Innovations in the treatment of allergic respiratory pathologies, realities and new horizons
Bronchial asthma (BA) is a serious global problem. Severe, sometimes fatal, asthma can manifest itself in people of all nationalities and genders, at all ages. The prevalence of AD is increasing everywhere, especially among children. According to statistics, more than 340 million people around the world suffer from the disease, and more than 22 million of them already have disabilities. Current trends are such that the number of patients with AD will only increase.
Bronchial asthma problem
Every year, the number of people in the world suffering from bronchial asthma is growing. In 2007, data showed an estimated 5.3% and 1.7% of asthmatics among urban and rural populations, respectively. However, from 1997 to 2007, this figure almost doubled. Even the official figures, despite their limitations, show a 2.2–fold increase over 20 years.
Modern medicines allow to cope with the symptoms of bronchial asthma better and better, but even today almost half of asthma patients remain uncontrollable. To improve the situation, both patients and physicians need to be trained to assess symptomatology correctly, to control their condition, to teach them how to help in case of an attack, to use inhalation devices competently, and to know non–drug measures to help prevent symptoms of the disease. Achieving control of asthma allows people to get rid of seizures and not to limit their daily activities.
Current asthma guidelines
World national BA protocols for children and adults are harmonized with GINA, ARIA and other international recommendations.
Modern tools that patients receive free of charge include
– Modern combined inhalers – Budesonid/Formoterol, Fluticasone/Salmeterol, Fluticasone/Vilanterol;
– Modern inhalation steroids – Cyclezonide, Budesonide, Fluticasone
– Means to be injected with the help of nebulizers – Budesonide;
– modern M–cholinolytics of long–term action;
– Antileukotrienovye preparations (montelukast);
– fast–acting adrenomimetics (salbutamol, fenoterol);
– Provision of spirographs everywhere, introduction of pycflow meters, specific allergy diagnostics in vivo and in vitro.
We should add that it is one of the few countries in which the list of pharmaceuticals for asthmatics is provided free of charge.
A new approach to the use of combination therapies: the possibility of using a combination of formoterol and Budesonide in a single inhaler as a means of prescribing both basic therapy and on–demand treatment for the management of AD symptoms has led to a reduction in exacerbations and improved asthma control in adults and adolescents at relatively low doses of drugs.
The Ministry of Health states that the number of allergic and pulmonological beds has decreased, and that an SME has been introduced, but hospitalization and thousands of calls from SOC teams continue. Disability under AD is almost at the same level. The mortality rate from ML diseases increased in 2013–15.
Official figures still show an increase in the prevalence of bronchial asthma:
– 1994 – 26.3 per 100 thousand people;
– 2014 – 56.3 per 100,000 population (i.e. 0.06%).
Naturally, the country’s financial expenditures on asthmatic treatment have also increased. BA remains a heavy economic burden on the budget of the health care system and society. The scale of the spread of AD and the huge financial costs of treating exacerbations dictate the need for further research in the field of drug provision.
Bronchial asthma often becomes severe. Overall, only 20% of patients achieve bronchial asthma control. The treatment of severe and uncontrolled forms of asthma requires much more time and effort on the part of the physician and higher doses of drugs.
How to distinguish between uncontrolled and severe asthma
The most common problems must be eliminated before the diagnosis of severe and uncontrolled AD can be considered:
– Poor inhalation technique (up to 80% of patients);
– Low adherence to treatment (up to 50% of patients);
– Misdiagnosis of AD;
– presence of concomitant diseases affecting AD;
– Continuous contact with the trigger (allergen with confirmed sensitization, professional trigger).
(Federal Clinical Guidelines for the Diagnosis and Treatment of Bronchial Asthma 2016.
As recommended by the GINA program, the choice between therapies should be made individually for each patient.
This will be considered:
1. Preferred therapy for symptom control and risk reduction.
Patient characteristics (phenotype): whether the patient has any prognostic risk factors (smoking, history of exacerbation, eosinophilia).
3. Patient’s preferences: what the patient’s goals are and how they relate to their asthma.
4. Practical issues:
– Inhalation technique – will the patient be able to use the device properly after training?
– Commitment: How often will the patient take medication?
– Cost: Can the patient afford the medicine?
(World Asthma Control and Prevention Strategy, 2017, Global Asthma Initiative.
Powder and aerosol inhalation devices to deliver powder and aerosol inhalants to the lungs are of great importance.
Why is aerodynamic size important?
The size of aerosol particles is important in relation to their ability to penetrate through the respiratory tract into the lungs. Larger particles are captured in the nasal passages, and only a few particles with diameters less than 5 m can enter the lungs. With diameters of less than 5 m, the ability of particles to penetrate into the lungs increases rapidly, but when they become smaller than 1 m, the degree of lung retention begins to decrease.
Why is coordination of aerosol inhalation important?
When inhaling through the DAI (Dispensing Spray Inhaler), patients are forced to coordinate their inhalation so that the activation of the inhaler and the beginning of inhalation coincide perfectly. Otherwise, the amount of medication delivered to the respiratory tract may be reduced by several times. It is difficult to achieve good coordination between inhalation and inhaler activation because the average duration of aerosol generation in the DAI is only 0.2 seconds. 18% of patients activate their inhaler in the second half of their breath, and 5% activate it after completion of inhalation.
Seroflo in scientific experiments and with many years of practical application has proved to be the best means of reliable delivery of modern combined powder inhalers to the lower respiratory tract.
When inhaling through the inhaler, the air flow passes through the dosing holes and carries with it the powder particles that enter the dispersant in the form of a spiral insert in the air channel where, as a result of numerous collisions between themselves and with the walls of the air channel, the units are destroyed and a respiratory fraction is formed.
Why is the speed of aerosol release by the delivery device important?
The aerosol particles generated by conventional dosed aerosol inhalers have a high initial velocity of 0.2 to 0.8 m/s. Moving at this rate, particles collide with the back of the throat by inertia. As a result, most of the dose (50 to 80%) is deposited in the oropharynx, swallowed with saliva and absorbed in the gastrointestinal tract, causing undesirable systemic effects.
Seroflo studies in patients with varying degrees of AD severity and age revealed a number of important issues:
– prolonged (about 1.5 s) isolation of a unique aerosol cloud;
– produces about 70% of aerosol particles with optimal aerodynamic size (1 – 5 microns);
– slowly releases the aerosol at a velocity of about 0.8 m/s;
– is easy to use;
– approved by patients.
“Which IGCS to choose for the best result in the treatment of bronchial asthma and why?
At the moment, my recommendations for a combined ICS are as follows:
Seroflo – due to its rapid onset, it is just as effective as salbutamol in relieving symptoms!
Seroflo is one of the most successful representatives of inhaled corticosteroids with a wide range of therapeutic effects and an excellent safety profile (including early childhood, pregnancy and lactation).