Professor of Medicine and Consultant Doctor at Obafemi Awolowo University Hospital, Ile-Ife, Professor Greg Efosa Erhabor, in this interview with Gboyega Alaka and Medinat Kanabe speaks on World Asthma Day, prevalence of the disease in Nigeria, link to obesity and the latest advances in treatment. Erhabor is also president / founder of Asthma and Chest Care Foundation
In celebration of World Asthma Day, can we say that Nigeria is doing well in the area of asthma management?
We have come a long way from where we used to be. World Asthma Day (WAD) is an annual international event aimed at improving awareness and care for asthma worldwide. Several breast doctors across the country now celebrate WAD annually to raise awareness in all geopolitical areas, educating healthcare professionals, patients, caregivers and the general public. This improved public attention, leading to a rapid response to asthma patients when they need help.
In addition, more resident doctors show an interest in pneumology and training to become breast doctors. This has resulted in more standardized ways of management at our various tertiary and secondary hospitals. Basic asthma medications, inhalation therapy and nebulizers are being used more and more by many hospitals and this shows some measure of progress. Although this is still below expectations and there is still a great divide between what happens in tertiary hospitals and in primary and secondary care services.
For the advancement of any disease, it is a triangle of patient management, training and research. There is still weak government involvement and active support to strengthen research and care for asthma patients in Nigeria.
Can we have statistics on the prevalence rate of asthma in Africa as a whole and in Nigeria in particular?
The prevalence of asthma varies from high prevalence countries such as South Africa, which has a prevalence of 33.1%, to low prevalence countries such as The Gambia, with 4.4%. Nigeria's prevalence falls in the middle. Studies carried out in the ISAAC study and studies carried out by academics in Nigeria show that the prevalence ranges from 5% to 18.7%, depending on the study cohort. Most studies show that there is an urban-rural gradient with more asthma diagnoses in urban than in rural areas. Anecdotal evidence has shown that about 15 million Nigerians may have asthma.
There are new risk factors associated with asthma management Do Nigerians need to look beyond avoiding smoking and other activities that trigger asthma attacks?
Basically, asthma results from the interaction of genetic and environmental factors, a situation known as nature and nutrition. Individuals with a family history of asthma are likely to develop asthma. When individuals with a genetic predisposition to asthma are exposed to certain triggering factors in the environment, they develop asthma symptoms. Triggers are extremely small and light particles carried by the air and inhaled through the lungs. They precipitate asthma attacks and are usually found in the environment. Triggers include pollens, house dust mites, cockroach allergens, cold air, spores, smoke, smoke, sprays, perfumes; exercise, certain drugs such as aspirin, tobacco smoke, prolonged exposure to air pollution and agents found in the workplace, such as chemicals, among others. People with allergies such as allergic rhinitis, conjunctivitis, sinusitis or atopic eczema are predisposed to developing asthma. The most common trigger still remains the domestic dust mite. However, there is a new interest in the role of obesity in the development of asthma.
Some people have linked obesity to asthma; what is the connection?
In recent years, there has been an increasing number of literature on obese asthma syndrome. Detailed discussion of this topic will be beyond the scope of this article. How obesity contributes to asthma in an individual can vary. However, these are some factors in progress that have emerged as the relationship:
First, obese people are more susceptible to many strong asthma risk factors, such as allergens, chemicals, smoking and air pollution. There are many things that have been attributed to it, but one common is that the diet that promotes obesity, like the Western diet, has high levels of saturated fatty acids, low fibers, low antioxidants and high sugar content. There is a growing literature that the harmful effects of these components of the diet can lead to an increase in neutrophilic inflammation, which predisposes to asthma and an increase in the bronchodilator response.
In addition, there are some studies showing that obesity can lead to low circulation of vitamin D and vitamin D deficiency has been implicated in the development of asthma and obesity.
There is also what we call a two-way relationship. Obesity predisposes to asthma and asthma also predisposes to obesity. For example, sixty percent of adults with severe asthma in the United States are obese.
Obese patients have worse asthma control and lower quality of life. Obese asthmatics do not respond as well to standard control drugs as inhaled corticosteroids and long-acting beta 2 agonists combined with inhaled corticosteroids (LABA / ICS) as non-obese patients. In addition, obese adults are 1.6 to 3 times more likely to develop wheezing and asthma.
Obesity can cause or worsen gastroesophageal reflux disease (GERD) and sleep apnea, and these two conditions have increased the risk of developing asthma.
Asthma patients who are obese often experience low-grade chronic systemic inflammation, caused by the release of certain pro-inflammatory chemicals (cytokines) in the body. One is leptin, which is synthesized by adipose tissue (adipose tissue) and its levels in the body increase with obesity. Leptin and leptin receptors are found in the cells of the lungs, promote inflammation and contribute to bronchial asthma. High levels of leptin cause impaired lung function, increased airway hyperresponsiveness (AHR), including exercise-induced bronchoconstriction and worsening asthma symptoms.
Why is asthma more prevalent in children than adults? Are there any genetic factors associated with it as well?
