapy for patients with regular daily asthma symptoms, and they should be started early after a diagnosis is made.[13] Thus, regular ICS uses are counseled for treatment of children and adults with persistent asthma. However, often worldwide, ICS are used intermittently by patients or recommended by the physicians to be used only at the onset of exacerbations.[14] In Libya, no such information, regarding this point, has been reported previously. Therefore, the present study was aimed to investigate whether the Libyan asthmatic patients are using the ICS regularly or during episode attacks, and their outcomes.


  Methods Top


Asthmatic patients visited the emergency room (ER) and their physician for usual follow-up, monthly, in the main two hospitals in Tripoli city for respiratory diseases, Tripoli Medical Center and Abouseta Hospital, were recruited to participate in this study. The clinical situation of all patients was based on patient history and the physician findings. Asthma symptoms were diagnosed by the use of stethoscope, as the first step, and then confirmed by the use of PEFR and the detection of the amount of oxygen in the peripheral. Before starting the study, ethical approval was obtained from both hospitals medical boards. As well, written informed consent was obtained from all the asthmatic patients.

An inclusion criterion includes 18 years and above stable asthmatic patients using ICS for the management of their disease. While the exclusion criteria include patients who are cigarette smoking, patients having chronic obstructive pulmonary disease, respiratory tract infection, and patients on oral steroids during the study period. Of the 300 asthmatic patients participated in this study, 156 patients did use ICS regularly, and 144 patients did use ICS during attacks only. The present study form covers patient's demographic data, regular or on-demand use of ICS, previous visit to ER or hospital admission, whether the patient gets asthma attack immediately after stopping ICS or later on, physician follow-up and if the patients preferred inhaled or oral medications.

Patients were face-to-face interviewed with the investigator either at the outpatients' clinic or at the emergency department after the patient gets stable and no more asthma exacerbation “asthma exacerbation means that when the patient suffers from a spasm and obstruction of the airways associated with a decline in the PEFR and forced expiratory volume in one second.” All obtained information included in the study form was carefully collected and evaluated.


  Results Top


Three hundred patients were participated in this study; their mean age (±standard deviation [SD]) was 51 years (±29.1; rang 18–86 years). One hundred and four patients (35%) were males, with mean age (±SD) 49 years (±14.9) and 196 were female patients (65%) with a mean age (±SD) 52 years (±34.3). All patients were advised, by their physicians, to use the usual asthma medication; ICS, long-acting beta-agonist (regularly), and short-acting beta-agonist. Our data showed that 156 patients (52%) used the ICS regularly (male: 35%, female: 65%). On the other hand, 144 patients (48%) used ICS during attacks (male: 35%, female: 65%). Most of the patients (90.3%) had a history of using oral steroids and stated that oral steroids were the choice when their asthma attack gets worst. In addition, 164 patients (55%) reported experienced hospital admission. Moreover, the majority of patients (97%) stated that had a previous ER visit due to acute asthma exacerbation and received, in addition, to nebulized bronchodilators a single intravenous, dose of hydrocortisone injection.

The present study demonstrates that exposure to cold, dust, and inhalers misuse are the most causes of asthma exacerbation symptoms among patients after discontinuing ICS use. Of total patients, 71% of patients reported that had exacerbation due to exposure to cold, 12% stated that exacerbation was due to dust contact, and 5% of patients experience asthma exacerbation due to inhalers misuse. One hundred and eighty-two patients (61%, male: female, 1:2; regular use: on demand, 0.69:0.51) did complain asthma exacerbation during 1 month after ceased ICS use. The rest 118 patients (39%, male: female, 1:1.6) described that exacerbation of asthma attack was started after 30 days of withdrawing ICS medication due to different reasons.

Regarding to the attitude and practice of Libyan asthmatic patients toward ICS use, our data showed that 178 patients (59%) preferred to use ICS regularly and 122 patients (41%) favored use of ICS when are necessary. Moreover, it was observed that 91% of patients found that it is easy to use ICS inhalers and 77% of patients are on regular medical follow-up.


  Discussion Top


Asthma is a disease caused by underlying inflammation in the airways. Asthma exacerbation occurs when the airways contracts making it difficult to normal breath. In mild asthmatic patients, ICS are often advised to be used every day to control the underlying inflammation.

A step-wise approach to the pharmacological treatment of asthma is recommended by GINA guidelines[10] and BTS/SIGN[11] in attempt to achieve optimal control. These guidelines comprise a step-up process until disease control is achieved. Once asthma control is achieved and maintained for a sufficient period of time “usually at least 3 months,” a gradual decrease in the maintenance dose is recommended until get the minimum ICS therapy required.

