Plenary 2 - Implementation of MART/AIR therapy in children from low middle income countries is impractical

Plenary 2

The reasons why implementation of MART/AIR therapy in children from low-middle income countries is impractical can be grouped to two main categories; (a) the limited evidence for its use in children and (b) the many feasibility issues. 

In adults with asthma, there excellent evidence that the use of MART is superior to SABA alone in reducing severe exacerbations. However, MART has little effect for improving asthma symptoms (ACQ improvement 0.15 which is less than the minimum clinical important difference [MCID] of 0.5). Also in systematic reviews, the improvement in lung function is lower than the MCID value. But we know that children are not little adults and even GINA admits the lack of evidence for some groups of children. This has been eloquently discussed in several recent papers.1,2,3 In several papers where children were included and analysed separately, while MART was superior to SABA alone for adults, it was not so for children/adolescents. Further, almost all studies were undertaken using dry powder inhalers (DPIs) which can only be used in older children.

The feasibility issues that limits its use in LMICs include: (a) the poor availability of ICS and ICS/LABA, (b) its relative high cost relative to median income, (c) weather effects on DPI bioavailability and (d) the health literacy issues in many LMICs which makes limits the use MART/AIR. 

References

Andrew Bush
Imperial College and Royal Brompton Hospital, London, United Kingdom

There is conclusive evidence that MART (Maintenance and reliever therapy) and AIR (Anti-inflammatory reliever) but (a) only in high income settings; and (b) only in young people age 12 and over. The evidence in 5-12 is a single relatively small study, and in pre-schoolers there is no evidence; if anything, the evidence is unfavourable. Before rushing to implement MART/AIR in low- and middle-income (LMIC) settings, we would be well advised to attend to ensure that cheap generic inhaled corticosteroids, short acting β-2 agonists (SABA), spacers and prednisolone are available to every child with asthma. The huge benefits of low dose inhaled corticosteroids in LMICs should not be forgotten, and making these freely available should be a priority. Furthermore, the WASP study [Int J Epidemiol. 2023; 52: 611-623] has demonstrated that the nature of asthma varies across the world, and thus so should treatment approaches. Finally, the fiscal cost to the families We therefore need studies in LMICs to assess MART/AIR as opposed to SABA need to be remembered; will MART/AIR be cheap enough for all families to implement? Although it is likely that MART/AIR will be beneficial in LMICs, some thought is required before committing resources to implementation.