Asthma is not really more prevalent in children, as more recent studies have shown. However, we need to do more multinational and intercontinental research to assess the prevalence, as it appears that asthma is still very underdiagnosed in children and adults. Asthma has a bimodal pattern – childhood asthma and adult asthma. Asthma tends to be more numerous and severe among boys than girls in childhood. This becomes balanced at puberty between the ages of 12 and 14. However, between 15 and 50 years old, females predominate. Early childhood events can influence the development of asthma, the so-called hygiene hypothesis. However, what determines progression is being debated. Some believe that when you develop childhood asthma, you continue to have symptoms. Others believe that there is a third party rule; that after the development of asthma, one third goes to rest, some recover and others progress.
In the face of the COVID-19 pandemic, where medical care is becoming difficult, what is your advice for ordinary people living with asthma out there?
Asthma management is usually a partnership between the doctor and the asthma patient. Asthmatics are encouraged to work with their doctors to develop a self-management plan, which includes a plan for acute exacerbation of asthma. The central point of this management is the following:
- It must be individualized and personalized. It is necessary to study asthma and the treatment must be personalized for each person.
- Education is essential. They need to be educated about asthma, the different components of asthma, how to recognize its triggers, inhalation techniques, self-management plan, among others.
- Early use of anti-inflammatory drugs including inhaled steroids is recommended.
- Rescue medication reserve only for acute exacerbation. The lower the use, it shows good asthma management.
- The use of combination therapy using long-acting beta 2 agonists and inhaled corticosteroids (such as Budesonide / Formoterol, fluticasone / salmeterol propionate, fluticasone propionate / Formoteroletc) for prolonged asthma maintenance. These drugs can also be used as rescue drugs. There are other newer drugs used in advanced countries, but these are not readily available and are affordable.
- As a principle, it is advisable to take inhaled medicines for asthma, because it is delivered to the site of the action, and small doses give the maximum effect. However, some inhaled medications can cause oral candidiasis and this can be prevented by using spacer devices or by rinsing your mouth immediately after use.
- Monitoring your asthma using a peak flow meter, which allows you to calibrate your asthma because the peak flow meter has a red, yellow and green color-coded part. The green zone shows that you have good control, with no asthma symptoms and you can continue taking your medications as normal. Your peak flow reading at this time is between eighty to one hundred percent of your normal readings. The Yellow Zone is called the caution zone! The patient may have a cough, wheezing, chest tightness or shortness of breath. He or she may be waking up at night due to asthma and can do some, but not all, usual activities. Use your inhaled bronchodilator with your anti-inflammatory drugs and you can think about changing your medications or increasing your dose. The Red Zone is the medical alert! The patient is usually short of breath and quick relief medications have not helped. That person needs urgent attention.
Asthmatics should be treated as when there was no pandemic. When they see a deterioration in their health, they should contact the nearest health facility as soon as possible. Continued use of medications such as aminophylline can be dangerous and should be discouraged. Early use of steroids is encouraged because of the anti-inflammatory properties.
What are the new therapies in the treatment of asthma?
Sometimes, severe allergic asthma can be very difficult to treat; in other words, they may not respond to commonly used asthma medications. In recent times, several new drugs, known collectively as "biological", have been approved for the treatment of moderate to severe asthma. Biological products are unique in that they target a specific antibody, molecule or cell involved in asthma. For this reason, they are known as "accurate" or "personalized" therapy.
A biological is a medicine made from the cells of a living organism, such as bacteria or mice, that is modified to target specific molecules in humans. For asthma, the targets are antibodies, inflammatory molecules or cellular receptors. By targeting these molecules, biologicals work to interrupt the pathways that lead to the inflammation that causes asthma symptoms.
Some examples of these drugs include: Omalizumab, which targets allergic antibodies known as IgE and Mepolizumab, reslizumab and benralizumab, which target pathways that affect eosinophils – cells involved in the asthma disease process. The most common and most used is Omalizumab, mainly in Europe, the United States and other regions. These drugs are used as complementary therapies for the treatment of severe persistent allergic asthma, inadequately controlled, despite the use of high-dose inhaled steroids and long-acting bronchodilators in patients aged 6 years and over.
Among those who used these drugs, it was noted that severe exacerbations decreased significantly. Omalizumab is given under the skin injection once every 2-4 weeks, based on the initial serum IgE level and body weight.
The main disadvantage of these agents is the prohibitive cost. For example, a 150 mg bottle of Omalizumab costs an average of $ 1,188. In addition, these drugs are not readily available in most low- and middle-income countries, such as Nigeria. Another disadvantage is that they are mostly injectable and, therefore, must be administered in the hospital environment under strict monitoring.
Adverse effects, such as fever, increase susceptibility to upper respiratory infections, headache, fever, hives, induration at the injection site, itching at the injection site, pain and bruising, all contributed to making the use of these drugs less desirable.
Other forms of therapy include bronchial thermoplasty, an innovative, non-drug procedure designed to treat severe persistent asthma. It involves the use of thermal energy to reduce the increase in airway muscle associated with airway constriction in patients with asthma and also to prevent permanent airway damage, also called airway remodeling.
