Table Info

Table 1.

Responses to the consensus statements

Consensus statements	Total participants (n = 26)
Consensus statements	Disagree	Neutral	Agree
GINA 2022 guidelines consensus statements
1. The GINA 2022 guidelines are practical in the patient population that I cover	0 (0%)	0 (0%)	23 (88.5%)
2. I am familiar with the changes in the GINA 2022 guidelines	0 (0%)	1 (3.8%)	22 (84.6%)
Confirmation of diagnosis and identifying risk factors
3. At a global level, spirometry before and after bronchodilator is the most useful initial investigation (GINA 2022)	1 (3.8%)	1 (3.8%)	21 (80.8%)
4. Confirmation of asthma diagnosis with lung function testing, before commencing long-term treatment, is common practice	4 (15.4%)	4 (15.4%)	15 (57.7%)
5. Treatment of modifiable risk factors in every asthmatic patient is highly recommended and practiced	1 (3.8%)	0 (0%)	22 (84.6%)
6. Patients with apparently mild asthma are still at risk of serious adverse events [7, 8]	0 (0%)	3 (11.5%)	20 (76.9%)
Management
7. The recommended first-line rescue inhaler, for the majority of patients is a short-acting β₂ agonist (SABA) inhaler, e.g., Albuterol	8 (30.8%)	6 (23.1%)	10 (38.5%)
8. Low-dose inhaled corticosteroid (ICS)-formoterol as the reliever, is the preferred strategy because of the evidence that using ICS-formoterol as a reliever reduces the risk of exacerbations compared with using a SABA reliever, e.g., Albuterol	0 (0%)	3 (11.5%)	20 (76.9%)
9. Compared with as needed SABA, the use of ICS-formoterol reduced the risk of severe exacerbations by 60–64% [SYmbicort Given as needed in Mild Asthma (SYGMA) 1, novel Inhaled Steroid Treatment as Regular Therapy in Early Asthma (START)]	2 (7.7%)	3 (11.5%)	18 (69.2%)
10. SABA, e.g., Albuterol inhaler, as the reliever, is the non-preferred strategy; it is less effective than track 1 (the reliever is as needed low-dose ICS-formoterol) for reducing severe exacerbations	2 (7.7%)	5 (19.2%)	16 (61.5%)
11. Regular use of SABA, even for 1–2 weeks, is associated with increased airway hyperresponsiveness (AHR), reduced bronchodilator effect, increased allergic response, and increased eosinophils [9, 10]	9 (34.6%)	1 (3.8%)	13 (50%)
12. Track 2 (SABA is the reliever medication) involves using as needed SABA as a reliever, and taking the ICS whenever SABA is taken	6 (23.1%)	3 (11.5%)	14 (53.8%)
13. Patients with exacerbations should receive at least a medium dose of ICS-long-acting β₂ agonist (LABA) before considering an add-on long-acting muscarinic antagonist (LAMA)	1 (3.8%)	2 (7.7%)	20 (76.9%)
14. LAMAs, e.g., Spiriva, should not be used as monotherapy for asthma (i.e. without ICS) because of the increased risk of severe exacerbations [11]	2 (7.7%)	0 (0%)	21 (80.8%)
Maintenance
15. Checking the inhaler technique in every patient is highly recommended and practiced at every visit	0 (0%)	4 (15.4%)	19 (73.1%)
16. Every patient with suspected severe asthma should be seen within 12 weeks of referral to an appropriate specialist severe asthma service	2 (7.7%)	2 (7.7%)	19 (73.1%)

Declarations

Author contributions

YO, MAA, and AA equally contributed to: Investigation, Data curation, Formal analysis, Writing—original draft, Writing—review & editing. All authors read and approved the final manuscript.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Ethical approval

The study was approved by the Ethics Committee of Kuwait University and the Ministry of Health (1239/2023) and complied with the Declaration of Helsinki.

Consent to participate

Informed consent to participate in the study was obtained from all participants.

Consent to publication

Not applicable.

Availability of data and materials

The raw data could be available from the corresponding author upon reasonable request.

Funding

Not applicable.

Copyright

References

Ziyab AH. Prevalence and risk factors of asthma, rhinitis, and eczema and their multimorbidity among young adults in Kuwait: a cross-sectional study. Biomed Res Int. 2017;2017:2184193. [DOI] [PubMed] [PMC]

Khadadah M. The cost of asthma in Kuwait. Med Princ Pract. 2013;22:87–91. [DOI] [PubMed] [PMC]

Linstone HA, Turoff M, editors. The Delphi method: techniques and applications. Addison-Wesley; 1975.

