The burden of asthma exacerbations and mortality is disproportionately seen in low- and middle-income countries (LMIC), where essential inhaled medications such as short-acting beta2-agonists (SABA) and inhaled corticosteroids (ICS) are often unavailable or unaffordable. Asthma is often managed as a recurrent acute event with high-dose SABA and oral corticosteroids (OCS), which have cumulative long-term adverse effects. Guidelines developed for LMICs are based on the historical assumption, unsupported by evidence and unchallenged until recently, that patients with asthma symptoms <1–3 times per week do not need ICS.
The Global Initiative for Asthma (GINA) recommends a simple single-inhaler strategy across all treatment steps from the time of diagnosis, using low-dose combination ICS-formoterol, which can be used for both symptom relief and maintenance controller treatment. Used only as-needed, ICS-formoterol reduces the risk of emergency visits or hospitalisations by two-thirds compared with SABA-only treatment. The same inhaler can be added as regular maintenance treatment if needed, reducing severe exacerbations compared with a higher dose of ICS plus as-needed SABA. The single-inhaler ICS-formoterol strategy also avoids setting up SABA reliance, requires only one medication strength for most asthma patients, and avoids confusion about different inhaler techniques.
This paradigm-changing GINA strategy has great potential to reduce asthma burden, but ICS-formoterol inhalers are currently very poorly available or unaffordable in LMICs. To make progress, a World Health Assembly Resolution on universal access to affordable and effective asthma care is needed, along with cost-effectiveness analyses of the GINA strategy for the context of LMICs.