Relationship Between Asthma Therapy Types, Pulmonary Function, and Asthma Control in Primary Healthcare Facilities in Medan

INTRODUCTION

Asthma is a frequently encountered disease that generally affects 1 - 18% of the world's population. Asthma affects 235 million people worldwide and continues to increase up to 50% of the world's asthma incidence every decade, especially in low-income countries.[1] Asthma can affect all age groups but is most common in childhood, with 60% of adults with asthma and 50% of children with asthma failing to adequately control their condition. Currently, about 300 million people worldwide have asthma and will reach 400 million by 2025.[1-3]

A stepwise approach to asthma control is the cornerstone of controlling symptoms, preventing acute asthma exacerbations and improving lung function.[1] Many asthma patients are uncontrolled despite evidence-based recommendations and evolving treatments. Uncontrolled asthma is characterized by daytime symptoms, requiring short-acting inhalers more than twice per week, limiting one's activities due to asthma, or waking up during the night due to asthma attacks.[4] Asthma self-management includes advice and education on self-monitoring and a defined asthma management plan supported by professional review. Self-management is recognized as an effective method to improve asthma control and quality of life and reduce unscheduled consultations and hospitalizations across a wide range of demographic groups.[5] Although there are many evidence-based guidelines and effective treatments for the disease, many asthma patients still have uncontrolled symptoms.[6] The asthma population has between 47 - 57 % adherence which is lower than chronic diseases such as rheumatological or gastrointestinal diseases.[7] The exact cause and cure of asthma is unclear. Fortunately, symptoms can be significantly controlled with proper asthma management.[8]

Tumor cell proliferation, apoptosis suppression, tumor-driven angiogenesis, metastasis, and DNA damage repair are all significantly impacted by EGFR activation. This makes EGFR a key target in cancer therapy, particularly lung cancer. Chemotherapy and radiotherapy may be improved by inhibiting EGFR.[8] Thus, identifying cancer genotypes enables a more targeted approach to lung cancer treatment. The extracellular ligand-binding region of EGFR has been the target of a class of monoclonal antibodies since it was discovered in 1962, blocking receptor activation and reducing its surface expression through antibody-induced receptor dimerization. Additionally, EGFR is inhibited by small molecule tyrosine kinase inhibitors (TKIs) via competition with ATP for attaching to the intracellular tyrosine kinase subunit, suppressing the receptor’s catalytic activity and downstream signaling pathways. TKIs have shown substantial antitumor efficacy in cancers characterized by EGFR overexpression.[8]

Inhaled medications are the cornerstone of pharmacologic treatment of patients with asthma. The two main classes of inhaled medications include corticosteroids (ICS) and bronchodilators. There is wide diversity in the molecules in both classes. In addition, there is a wide variation in delivery systems. When prescribing a particular inhaler device, clinicians should consider a number of factors, including the ability to generate adequate inspiratory flow, the capacity to handle the device appropriately and, importantly, its coordination with inspiratory effort.[9,10]

METHOD

This study was conducted at Puskesmas Tuntungan, Padang Bulan Medan Medan Johor, Bromo, & Amplas, the subjects of this study were taken from the population of asthma patients at Puskesmas Tuntungan Medan and Puskesmas Padang Bulan. The study population was all prescriptions for asthma patients who were established based on anamnesis, physical examination and supporting examination. The sampling technique in this study used consecutive sampling where each population that met the inclusion and exclusion criteria would be sampled in the study. The sample size in this study with a proportion of 1% based on Riskesdas survey data in Medan city amounted to 48 samples.

This study is a descriptive study, data collection was carried out by retrospective method with prescriptions in the medical records of asthma sufferers at the Medan Tuntungan Health Center and Padang Bulan Health Center in the period May 2022 to May 2023. The instruments used in this study were prescriptions and medical records, in patients who received asthma drugs at the Tuntungan, Padang Bulan Medan Health Center, Medan Johor, Bromo, & Amplas. The data analysis technique used in the study was univariate analysis using the SPSS version 23 application.

RESULTS

Women are the most asthma patients with 40 patients (83.3%), and men are the least patients with 8 patients (16.7%). Then it was found that patients aged >50 years were 30 people (62.5%), patients aged 26-50 were 13 people (27.1%), and patients aged 17-25 years were 5 people (10.4%). The most patients were patients aged >50 years as many as 30 people (62.5%), and the least were patients aged 17-25 years as many as 5 people (10.4%). Then, patients with normal BMI are the most IMT as many as 29 patients (60.4%), and Underweight is the least IMT as many as 2 patients (4.2%). The highest level of education was high school as many as 33 patients (69%), then the S1 education level was 13 patients (27%), and the junior high school and D3 education levels were 1 patient (2%).

The occupations of the most asthma patients were housewives as many as 21 patients (44%), self-employed as many as 10 patients (21%), civil servants as many as 9 patients (19%), retired civil servants and students as many as 2 people (%) and teachers, farmers, traders, and students as many as 1 person (2%).