Recently, experts have also advocated the use of Tiotropium, which is a long-acting antimuscarinic agent. This medication works by relaxing the smooth muscles of the airways and reducing the increase in mucus secretion associated with difficult-to-treat asthma.
With the current COVID-19 pandemic, are there more asthmatics presenting with COVID-19?
Current observational research has shown that asthmatics do not exhibit greater exacerbation during COVID-19. But this is still evolving because COVID-19 affects the lung parenchyma and not the airways.
Perhaps asthma protects against COVID 19 through a different immune response caused by the disease. The ACE 2 receptor expressed in the respiratory epithelium has been documented as the route of entry for SARS-Cov2 in humans. However, patients with asthma have decreased expression of these ACE2 receptors.
Therapies used by patients with asthma can reduce the risk of infection or the development of symptoms that lead to diagnosis. Suppression of viral replication has been demonstrated, since the inhaled corticosteroid, ciclesonide, blocks the replication of coronavirus RNA, targeting viral NSP15. The inhibitory effects of glycopyrronium, formoterol and budesonide on HCoV-229E coronavirus replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells have also been reported.
What is the best way to deal with a severe allergic reaction, such as a cough or wheezing at the block site, that would not be misunderstood or taken over by symptoms of COVID-19?
As doctors, we often say that all that wheezing is not asthma. However, wheezing in the chest is not one of the symptoms of COVID-19. The cough in COVID-19 is dry, continuous, associated with fever, sore throat, muscle pain, shortness of breath and other constitutional symptoms. Cough in asthma is usually episodic, associated with wheezing, shortness of breath, chest tightness and triggered by exogenous factors.
At what point exactly do you place an asthma patient in the nebulizer?
The nebulizer is a medication delivery device used to deliver medication in the form of an inhaled mist in the lungs. Nebulizers divide medical solutions and suspensions into small drops of aerosol that can be inhaled directly from the mouthpiece of the device. They can be powered by oxygen, providing a dual approach to the effective management of asthma patients. There are several forms of nebulizers. These include ultrasonic, jet-powered and mesh nebulizers. These devices are basically used to control acute exacerbations of asthma, chronic obstructive pulmonary disease and to administer certain medications to control other diseases. The goal of nebulizer therapy is to provide a therapeutic dose of a desired drug as an aerosol in the form of respirable particles within a short period of time, usually 5 to 10 minutes.
Medicines delivered via nebulizers can also be delivered using an inhaler with a spacer device and this can achieve the same result with a nebulizer. However, nebulizers are useful in acute environments. It is useful when patients do not have spacer devices, if they are too young to cooperate or in the elderly who have poor coordination between the performance of the device and breathing, or any condition that makes it difficult to use inhalation therapy. Research has shown that health professionals find it more convenient to administer nebulizers to patients with severe breathing difficulties, because less education or cooperation is needed at these times, it can be triggered by oxygen and is less dependent on the patient.
When conducting massive asthma management awareness campaigns, what strategies would you suggest to reach those who really need this education?
I met with a group of experts in Tromso, Norway, about two years ago and we were thinking about using the & # 39; M & # 39; Health as a means of education and in the management of patients with diseases such as asthma and COPD. & # 39; M & # 39; Health is a term used for the practice of medicine and public health supported by mobile devices such as phones, tablets, computers, PDAs, smart variable devices, etc. This is a very easy way to use the smart device to track patients; It also contains apps that can allow patients to make informed decisions about what to do and also connect with their doctors in very serious conditions. This is an innovative step.
Other things that can be done include raising public awareness through television, newspapers, radio, social media networks and using various public forums. There is also a need for mass education in schools, churches and mosques and massive distribution of information leaflets on asthma.
How readily are nebulizers and peak flow meters available in our country?
Nebulizers and peak flow meters are now increasingly available in Nigeria compared to what used to happen in the past. OMRON has been actively involved in educating doctors, pharmacists and other healthcare professionals around the world about asthma and the use of peak flow meters and other asthma devices, such as nebulizers. I am also aware that OMRON is collaborating with NEW HEIGHTS and they are involved in large discounted sales of peak flow meters and nebulizers. In addition, there are some pharmaceutical products that distribute peak flow meters free of charge to patients. There are also charitable organizations, such as the Asthma and Chest Care Foundation and the Breathe Easy Foundation, UK, that have been actively involved in the free distribution of peak flow meters to patients. However, this is not enough, we hope a greater participation of philanthropists to make nebulizers, peak flow meters and asthma medications available to the masses. One of my goals as a breast doctor is to ensure that everyone with asthma on the Earth's surface, especially in developing countries, has a peak flow meter at their disposal.
On a final note, we want to commend bodies like the Nigeria Thoracic Society, led by Prof. Prince He, for his work on asthma in Nigeria. The Asthma and Breast Care Foundation, my foundation, has also been at the forefront in providing education, patient assistance and counseling, training of health professionals; advocacy and conducting research projects to improve the lives of people with asthma and other lung diseases. We look forward to the philanthropists who will support these agencies in order to increase government efforts in managing asthma.