Asthma in adults: a general practice perspective

Introduction

Having worked as a general practitioner in private practice in South Africa for more than thirty years, with a focus on allergic diseases and asthma for over twenty-five years, I have had the privilege of witnessing and experiencing many changes and challenges in asthma management. Most asthmatics receive treatment from general practitioners. The majority have mild to moderate asthma, while only about 10% suffer from severe disease. However, the important fact that acute exacerbations can be severe in any asthmatic and may even be fatal, remains.¹

A key concern is the lack of awareness that poorly controlled inflammation drives these exacerbations. Simply increasing the dose of the Short-acting Beta-2 agonist (SABA)^2,3 and administering systemic steroids whenever symptoms arise does not address the underlying problem. Instead, this approach contributes to future exacerbations and steroid-related complications.⁴

Discussions about asthma facts, its pathophysiology, the complications of poor control, and available treatment options are not frequently found on social media, in lay publications, or even in continuing medical education programs in South Africa. This is concerning, given the fact that asthma is one of the most common chronic diseases affecting adults.

Patients with asthma should be better informed about the condition and receive optimal treatment, leading to improved quality of life and preserved lung function. General practitioners are in a unique position to make a significant impact by bridging the gaps in asthma diagnosis and treatment in South Africa.

Definition

Asthma is a heterogeneous disease usually due to chronic inflammation characterised by variable airflow limitation and presents with symptoms including wheezing, chest tightness, shortness of breath and coughing, which can also vary over time and in intensity.^1,2

Chronic inflammation leads to hyperresponsiveness when exposed to various triggers, including viral infections, weather changes, allergen exposure, poor air quality, aspirin sensitivity and exercise.⁵

Asthma Phenotypes

The inflammatory pathways, as well as characteristics such as severity, triggers, and response to treatment, can vary among asthmatics. These variations are referred to as “asthma phenotypes.”²
Since Wentzel's first publication on phenotypes in 2006, extensive research has been conducted.6 However, we still lack specific biomarkers that can be used in clinical practice to differentiate between these phenotypes.
For the General Practitioner (GP) it would be important to attempt to distinguish between the “Allergic Asthmatic” and “Non-Allergic Asthmatic”.
Allergic asthma usually has its onset in childhood, but it may also present for the first time in adulthood. These patients would often have concomitant allergic rhinitis and might also have atopic dermatitis and a family history of Atopy. These patients generally respond well to inhaled corticosteroids (ICS). ⁷
Non-allergic asthma typically presents for the first time in adulthood. It is often more severe and less responsive to inhaled corticosteroids (ICS).⁸
Elevated eosinophil levels in peripheral blood can indicate a severe asthma phenotype, and the test is easy to perform.⁹

Burden of disease

According to the GINA (Global Initiative for Asthma) report of 2024, asthma affects about 300 million people in the world and is the cause of about 1000 deaths per day globally. Most of the deaths occur in low- and middle-income countries and most of the time could have been prevented.¹
Asthma prevalence in South Africa is the 25^th highest in the world and increasing and we have a very high mortality rate, ranking at 5th highest in the world.3 General practitioners should make the patients aware of these facts. Patients must understand that uncontrolled asthma is as dangerous as uncontrolled diabetes or ischemic heart disease, all having a high mortality rate.

Diagnosis of asthma

The initial diagnosis of asthma depends on thorough history taking. The presence of wheezing, chest tightness, breathlessness, and regular coughing, with variability of symptoms due to various triggers, would be suggestive of asthma. A history of responsiveness to bronchodilator treatment, such as short-acting beta-2 agonists (SABA), would further support the diagnosis as would the co-existence of allergic rhinitis.^1,2
The GP, as a family practitioner, is in an ideal position to make the diagnosis, having access to the patient’s medical records over time. Often, the GP has known the patient since childhood and is aware of any family history of atopy and concomitant allergic conditions, such as allergic rhinitis, in the individual.
The diagnosis of adult-onset asthma is often less clear from the history. In a Finnish questionnaire survey, of the 496 asthma patients with adult-onset, the median time from onset of symptoms until the diagnosis of asthma was made, was three years.¹⁰In a Danish study involving participants aged 14 to 44 years, initial screening was conducted using questionnaires. Those with symptoms suggestive of asthma or allergic rhinitis were further assessed based on medical history, skin prick testing, and lung function testing. A total of 726 individuals were identified as having asthma and/or allergic rhinitis. Asthma was undiagnosed and untreated in 50% of the identified asthmatic cases. ¹¹
Under-treatment due to missed diagnosis may lead to severe asthma and airway remodelling with irreversible airway obstruction.¹²
Spirometry testing can aid with the diagnosis, but a normal test does not exclude asthma due to the variability of the disease but remains the best proof of reversibility, if the criteria of improvement of ≥12% in FEV1 (forced expiratory volume in one second) and 200ml after bronchodilator use, can be documented.²
Spirometry is not readily available in general practice or other primary care facilities in South Africa. However, peak flow meter results may help demonstrate variability in airflow throughout the day. An average daily diurnal variability of 10%, measured over two weeks, would be diagnostic of asthma.¹
More detail regarding the diagnosis of asthma is available from the “Position statement of the South African Thoracic Society – 2021 update” 2 and from the GINA 2024 guideline.¹

Treatment

Most adult asthmatics are treated by GPs or at primary care facilities in South Africa and globally.3,13 It is crucial to regularly review the latest guidelines on asthma management and discuss them at educational events and online webinars to ensure that healthcare providers can apply the latest knowledge and apply guidelines in treating their asthmatic patients.