Table 1. Demographic Characteristics of Research Subjects

Demographic Characteristics	n = 48
Gender, n (%)
Male	8 (16,7)
Female	40 (83,3)
Age, n (%)
17-25	5 (10.4)
26-50	13 (27.1)
>50	30 (62.5)
BMI (%)
Underweight	2 (4,2)
Normal	29 (60,4)
Overweight	17 (35,4)
Education
Junior High	1 (2)
Senior High	33 (69)
Diploma	1 (2)
Bachelor’s Degree	13 (27)
Job
Bachelor Student	2 (4)
Self Employed	10 (21)
Housewife	21 (44)
Retired Civil Servant	2(4)
Teacher	1 (2)
Farmer	1 (2)
Trader	1 (2)
Civil Servant	9 (19)
Student	1 (2)

Table 2 Overview of Lung Function

Lung Function	(n=48)	(%)
APE ≥60% Prediction	35	73,0
APE <60% Prediction	13	27,0

Pulmonary function of asthma patients who have APE> 60% prediction is the most patients, namely 35 people (73%), and the lowest pulmonary function of asthma patients is asthma patients who have APE < 60% prediction, namely 13 people (27%).

Table 3. Overview of Asthma Control Level

Asthma Control Level	(n=48)	(%)
Fully and Partially Controlled	6	68,8
Uncontrolled	42	31,2

The highest level of asthma control was uncontrolled in 42 patients (68.8%), and the lowest level of control was fully and partially controlled in 15 patients (31.2%).

Table 4. Type of Drugs

Type of Drugs	(n=48)	(%)
Inhaler	33	68.8
Inhaler Oral	15	31.2

The most common type of drug used was the Inhaler type, with as many as 33 patients (68.8%).

Table 5. Relationship between Asthma Therapy Type and Pulmonary Function

Therapy	APE				Pr	ci	p-value*
	≥60% prediction		<60 prediction
	n	%	N	%			1,000
Inhaler	24	72,0	9	28,0	1,023	0,373 – 2,800
Inhaler+Oral	11	74,0	4	26,0
Total	35		13

Notes: *Chi-Square test

The relationship between the type of asthma therapy and lung function was found to have a p-value of 1.000; the p-value is greater than 0.05, which means that there is no relationship between the type of asthma therapy and lung function.

Table 6. Relationship between Asthma Therapy Type and Asthma Control Level

Terapi	ACT				pr	Ci	p-value
	Fully and Partially Controlled		Uncontrolled
	n	%	n	%
Inhaler	22	66,7	11	33,3
Inhaler+Oral	11	73,3	4	26,7	1,281	0,933 – 1,759	0,67
Total	6		42

Notes: *Chi-Square test

The relationship between the type of asthma therapy and the level of asthma control was found to have a p-value of 0.067; the p-value is more significant than 0.05, which means that there is no relationship between the type of therapy and the level of asthma control. The relative risk for uncontrolled asthma is higher than for controlled asthma.

DISCUSSION

Based on the results of the study, women were the most asthma patients with 40 patients (83.3%), and men were the least patients with 8 patients (16.7%). This is in line with American Lung Association data showing that among adults aged >18 years, 62% of women are more likely to experience asthma symptoms, and the prevalence rate is 35% higher than men. In addition, mortality due to asthma in female patients is also higher. Data from the Centers for Disease Control and Prevention states that the prevalence of confirmed asthma is higher in adult women than men. The reasons for gender differences in asthma recurrence are unclear. Still, they may be related to immunologic and hormonal factors and/or differences in gender-specific responses to environmental or occupational exposures.[11] The mechanisms underlying gender differences in asthma prevalence are still being investigated but mainly refer to hormonal differences and differences in lung capacity.[11]

The most patients were patients aged >50 years, as many as 30 people (62.5%), and the least were patients aged 17-25 years, as many as 5 people (10.4%). This is in line with Andriani's research in the pulmonary clinic of Dr. M. Djamil Hospital, which says that most asthma patients are in the middle adult age group of 40-60 years.41 This study is also in line with Postma DS, 2007, which states that hormonal changes that occur in adulthood contribute to the development of asthma.[12] Estrogen and progesterone hormones can affect the level of free cortisol, which causes a decrease in the amount of cortisol. The result of a decrease in cortisol can cause narrowing of the bronchi, which in turn causes asthma attacks. Postma D research in 2007 reported that the hormone estrogen increases adhesion to endothelial cells in the blood vessels, and the combination of estrogen and progesterone hormones can increase the degranulation of eosinophils so as to facilitate the occurrence of bronchial asthma attacks.[12]

The highest level of education is high school, with as many as 33 patients (68.8%); then the S1 education level, as many as 13 patients (27.1%); and the junior high school and D3 education levels, as many as 1 patients (2.1%). This is in line with Dorevitch's research, which states that a person's education will affect their mindset; the higher a person's education, the better their thinking and behavior26. The better knowledge an asthma patient has, both how to use drugs, the process of asthma, precipitating factors, and symptoms that arise, the better the level of asthma control tends to be.[13]

