Assessing Physician Awareness, Management of Coexisting Asthma and Allergic Rhinitis in Asia-Pacific Region

Asthma and allergic rhinitis (AR) frequently coexist, and it is known that having both asthma and AR is associated with uncontrolled asthma and a heavier disease burden. A recently published study of physicians’ beliefs and practices about diagnosis, assessment, and treatment of coexistent disease in the Journal of Asthma and Allergy shows a widespread acceptance of coexistent asthma—AR and the associated burden, but highlights the need for increased healthcare practitioner communication and awareness to improve the appropriate treatment and management of these 2 coexistent conditions.¹

Bhumika Aggarwal, MD, and colleagues at GlaxoSmithKline in Singapore; Philadelphia, Pennsylvania; and London, England, developed the Asia-Pacific Survey of Physicians on Asthma and Allergic Rhinitis (ASPAIR) to assess physicians’ perceptions and management practices for patients with coexisting asthma—AR. A total of 1204 general physicians and pediatricians from 6 countries (China, India, Malaysia, the Philippines, Thailand, and Vietnam) who routinely treat asthma patients were interviewed in person for the study. Physicians were questioned about their attitudes and beliefs about coexistent asthma–AR, how they diagnose and treat patients, and their knowledge of international guideline recommendations.

The survey used probability-based sampling methodology to obtain a representative national sample of physicians across regions in each country, comprising approximately 200 physicians per country (50% general physicians, 50% pediatricians). More half the physicians were female, and age distributions varied across countries; 68% were hospital based; the mean number of years in practice was 15.5 years. Most had received some form of additional training in the management of asthma and AR.

The study found:

• Physicians reported that 45% of their patients with asthma have coexistent AR and 37% of their patients with AR have coexistent asthma.
• Most (77%) agreed that coexistent asthma—AR is a genuine condition, and 86% said that patients suffer worse symptoms with both conditions versus one alone.
• Nearly all (91%) agreed that both asthma and AR should be treated and that intranasal (INS) and inhaled corticosteroids (ICS) could be given concurrently to these patients. However, 40% thought that treating both conditions effectively at the same time is difficult.
• Approximately 25% believed that corticosteroid therapy should be delayed in children for both asthma and AR.
• Although more than 80% of physicians in all countries surveyed recognized and accepted that guidelines provide sufficient information for treating uncontrolled coexistent disease, 41% of the physicians’ asthma patients are being treated with short-acting rescue medications alone, and only 47% said that treatment with concurrent INS and ICS—as recommended in the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines—was their preferred treatment for coexistent disease.

The researchers noted that although there has been a high prevalence of coexistent asthma—AR reported in some low- and middle-income countries, consistent with that reported in higher-income countries, there is a potential for underdiagnosis and suboptimal management of coexistent disease in low- and middle-income countries, possibly related to a lack of awareness and low public health prioritization of these diseases. ARIA guidelines recommend that patients with persistent AR should be routinely evaluated for asthma, and patients with asthma should be assessed for rhinitis. The guidelines also recommend a combined strategy for treating the upper and lower airways, citing the co-administration of INS and ICS as the most effective medications for coexistent asthma–AR. Earlier studies² have reported an underuse of ICS to treat asthma, together with an overuse of oral steroids in the Asia-Pacific region compared with the US, Canada, and Europe.

The authors noted that there may have been an oversampling of urban versus rural physicians due to the sampling method used, and as countries in the Asia-Pacific region were represented, the reported findings may not be globally applicable in their entirety. Also, this was a cross-sectional survey, and thus no conclusions about longitudinal behaviors can be derived from these results. A further important limitation may have been “social desirability bias”; that is, physicians are aware of the guidelines and know that they should be following them, and so responses may reflect that. This may be particularly pertinent in the ASPAIR survey as interviews were in-person. However, to mitigate this, questions were spaced out during the interview to eliminate priming.

All the authors are employees of GlaxoSmithKline (GSK) and all hold shares of the company. Editorial support for the study was funded by GSK.

Reference

1. Aggarwal B, Shantakumar S, Hinds D, Mulgirigama A. Asia-Pacific Survey of Physicians on Asthma and Allergic Rhinitis (ASPAIR): physician beliefs and practices about diagnosis, assessment, and treatment of coexistent disease. J Asthma Allergy. 2018;11:293-307. https://doi.org/10.2147/JAA.S180657?rel=0" ?rel=0" .
2. Nathan RA, Thompson PJ, Price D, et al. Taking aim at asthma around the world: global results of the Asthma Insight and Management Survey in the Asia-Pacific Region, Latin America, Europe, Canada, and the United States. J Allergy Clin Immunol Pract. 2015;3(5):734—742.