• Education

Education is the cornerstone of asthma treatment and begins as soon as the diagnosis is made. Asthmatic patients must understand key facts about the disease, including its variability and, more importantly, its chronic nature. Identifying specific triggers for their symptoms and avoiding them whenever possible is essential.⁵
It is important to avoid using terminology like “mild asthma,” as recommended by GINA.1,14 This type of wording may lead patients to underestimate the significance of their diagnosis and mistakenly believe that long-term medication is unnecessary.14 Some adults may even assume they will outgrow asthma or that a short course of treatment will provide a cure.
The difference between medications that provide immediate symptom relief (relievers) and those that treat chronic inflammation (controllers) must be clearly explained and understood.
Explaining how to use different asthma devices once an inhaler has been prescribed, along with demonstrating the proper technique, has been shown in studies to improve compliance and asthma control.^1,15

• Goals in asthma management

The target of treatment in modern asthma research and guidelines is set to high standards for good reason. All treating physicians, including general practitioners, should adopt a “Treat to Target” approach, with the ultimate goal always being total asthma control.^1,2.16
 The criteria for controlled asthma, as defined by GINA, are listed in Table 1.
Historically, asthma management focused on controlling symptoms or treating exacerbations only after they occurred—an approach often referred to as 'Treat-to-Failure.'16 This has led to the dilemma of SABA overuse when symptoms arise and the frequent prescription of oral steroids for acute exacerbations4 and under prescribing of inhaled corticosteroids (ISC).¹³
In this regard, the GP once again plays a critically important role in changing perceptions and promoting a more proactive approach to asthma management.

• Choosing medication

There is no single asthma medication that can be considered the best choice for initiating treatment in all asthmatic patients. Many factors must be taken into consideration.
"Shared decision-making" has become a buzzword in medical publications—and rightly so.^1,2 Patients have a voice, as well as their own opinions and preferences. General practitioners are in a privileged position, having built a long-term relationship with their patients. This allows them to understand their patients' thought processes and tailor treatment plans to fit their lifestyles and personalities.
The only mistake would be to withhold controller medication once the diagnosis has been made!

• The two Tracks of GINA

Since 2019 GINA has recommended that all adult and adolescents asthmatic patients should receive ICS-containing controller treatment and not SABA-only regimes due to safety concerns.1
There is clear evidence in the literature that using SABA alone to treat any form of asthma leads to poor long-term asthma control, deteriorating lung function, and increased exacerbation and mortality rates.1,2 Studies conducted globally have consistently demonstrated these findings.^3,13,17,18

• DATA on SABA Over-use

The SABINA (SABA Use IN Asthma) III (International) study was conducted across 24 countries on five continents, including 8,351 patients. The study found that SABA overuse was prevalent, with more than one-third of patients being prescribed ≥3 canisters per year.^3,13
Data from the South African cohort of the SABINA III trial confirms that most asthmatic patients are treated by primary care physicians and are more frequently diagnosed with “mild asthma” compared to the “moderate-to-severe” cases observed in other countries. A higher proportion of patients in South Africa received three or more canisters of SABA per year, with 23.5% receiving 10 or more per year as monotherapy and 69.8% in combination with maintenance therapy. Additionally, at least 45.6% of patients purchased three or more canisters of SABA without a prescription. Only 39.7% of the cohort had well-controlled asthma, while 46.1% experienced at least one exacerbation in the year preceding data collection.³

• Initiate treatment

According to the Two-Track approach, treatment is initiated with either a low-dose ICS/Formoterol combination inhaler as needed - the preferred track according to GINA - or the alternative track of using a low-dose ICS whenever SABA is used.¹
The frequency of controller treatment, as well as the dose of ICS, will increase based on the patient’s symptoms and need for reliever medication. Treatment initiation can follow the guidelines outlined in the 2021 Position Statement of the South African Thoracic Society (Table 2).²