Normal BMI is the most IMT for as many as 29 patients (60.4%). This study is not in line with Andriani's research, which states that the IMT of most asthma patients is in the overweight & obese classification (49.2%), followed by normal weight (44.4%) and underweight (6.3%).[11] This study found that the IMT of asthma patients was mainly in the overweight classification. Sastre explained that obesity can cause asthma involving several factors such as genetic, hormonal, dietary, and mechanical.[14] This may occur because the risk factors for asthma are not only seen from BMI, but according to PDPI Asthma, where there are risk factors for asthma is an interaction between host factors and environmental factors. Host factors include genetic predispositions that influence the development of asthma, namely genetic asthma, allergies (atopy), bronchial hyperreactivity, gender, and race. Environmental factors affect individuals with a predisposition to develop asthma, causing exacerbations and or causing asthma symptoms to persist. Environmental factors include allergens, workplace sensitization, cigarette smoke, air pollution, respiratory infections (viruses), diet, socioeconomic status, and family size.[2]

Most asthma patients were housewives as many as 21 patients (43.8%), self-employed as many as 10 patients (20.8%), civil servants as many as 9 patients (18.8%), retired civil servants and students as many as 2 people (4.2%) and teachers, farmers, traders, and students as many as 1 person (2.1%). This is not in accordance with Andriani's research in the pulmonary clinic of Dr. M. Djamil Hospital, which says that most (31.7%) asthma patients work as Civil Servants (PNS), followed by the work of Housewives (IRT) 20.6%, Etc. 14.3%, Laborers / Farmers and Retirees both amounted to 9.5%, Not working at 6.3% and 0% for traders and TNI / Polri.[11] According to PDPI Asthma, where there are risk factors for asthma is an interaction between host factors and environmental factors. Environmental factors that cause asthma are allergens, work environment sensitization, cigarette smoke, air pollution, respiratory infections (viruses), diet, socioeconomic status, and family size.[2] The work environment of IRTs is exposed to cigarette smoke and cooking smoke, increasing the risk of asthma.

The relationship between the type of asthma therapy and lung function was found to have a P value of 1.000; the P value was more significant than 0.05, which means that there is no relationship between the type of asthma therapy and lung function. The types of therapy observed in this study were inhalers and inhalers plus oral where inhaler therapy uses a combination of inhaled corticosteroids with inhaled long-acting beta 2 agonists. This is in line with Ranushar's research that there is no significant relationship between asthma therapy methods and lung function with a p-value of 0.609.[15] This is also in line with Syafiaturrahma research, the combination of inhaled corticosteroids with long-acting beta 2 agonists does not make a difference to lung function values.[16]

The relationship between the type of asthma therapy and the level of asthma control yielded a p-value of 0.067, which is greater than 0.05, indicating that there is no significant relationship between the type of therapy and the level of asthma control. This finding is not consistent with Ridwan's study at Wahidin Sudirohusodo Hospital, which reported a significant relationship between therapy type and control level, with a p-value of <0.0001.[17] In that study, 9.3% of asthma patients were fully controlled, 56.5% were partially controlled, and 34.3% were uncontrolled.

Similarly, Ranushar's study also found a significant relationship between therapy methods and asthma control levels, with a p-value of 0.001.[15] These results differ from the findings of this study, where the number of uncontrolled asthma patients was higher than those who were fully or partially controlled. The researcher suspects that this may be related to the severity of bronchial asthma patients who have not received an appropriate therapy dosage according to their asthma severity. Data obtained in this study indicate that some patients in primary healthcare facilities received the exact inhaler dosage each month without dose adjustments, either increases or decreases, based on their asthma severity.

According to GINA and PDPI guidelines, asthma patients should be monitored regularly to assess symptom control, risk factors, attack occurrences, and responses to treatment adjustments so that medication doses can be adjusted accordingly to asthma severity.[2] Another possible reason for the high number of uncontrolled asthma cases in this study is improper inhaler usage by patients. Demographic factors, particularly education levels, could influence this, as a large proportion of the sample had only completed high school education. Dorevitch’s study suggests that education influences cognitive patterns-higher education levels are associated with better thinking and behavioral patterns.[18] The better an asthma patient’s knowledge about medication use, asthma pathophysiology, triggering factors, and symptoms, the more likely they are to achieve better asthma control.[13-18]

CONCLUSION

There is no significant association between asthma therapy type and pulmonary function or asthma control level. Despite receiving treatment, a high proportion of patients remained uncontrolled. Factors such as treatment adherence, proper inhaler usage, and dose adjustments based on asthma severity may play a crucial role in achieving better asthma control.

DECLARATIONS

The authors would like to acknowledge all patients who participated in this study. Medicine, Faculty of Medicine, University of North Sumatra, Medan

CONSENT FOR PUBLICATION

The Authors agree to publication in Journal of Society Medicine.

FUNDING

None

COMPETING INTERESTS

The authors declare that there is no conflict of interest in this report.

AUTHORS’ CONTRIBUTIONS

All authors significantly contribute to the work reported execution, acquisition of data, analysis, and interpretation, or in all these areas. Contribute to drafting, revising, or critically reviewing the article. Approved the final version to be published, agreed on the journal to be submitted, and agreed to be accountable for all aspects of the work.

ACKNOWLEDGMENTS

None

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