Global Initiative for Asthma. Global strategy for asthma management and prevention [Internet]. Global Initiative for Asthma; 2022 [cited 2023 Jan 12]. Available from: https://ginasthma.org/wp-content/uploads/2023/05/GINA-Main-Report-2022-WMSA.pdf

Alzaabi A, Idrees M, Behbehani N, Salah F. Patients’ and physicians’ attitudes and perception about asthma in the Gulf: a subset analysis from the asthma insights and management survey in the Gulf and Russia. Allergy Asthma Proc. 2021;42:e77–85. [DOI] [PubMed]

Upham JW, Le Lievre C, Jackson DJ, Masoli M, Wechsler ME, Price DB; Delphi Panel. Defining a severe asthma super-responder: findings from a Delphi process. J Allergy Clin Immunol Pract. 2021;9:3997–4004. [DOI] [PubMed]

Dusser D, Montani D, Chanez P, de Blic J, Delacourt C, Deschildre A, et al. Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations. Allergy. 2007;62:591–604. Erratum in: Allergy. 2007;62:968. [DOI] [PubMed]

Bergström SE, Boman G, Eriksson L, Formgren H, Foucard T, Hörte LG, et al. Asthma mortality among Swedish children and young adults, a 10-year study. Respir Med. 2008;102:1335–41. [DOI] [PubMed]

Hancox RJ, Cowan JO, Flannery EM, Herbison GP, McLachlan CR, Taylor DR. Bronchodilator tolerance and rebound bronchoconstriction during regular inhaled β-agonist treatment. Respir Med. 2000;94:767–71. [DOI]

10.

Aldridge RE, Hancox RJ, Robin Taylor D, Cowan JO, Winn MC, Frampton CM, et al. Effects of terbutaline and budesonide on sputum cells and bronchial hyperresponsiveness in asthma. Am J Respir Crit Care Med. 2000;161:1459–64. [DOI] [PubMed]

11.

Baan EJ, Hoeve CE, De Ridder M, Demoen L, Lahousse L, Brusselle GG, et al. The ALPACA study: (in)appropriate LAMA prescribing in asthma: a cohort analysis. Pulm Pharmacol Ther. 2021;71:102074. [DOI] [PubMed]

12.

Louis R, Satia I, Ojanguren I, Schleich F, Bonini M, Tonia T, et al. European Respiratory Society guidelines for the diagnosis of asthma in adults. Eur Respir J. 2022;60:2101585. [DOI] [PubMed]

13.

Kavanagh J, Jackson DJ, Kent BD. Over- and under-diagnosis in asthma. Breathe (Sheff). 2019;15:e20–7. [DOI] [PubMed] [PMC]

14.

Levy ML, Bacharier LB, Bateman E, Boulet LP, Brightling C, Buhl R, et al. Key recommendations for primary care from the 2022 Global Initiative for Asthma (GINA) update. NPJ Prim Care Respir Med. 2023;33:7. [DOI] [PubMed] [PMC]

15.

Bourdin A, Bjermer L, Brightling C, Brusselle GG, Chanez P, Chung KF, et al. ERS/EAACI statement on severe exacerbations in asthma in adults: facts, priorities and key research questions. Eur Respir J. 2019;54:1900900. [DOI] [PubMed]

16.

Nwaru BI, Ekström M, Hasvold P, Wiklund F, Telg G, Janson C. Overuse of short-acting β₂-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020;55:1901872. [DOI] [PubMed] [PMC]

17.

Hatter L, Bruce P, Braithwaite I, Holliday M, Fingleton J, Weatherall M, et al. ICS-formoterol reliever versus ICS and short-acting β₂-agonist reliever in asthma: a systematic review and meta-analysis. ERJ Open Res. 2021;7:00701-2020. [DOI] [PubMed] [PMC]

18.

Beasley R, Braithwaite I, Semprini A, Kearns C, Weatherall M, Harrison TW, et al. ICS-formoterol reliever therapy stepwise treatment algorithm for adult asthma. Eur Respir J. 2020;55:1901407. [DOI] [PubMed]

19.

Reddel HK, FitzGerald JM, Bateman ED, Bacharier LB, Becker A, Brusselle G, et al. GINA 2019: a fundamental change in asthma management. Eur Respir J. 2019;53:1901046. [DOI] [PubMed]

20.

Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, et al. Global Initiative for Asthma Strategy 2021: executive summary and rationale for key changes. Am J Respir Crit Care Med. 2022;205:17–35. [DOI] [PubMed] [PMC]

21.

Crossingham I, Turner S, Ramakrishnan S, Fries A, Gowell M, Yasmin F, et al. Combination fixed-dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database Syst Rev. 2021;5:CD013518. [DOI] [PubMed] [PMC]

22.

Vanfleteren L, Fabbri LM, Papi A, Petruzzelli S, Celli B. Triple therapy (ICS/LABA/LAMA) in COPD: time for a reappraisal. Int J Chron Obstruct Pulmon Dis. 2018;13:3971–81. [DOI] [PubMed] [PMC]

23.

Usmani OS, Lavorini F, Marshall J, Dunlop WCN, Heron L, Farrington E, et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respir Res. 2018;19:10. [DOI] [PubMed] [PMC]

24.

Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008;72:26–33. [DOI] [PubMed]

25.

Légaré F, Ratté S, Gravel K, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals’ perceptions. Patient Educ Couns. 2008;73:526–35. [DOI] [PubMed]

26.

Jackson DJ, Butler C, Chaudhuri R, Pink K, Niven R, Prigmore S, et al. Recommendations following a modified UK-Delphi consensus study on best practice for referral and management of severe asthma. BMJ Open Respir Res. 2021;8:e001057. [DOI] [PubMed] [PMC]