• Acescent of control and Adjustment of treatment

Assessing asthma control is just as important as making the diagnosis and prescribing medication. According to the South African guidelines, newly diagnosed asthmatic patients should be re-assessed within two to three months. It is essential to schedule this appointment before the patient leaves the practice.²
Establishing the habit of scheduling regular follow-up appointments for known asthmatic patients is equally important. A study from the UK found that most asthma prescriptions were issued at the patient's request rather than during a scheduled doctor's visit.¹⁹ Regular assessments should include symptom control, inhaler technique, and a history of acute exacerbations requiring emergency care.^1,19 Patients often fail to inform their GP about exacerbations, allowing a pattern of frequent flare-ups to go unnoticed.
Assessing asthmatic patients for multimorbidities is essential, as allergic rhinitis is present in up to 80% of cases. Uncontrolled allergic rhinitis can lead to poor asthma control.^20,21 Evaluating allergic sensitisation can aid in diagnosing house dust mite allergy, which, according to GINA, may be a target for treatment with Allergen-Specific Immunotherapy.¹
The simplest way to assess asthma control is the Asthma Control Test (ACT). It consists of five easy-to-understand questions, requires minimal time, and is a validated tool.^1,17,22 Spirometry provides objective proof of asthma control and helps monitor lung function over time;^1,2 however, it is unfortunately not readily available in South Africa.
A peak flow meter can be useful for assessing asthma control over time. It is easy to use, and daily variations in flow volume can help guide medication adjustments even before symptoms are noticed.
After the assessment is completed, treatment adjustments should be made if asthma is not well controlled. This may include increasing the frequency of inhaled corticosteroids (ICS) from an as-needed regimen to daily use, increasing the ICS dose, or adding another medication in accordance with guideline recommendations.^1,2
Too often, patients experience an acute exacerbation, receive a short course of oral steroids, and yet no adjustments are made to their long-term treatment plan.^17,19 Providing each patient with a written asthma action plan is of enormous value in ensuring better disease management.
Taking the time to assess asthmatic patients, ensuring they are well controlled is often neglected in general practice in South Africa and globally.¹⁷
A study conducted in Italy found that while 22% of patients were diagnosed with mild asthma, 72% reported a poor quality of life, and 25% experienced more than one exacerbation per year.¹⁴
Similarly, a study conducted in five European countries revealed that most patients responded to worsening symptoms by simply increasing their SABA dose rather than stepping up their ICS dose as recommended.19 Some patients also become comfortable relying on oral steroids, and unfortunately, many general practitioners continue to prescribe them without adjusting long-term treatment plans. This practice leads to increased SABA and oral steroid use, ultimately worsening asthma control over time.

Challenges and risks in asthma management

The greatest challenge in treating asthmatic patients is poor compliance, driven by several factors discussed in this article. These include a lack of understanding of the chronic nature of asthma, underestimation of disease severity, inadequate patient assessments, and the failure to provide personalized treatment plans. Additionally, cultural differences, limited access to healthcare facilities, and financial constraints often contribute to poor adherence.
The greatest risk in asthma management is an acute exacerbation. The best predictor of a future exacerbation is a previous one, and both patients and GPs need to be aware of this. It is essential to discuss the importance of a follow-up visit within one to two weeks after an Emergency Department visit.¹ This follow-up allows for identifying triggers, assessing whether the treatment plan remains optimal or needs adjustment, and ensuring good adherence to current treatment. Short courses of oral steroids are often prescribed without recognizing that their necessity, by definition, indicates an acute exacerbation.²³ Such cases should be managed similarly to an Emergency Department visit or hospitalization, with thorough evaluation and re-evaluation.
The GP can play a critically important role in identifying difficult-to-control asthma by assessing medical records, noting episodes of exacerbation, and reviewing prescriptions. Additionally, specifically inquiring about the number of SABA canisters used in recent months can provide further insight. By recognizing these trends, true severe asthma can be diagnosed, distinguishing it from cases of poor compliance. Referring these patients to a pulmonologist or specialist physician can open the door to potential biological treatments.

Final thoughts

In conclusion, asthma is one of the most common chronic conditions affecting adults and is primarily managed by general practitioners in South Africa. Although our country's asthma control rates are low and mortality rates high, I believe that by increasing education, adhering to practical treatment guidelines, and regularly assessing patients' asthma control, we can improve asthma outcomes in South Africa.

Table 1:
Goals of Asthma Management

Ref: Adapted from GINA 2024 ¹

Tabel 2
Adapted from: Guidelines for the management of asthma in adults and adolescents: Position statement of the South African Thoracic Society – 2021 update

1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2024. Updated May 2024. Available from: www.ginasthma.org
2. Lalloo UG, Kalla IS, Dheda K, Koegelenberg CFN, Feldman C, van Zyl-Smit RN.  Guidelines for the management of asthma in adults and adolescents: Position statement of the South African Thoracic Society – 2021 update. Afr J Thoracic Crit Care Med 2021;27(4):187-199.

3. Smith C, Ambaram A, Mitha E, Abdullah IA, Reddy J, Trokis J, et al. Over-prescription of short-acting β2-agonists for asthma in South Africa: Results from the SABINA III study. Afr J Thorac Crit Care Med. 2022 Dec 19;28(4):10.7196
4. Tran TN, Heatley h, Bourdin A, Menzies-Gow A, Jackson D, Maslova E et al. Healthcare Resource Utilization Associated with Intermittent Oral Corticosteroid Prescribing Patterns in Asthma. Journal of Asthma and Allergy 2024:17 573–587

1. Janssens T, Ritz T. Perceived Triggers of Asthma: Key to Symptom Perception and Management. Clin Exp Allergy. 2013 September; 43(9): 1000–1008.

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