Looking beyond the magic bullet: Novel asthma drugs or education, which works better?

Abstract

Over the past decade, there has been an increase in new anti-asthma medications, particularly in biological agents recommended for adult asthmatics. [1] Despite the increased access to novel agents, there has been a dearth of data and recommendations on the positioning of these drugs in the paediatric arena. Although children with severe asthma are a smaller component of the total asthmatic population (˂5%), there is a need for evidence-based recommendations for the use of these novel drugs in asthmatic children, as they consume a disproportionate amount of healthcare resources. [2,3] Biological agents are typically recommended for use in specific asthma phenotypes and endotypes, with predefined criteria predicting treatment response. [4,5] The role of asthma comorbidities and asthma education has been emphasised in the most recent international guidelines, with patient adherence and motivation forming a critical part of a package of care for asthma management and successful therapy. [1] The purpose of this continuing medical education article is to review the current literature on novel asthma drugs and to assess the evidence for their use or avoidance in the paediatric age group. The role of asthma education and strategies to improve asthma outcomes are also reviewed. Methods The South African Childhood Asthma Working Group (SACAWG) convened in January 2017 to review the current available literature on novel treatments of asthma and asthma self-management plans (Appendix A). The scientific literature was assigned evidence levels according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system (Appendix B). Novel asthma molecules in South Africa Fluticasone furoate/vilanterol Few studies have been done in children with the new combination agent of an inhaled corticosteroid (ICS) and an ultra-long-acting beta-agonist. In 5-11-year-old patients with well-controlled asthma, fluti ca sone furoate/ vilanterol has a similar tolerability, safety profile, pharmacodynamic effect and pharmacokinetic profile as fluticasone furoate alone. [6,7] The new combination drug is currently registered for children >12 years of age and recommended for children with moderate to severe asthma (evidence level B) Tiotropium bromide Tiotropium bromide is a once-daily long-acting anticholinergic drug initially approved for chronic obstructive pulmonary disease This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Severe asthma in South Africa: A literature review and management approach for primary care

“…Besides adjusting therapy to a reviewed diagnosis and optimising management of comorbidities and modifiable risk factors, Masekela et al strongly advise primary carers to provide patients with an asthma self-management plan, preferably written out. 14,45 SACAWAG convened in January 2017 to review and grade scientific literature on asthma selfmanagement plans as an objective. The finding that thorough education benefits patients more than limited education added to the superiority of written asthma action plans over oral education, and graded as evidence level A.…”

“…Individualised asthma plans should be developed in accordance with the patient's health-seeking behaviour. 45 The GINA Patient Guide explains to the patient how to monitor danger symptoms, such as increased respiratory rate, decreasing oxygen saturation and/or a decrease in PEF; hence, patients are empowered to respond timeously to an exacerbation using an asthma self-management plan. 46,47 Clinicians need to realise that education given during an emergency visit is not as effective as education during followup visits (evidence level A).…”

“…46,47 Clinicians need to realise that education given during an emergency visit is not as effective as education during followup visits (evidence level A). 45 After receiving emergency treatment for an asthma attack, patients need flagging for a definite follow-up date with the primary carer and were made aware that they are at risk of a fatal asthma attack in the future. 14 Consider non-pharmacological add-on therapy, which includes physical exercise, a healthy diet and weight loss.…”

Triangulated children's reality: Medical model's concealing effect versus family systems' revealing effect

“…In fact, according to Anand and Malhi (2011), U.S. psychiatry's alignment with the medical model was further concreted by the pharmacological armamentarium's expansion. Consequently, clinicians bred in DSM's bible come to consider it “as the definitive authority on psychiatric diagnosis” (Anand & Malhi, 2011, p. 348), thereby attributing mental symptoms to innate biological causes and ultimately resorting to magic psycho pharmacological bullets (i.e., drugs; Masekela et al, 2018) for mental health restoration.…”

He who refuses to obey cannot command: A guide to paediatric asthma management

“…Two CME articles in this issue of SAMJ address the management of mild-to-moderate asthma in children [2] and the place of the novel biological agents. [3] Key to these issues is that childhood asthma can mainly be managed by primary healthcare providers and the appropriate use of inhaled corticosteroids via metered-dose inhalers with a spacer device, and the provision of reliever medication for acute exacerbations. With this approach, >80% of children can achieve good asthma control, provided the package of care is linked to education regarding the correct technique when using asthma devices, the correct use of reliever medications and the provision of emergency care plans.…”