Adherence to Updated Asthma Control and Relief Recommendations

Asian woman using a pressurized cartridge inhaler extended pharynx, Bronchodilator
How widely have physicians adopted the 2021 Global Initiative for Asthma recommendations on MART dosing and the use of ICS/formoterol for asthma control and relief?

A recent study exploring real-world application of the 2021 Global Initiative for Asthma (GINA) found that recommendations on using as-needed inhaled corticosteroid (ICS)/formoterol for asthma control and relief, even in patients with mild symptoms, had not been widely adopted. Investigators further reported that many physicians lacked an awareness or understanding of GINA recommendations for maintenance and reliever treatment (MART) dosing, which involves low- or medium-dose ICS/formoterol as daily maintenance, with additional use of this therapy as needed. Study findings were recently published in Respiratory Medicine.

Investigators for the Asthma Patients’ and Physicians’ Perspectives on the Burden and Management of Asthma (APPaRENT) study, which surveyed patients and physicians in Australia, Canada, China, and the Philippines, recruited physicians and patients from online panels between July and August 2020, inviting them to complete an online survey. Participating patients were at least 18 years old and had a history of prior or current asthma.

The physician survey targeted primary care physicians (as well respirologists and/or respiratory therapists in Canada) who were personally responsible for the treatment/management of patients with asthma, had at least 3 years of clinical practice, and treated at least 4 patients with asthma per month. A total of 8376 physicians and 1216 patients were included in the study. Although the 2021 GINA recommended treatment with as-needed ICS/formoterol to control symptoms for patients across the asthma severity spectrum (and as part of MART for patients with moderate to severe asthma), study findings indicated that implementation of this recommendation was limited. Physician prescribing rates for MART and patient-reported use of MART were low; the most widely used regimens in all countries were daily maintenance ICS or ICS with long- or short-acting beta agonists (LABA or SABA) for reliever therapy.

Although more than half of all physicians surveyed said they were aware of MART dosing, physicians indicated that they prescribed a SABA in addition to MART at least some of the time. For patients with mild asthma, most physicians reported using as-needed SABA only (30% to 70%) or low-dose ICS plus as-needed SABA (10% to 20%), despite the current GINA recommendation of using as-needed ICS/formoterol as controller and reliever therapy.

Among patients surveyed, 8% to 15% reported using a MART dosing strategy, whereas 66% to 81% reported using ICS as regular maintenance therapy, with or without the use of SABA or LABA for reliever therapy as needed.

In determining which daily asthma maintenance medication to prescribe, most physicians prioritized preventing symptoms over reducing the risk of exacerbations in patients with mild and moderate asthma. This focus on symptom relief was shared by patients surveyed and is aligned with the GINA report, which also promotes symptom control as a good way to reduce the risk of disease exacerbations.

The investigators said study findings suggest a lack of patient and physician understanding of the clinical benefits of MART, indicating “a need for improved education on treatment strategies, particularly treatment regimens involving as-needed ICS/formoterol,” They noted that “continuing use of separate controller and reliever inhalers, with controller used to suppress the need for reliever, suggests that real-world clinical practice takes some time to evolve and adopt new recommendations.”

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Chapman KR, An L, Bosnic-Anticevich S, et al. Asthma patients’ and physicians’ perspectives on the burden and management of asthma. Respir Med. Published online June 29, 2021. doi:10.1016/j.rmed.2021.106524