Page 130 - Škrgat, Sabina, ed. 2022. Severe Asthma - Basic and Clinical Views. Koper: University of Primorska Press. Severe Asthma Forum, 1
P. 130
or are permanently on oral steroid therapy. As (57.1%). Croatian pulmonologists also iden-
half of them have type 2 inflammation24, then tified the problem of financial restrictions at
severe asthma forum 1: severe asthma - basic and clinical views it is reasonable to assume that there are 1780 the level of hospitals. When we examine the
patients in Croatia eligible for some kind of bi- guidelines prescribed by CHIF, poor lung
ological therapy. function (FEV1 <60% expected) is for all bio-
logics one of the key criteria that had to be ful-
If we consider a different count, paral- filled. In international guidelines, poor lung
lelly, in Croatia as in the Netherlands, where function is not mentioned for indications for
1.5% of all asthma patients are eligible for bi- biologicals or it is restricted to FEV1 ≤80%.
ologicals, we get similar numbers. In Croatia, Therefore, negotiations with CHIF based on
1.5% of all asthma patients consist of 3237 in- pharmaco-economic and health-related qual-
dividuals. Half of those patients are 1618 pa- ity of life (HRQoL) criteria should be initiat-
tients with severe asthma who are allergic or ed to implement less stringent criteria for the
have eosinophilic asthma, or have asthma reimbursement of biologics according to in-
with type 2 inflammation - all of them are ternationally recommended guidelines25.
eligible for either anti-IgE, antiIL-5 or an-
ti-IL-4/IL-13 biological therapy. Third controversy: Are we Emphasizing
the Necessity of Smoking Cessation
We investigated Croatian pulmonolo- Enough?
gists’ attitudes toward the prescription of bi-
ologicals in severe asthma patients, to iden- Asthma is not considered a disease of high
tify reasons for the discrepancy between the mortality. Still, each day there are 3-6 deaths
number of eligible severe asthma patients and from asthma, as reported in Brazil26. Investi-
proper biological treatment. Biologics can be gations have proven that decreasing the num-
prescribed only by a pulmonologist following ber of smokers also decreases the prevalence
specific guidelines proclaimed by the Nation- of respiratory deaths27.
al Health Insurance (Croatian Health Insur-
ance Fund, CHIF) and has to be approved by Tobacco smoke from cigarettes has many
the Hospital Medicines Committee (HMC). toxic compounds such as acrolein, acetalde-
We found that regular treatment with system- hyde, and formaldehyde, which contribute to
ic glucocorticoids and frequent acute exacer- respiratory irritation28. Tobacco can increase
bations were the most frequent major indica- the prevalence of allergic diseases, like asth-
tions for biologics in severe asthma patients, ma, allergic rhinitis and atopic dermatitis. It
91.7% and 82.1%, respectively, followed by could precipitate allergic sensitization directly
frequent ER visits or hospitalizations (53.6%). – by affecting the IgE production on a cellu-
The average period from establishing the in- lar level, or indirectly – by increasing the per-
dication for biologic therapy until the actual meability of respiratory epithelium29. In the
application was estimated to be 2 months, sig- research conducted on Croatian citizens, we
nificantly shorter in university hospitals (58 have found a statistically significant increased
vs. 105 days, z=2.255, p=0.024) but without prevalence of allergic diseases and increased
a difference between regions (p=0.561). A sig- level of total IgE, both in active and passive
nificant number of pulmonologists reported smokers as opposed to non-smokers30. Active
that some of their patients did not receive bio- smoking increases the inflammatory process
logical treatment for their severe asthma dur- with cell infiltrations, especially eosinophils31.
ing the last 12 months even though they need- The clinical picture of asthma in smokers is
ed it: due to inappropriate diagnosis (64.3%), more severe in terms of symptoms, with more
strict administrative directions for the reim- frequent exacerbations than in asthmatic
bursement by the Croatian Health Insurance non-smokers,. Secondhand smoking leads to
Fund (70.2%), and limited hospital resources
half of them have type 2 inflammation24, then tified the problem of financial restrictions at
severe asthma forum 1: severe asthma - basic and clinical views it is reasonable to assume that there are 1780 the level of hospitals. When we examine the
patients in Croatia eligible for some kind of bi- guidelines prescribed by CHIF, poor lung
ological therapy. function (FEV1 <60% expected) is for all bio-
logics one of the key criteria that had to be ful-
If we consider a different count, paral- filled. In international guidelines, poor lung
lelly, in Croatia as in the Netherlands, where function is not mentioned for indications for
1.5% of all asthma patients are eligible for bi- biologicals or it is restricted to FEV1 ≤80%.
ologicals, we get similar numbers. In Croatia, Therefore, negotiations with CHIF based on
1.5% of all asthma patients consist of 3237 in- pharmaco-economic and health-related qual-
dividuals. Half of those patients are 1618 pa- ity of life (HRQoL) criteria should be initiat-
tients with severe asthma who are allergic or ed to implement less stringent criteria for the
have eosinophilic asthma, or have asthma reimbursement of biologics according to in-
with type 2 inflammation - all of them are ternationally recommended guidelines25.
eligible for either anti-IgE, antiIL-5 or an-
ti-IL-4/IL-13 biological therapy. Third controversy: Are we Emphasizing
the Necessity of Smoking Cessation
We investigated Croatian pulmonolo- Enough?
gists’ attitudes toward the prescription of bi-
ologicals in severe asthma patients, to iden- Asthma is not considered a disease of high
tify reasons for the discrepancy between the mortality. Still, each day there are 3-6 deaths
number of eligible severe asthma patients and from asthma, as reported in Brazil26. Investi-
proper biological treatment. Biologics can be gations have proven that decreasing the num-
prescribed only by a pulmonologist following ber of smokers also decreases the prevalence
specific guidelines proclaimed by the Nation- of respiratory deaths27.
al Health Insurance (Croatian Health Insur-
ance Fund, CHIF) and has to be approved by Tobacco smoke from cigarettes has many
the Hospital Medicines Committee (HMC). toxic compounds such as acrolein, acetalde-
We found that regular treatment with system- hyde, and formaldehyde, which contribute to
ic glucocorticoids and frequent acute exacer- respiratory irritation28. Tobacco can increase
bations were the most frequent major indica- the prevalence of allergic diseases, like asth-
tions for biologics in severe asthma patients, ma, allergic rhinitis and atopic dermatitis. It
91.7% and 82.1%, respectively, followed by could precipitate allergic sensitization directly
frequent ER visits or hospitalizations (53.6%). – by affecting the IgE production on a cellu-
The average period from establishing the in- lar level, or indirectly – by increasing the per-
dication for biologic therapy until the actual meability of respiratory epithelium29. In the
application was estimated to be 2 months, sig- research conducted on Croatian citizens, we
nificantly shorter in university hospitals (58 have found a statistically significant increased
vs. 105 days, z=2.255, p=0.024) but without prevalence of allergic diseases and increased
a difference between regions (p=0.561). A sig- level of total IgE, both in active and passive
nificant number of pulmonologists reported smokers as opposed to non-smokers30. Active
that some of their patients did not receive bio- smoking increases the inflammatory process
logical treatment for their severe asthma dur- with cell infiltrations, especially eosinophils31.
ing the last 12 months even though they need- The clinical picture of asthma in smokers is
ed it: due to inappropriate diagnosis (64.3%), more severe in terms of symptoms, with more
strict administrative directions for the reim- frequent exacerbations than in asthmatic
bursement by the Croatian Health Insurance non-smokers,. Secondhand smoking leads to
Fund (70.2%), and limited hospital resources