Previous studies have showed a poor compliance among asthmatic patients ranging between 20% and 80%.[15] In line, McCowan et al.[16] have reported that about third of asthmatic patients are not using their prophylactic medication, ICS, as prescribed.[16] In the present study, although all patients were asked to use ICS as a routine treatment for the management of asthma, nearly half of them did use ICS during asthma attacks only. Our data also show that two-third of patients get back asthma attack on a longer period of time (>30 days), due to different reasons rather than discontinuing ICS use. Hence, this finding indicates that uses of ICS regularly are not required by asthmatic patients, and instead, it must be used during asthma attacks. Our findings are in agreement with a study prescribed by Volovitz et al.[17] It has been shown that 75% of asthmatic children were effectively controlled by the use of as-need basis with ICS technique. At the same time, since our observation that one-sixth (about 17%) of asthmatic patients, who did use their ICS regularly, exhibited acute exacerbation of asthma after stopping their ICS use, it also indicates that asthmatic patients do not need to use ICS regularly. Besides, since two-fifth (about 40%) of patients preferred to use ICS on demand also support our new plan of treatment strategy (on demand) since the possibility of ceasing ICS treatment, by the patients himself at any time is always expected. Furthermore, as more than half of the patients participated in this study had a previous hospital admission (regular ICS use: ICS use on demand; 2:1), it seems likely that use of ICS during attacks (i.e., as needed) much better improves the patient's lifestyle.


  Conclusion Top


The present findings demonstrate that, practically, half of the Libyan asthmatic patients, living in Tripoli city, are using ICS on demand and few of them had experienced asthma exacerbations after ICS pause use. Hence, in order to reduce the long-term exposure to ICS and patients' cost, our present study suggests, in contrast to international standards of asthma care, use of ICS just during attack as a new potential treatment option.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma; 2009. [Last accessed on 2009 Aug 01].  Back to cited text no. 1
    
2.
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Lavorini F, Corbetta L. Achieving asthma control: The key role of inhalers. Breathe 2008;5:120-31.  Back to cited text no. 3
    
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Holgate ST. Pathogenesis of asthma. Clin Exp Allergy 2008;38:872-97.  Back to cited text no. 4
    
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Davies RJ. Respiratory disease. In: Kumar PJ, Clark ML editors. Clinical Medicine. London: W.B. Saunders; 1998. p. 745-828.  Back to cited text no. 5
    
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Holgate ST. Has the time come to rethink the pathogenesis of asthma? Curr Opin Allergy Clin Immunol 2010;10:48-53.  Back to cited text no. 6
    
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Greene RJ, Harris ND. Pathology and Therapeutics for Pharmacists. A Basis for Clinical Pharmacy Practice. London: The Pharmaceutical Press; 2000.  Back to cited text no. 7
    
8.
Bradding P, Walls AF, Holgate ST. The role of the mast cell in the pathophysiology of asthma. J Allergy Clin Immunol 2006;117:1277-84.  Back to cited text no. 8
    
9.
Holgate ST, Arshad HS, Roberts GC, Howarth PH, Thurner P, Davies DE. A new look at the pathogenesis of asthma. Clin Sci (Lond) 2009;118:439-50.  Back to cited text no. 9
    
10.
Global Initiative for asthma. Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma; 2011. [Last accessed on 2011 Jan 01].  Back to cited text no. 10
    
11.
British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. National Clinical Guideline. Available from: http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline. 2009.pdf. [Last accessed on 2009 Aug 01].  Back to cited text no. 11
    
12.
Shrewsbury S, Pyke S, Britton M. Meta-analysis of increased dose of inhaled steroid or addition of salmeterol in symptomatic asthma (MIASMA). BMJ 2000;320:1368-73.  Back to cited text no. 12
    
13.
Schleimer RP, Busse WW, O'byrne PM. Inhaled Glucocorticoids in Asthma: Mechanisms and Clinical Actions. New York, Marcel Dekker; 1997. p. 500.  Back to cited text no. 13
    
14.
National Institutes of Health. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Iagnosis and Management of Asthma. National Institutes of Health; 2007.  Back to cited text no. 14
    
15.
Cochrane MG, Bala MV, Downs KE, Mauskopf J, Ben-Joseph RH. Inhaled corticosteroids for asthma therapy: Patient compliance, devices, and inhalation technique. Chest 2000;117:542-50.  Back to cited text no. 15
    
16.
McCowan C, Neville RG, Hoskins G. An academic, pharmaceutical and practice collaboration to implement asthma guidelines. Prim Care Respir J 2005;14:106-11.  Back to cited text no. 16
    
17.
Volovitz B, Nussinovitch M, Finkelstein Y, Harel L, Varsano I. Effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home. Clin Pediatr (Phila) 2001;40:79-86.  Back to cited text no. 17
    




 

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