Improper diagnosis and poor asthma care in India may have wrongly cast some patients as “severe” cases and pushed others towards hard-to-treat forms, fuelling inappropriate use of expensive therapies called biologics, three medical experts have cautioned.

Doctors and patients should rigorously evaluate diagnosis and treatment compliance before turning to biologics, two pulmonologists and a respiratory epidemiologist said, while asserting that biologics are essential only for patients with clearly defined treatment-resistant asthma.

“We must fix the fundamental issue — basic diagnosis and management,” pulmonologists Saibal Moitra and Kalpesh Panchal and epidemiologist Subhabrata Moitra wrote this week in the journal Clinical and Experimental Allergy, urging enhanced care through stronger doctor-patient engagement.

Biologics — lab-made antibodies introduced a decade ago that target specific molecules driving inflammation in asthma — are intended for patients who don’t respond adequately to standard treatments such as inhaled corticosteroids and bronchodilators.

“We’re worried that asthma patients might get prescribed biologics even when they don’t really need them,” said Saibal Moitra, a consultant pulmonologist and immunologist at the Apollo Multispeciality Hospitals in Calcutta, on Sunday in an interview with The Telegraph.

The concern is not just clinical — it is also financial.

Doctors say biologics for asthma in India cost ₹25,000 to ₹60,000 per month, compared to ₹600 to ₹1,200 per month for standard treatment with inhaled corticosteroids and bronchodilators.

While doctors in India have long raised concerns about underdiagnosis and undertreatment of asthma, Saibal Moitra and his coauthors have flagged a new issue — poor diagnosis and management leading to patients being wrongly labelled as severe cases.

A 2022 survey had suggested that roughly 2.8 per cent — or 35 million — Indians had asthma. The underuse of diagnostic tools such as spirometers by doctors and limited patient access to well-equipped clinics contribute to the underdiagnosis and poor asthma control.

Pharmaceutical sales data indicate that inhaled corticosteroids are widely underused in the country, with a 2022 study revealing only 26 million units sold against an estimated need of 384 million units based on India’s asthma burden.

“Many patients don’t like using inhalers, many aren’t taught how to use them properly, and many who learn either forget the correct technique or stop the inhaler once they feel better,” said Monica Barne, a former army doctor who is currently a director at the Pulmocare Research and Education Foundation, Pune, a non-government entity that conducted the 2022 study.

“The result is that inhalers are grossly underused,” she told this newspaper.

Poor asthma control, doctors say, can lead to chronic airway inflammation and progress to severe asthma.

“In such circumstances, hard-to-control asthma cases are mislabelled as severe,” said Subhabrata Moitra, an epidemiologist and lead author at Ahmedabad University.

“There are step-by-step diagnostic protocols to classify patients as having severe asthma, but they are rarely followed.”

Subhabrata Moitra and his colleagues have in the journal urged doctors to rigorously check whether their patients have faithfully adhered to their prescribed medications — even advising patients to maintain a diary of their medications — before prescribing biologics.

“Biologics should be prescribed only after a series of tests for biomarkers such as blood eosinophil levels, allergy-related antibodies and airway inflammation to determine which patients qualify for it,” said Subhabrata Moitra. “These are not always done — which means some prescriptions may not be justified.”

Barne said her centre had seen a woman in her 50s who had been prescribed a biologic, but proper use of the correct inhaled corticosteroids with the right inhaler device and right inhalation technique helped her avoid starting it.