The inhaler nobody picks up

India is home to an estimated 37 million people living with asthma — the second largest asthma burden in the world. Yet walk into the average Indian pharmacy and ask how many customers fill a prescription for inhaled corticosteroids (ICS) each week. The number will disappoint you. Because despite decades of global evidence, unambiguous GINA guidelines, and a robust domestic pharmaceutical industry capable of producing world-class inhalers at a fraction of their global cost, inhaled controller therapy remains the road not taken for most asthma patients in India.

This is not a supply problem. It is not a pricing problem. It is something far more complex — and far more uncomfortable to discuss.

The Device Problem Nobody Wants to Name

The inhaler is a counterintuitive device in a country that grew up on tablets and syrups. The first time a patient sees a dry powder inhaler or a pressurised metered-dose inhaler, the instinct is distrust. How can something I breathe in possibly work as well as a tablet I swallow? This scepticism is not irrational — it is a product of medical culture, patient conditioning, and decades of habituating patients to oral therapy.

Inhaled therapy demands that the patient become an active participant in their own treatment. It requires technique, consistency, and an understanding of why a drug that offers no immediate symptom relief is actually doing the most important work. Explaining that is hard. Writing a prescription for a Montelukast tablet is easy.

The oral route has been the default for so long that the inhaled route feels like the deviation — even though the science says the opposite. Inhaled corticosteroids deliver the drug directly to the airway, at a fraction of the systemic dose, with a far superior safety profile. This is not new information. GINA has held this position since 1993. And yet here we are.

Steroids — The Word That Ends Conversations

Ask any practicing physician about the single biggest barrier to ICS adoption in India, and almost universally, they will give you one word: steroids.

Steroid phobia is not a fringe phenomenon in India — it is the mainstream. Studies published in Indian journals show that over 70% of asthma patients and caregivers harbour significant concerns about corticosteroid use, even when the prescription is for an inhaled formulation delivering microgram doses with negligible systemic absorption. This fear is not spontaneous; it has been cultivated, often inadvertently, by years of seeing oral or injectable corticosteroids used in acute settings and associating those experiences with weight gain, diabetes, bone loss, and immune suppression.

The word “steroid” carries the weight of a category, not a molecule or a dose. When a physician prescribes budesonide 200 mcg inhaled twice daily, the patient hears “steroid” and mentally maps it to what they witnessed happen to a relative after a prolonged course of oral prednisolone. The physician knows the two are not remotely comparable. The patient does not — and the prescription goes unfilled.

What makes this particularly troubling is that the healthcare system has done very little to change this narrative at scale. Awareness campaigns, patient education tools, and physician communication training around ICS safety remain fragmented and inconsistently deployed. We have excellent molecules in the market. We have failed at the last mile.

When Asthma Starts — And Why We Refuse to Call It That

Asthma in India often begins in childhood. That is unremarkable — asthma begins in childhood everywhere. What is specific to India is the reluctance to diagnose it.

There is a persistent — and medically unjustifiable — hesitation among physicians, particularly at the paediatric level, to label a child’s recurrent wheeze as asthma and prescribe controller inhalers. The reasons are cultural as much as clinical. The word “asthma” carries social weight. Parents worry about the label following their child — affecting school admissions, sports participation, marriage prospects. Physicians, sensitive to this, often choose softer language: “reactive airway disease,” “viral-induced wheeze,” “chest allergy.” The child goes home with a salbutamol nebuliser and a prescription for Montelukast. No controller inhaler. No diagnosis that would trigger appropriate long-term management.

The consequences compound. A child whose asthma is not diagnosed is a child who does not receive ICS therapy during the critical window when airway inflammation is still most modifiable. That child grows into an adult with progressively worsening asthma, fixed airflow limitation, and a ten-year habit of managing symptoms with nebulisers and oral drugs rather than controlling the underlying disease.

We are, in effect, creating the future uncontrolled asthma patient at the paediatric consultation.

The Home Nebuliser — Comfort Masking Crisis

Few interventions have done more to undermine good asthma management in India than the home nebuliser. This is a difficult thing to say, because the nebuliser is not an inherently bad device. In acute settings — emergency departments, hospital wards — it is often essential. The problem is what has happened in India’s homes.

Across the country, families have purchased desktop nebulisers and stocked them with salbutamol or levosalbutamol vials. When a family member wheezes, they nebulise. When the wheeze resolves, the episode is considered managed. No one asks why the wheeze happened. No one adjusts the controller regimen. No one considers whether this represents a failure of preventive therapy.

The home nebuliser, used with a reliever bronchodilator, provides instant visible relief — the mist, the machine, the resolution of the acute symptom. This is deeply gratifying for patients and families. It is also profoundly misleading. It treats the symptom while the inflammatory process continues unchecked. And because the family has already “solved” the problem, there is no incentive to revisit the physician and review long-term therapy.

This pattern — recurrent acute episodes, each successfully “managed” with nebulised reliever, no escalation of controller therapy — is one of the most common presentations in Indian respiratory clinics. It is also one of the hardest to break, because it requires convincing a family that the solution they already have is actually contributing to the problem.

Montelukast — The Drug That Became an Answer to Everything

India’s Montelukast market tells a story worth pausing on. Montelukast — a leukotriene receptor antagonist — has a defined and limited role in asthma management according to international guidelines: it is an add-on therapy, not a first-line controller. It does not replace ICS. GINA explicitly states this. Yet India has become one of the largest markets for Montelukast globally, with the molecule appearing routinely — and often exclusively — in asthma prescriptions, frequently as a fixed-dose combination with antihistamines.

Why? Because Montelukast is oral, once-daily, “non-steroidal,” and the patient tolerates it without complaint. It partially suppresses eosinophilic inflammation, provides modest symptom reduction, and gives both the physician and the patient a sense that something meaningful is being done. But partial control is not the same as controlled asthma. A patient whose asthma is partially suppressed by Montelukast is still an inflamed airway waiting for the next trigger. They are also a patient who is not on ICS — meaning the most effective controller therapy available has been bypassed in favour of something that is easier to prescribe and easier to take.

The long-term cost of this substitution — measured in hospitalisations, emergency presentations, and quality-of-life years lost — dwarfs whatever convenience it offers at the prescription desk.

The Numbers We Cannot Afford to Ignore

India accounts for an estimated 42% of global asthma mortality. Put differently: nearly one in two asthma deaths worldwide occurs in India — a country that is home to around 18% of the global population. Approximately 57,000 Indians die from asthma every year, a number that has remained stubbornly elevated despite the availability of effective preventive therapy.

These are not deaths from treatment-resistant disease. The vast majority of asthma deaths are preventable. The Global Burden of Disease study has repeatedly identified suboptimal preventive inhaler use — particularly ICS underuse — as the primary driver of avoidable asthma mortality worldwide. In India, this is compounded by underdiagnosis, poor adherence, and the systematic substitution of controller therapy with symptom-masking alternatives.

Meanwhile, India’s COPD burden — an estimated 55 million patients by conservative estimates — presents an almost identical pattern: inhaler underuse, oral therapy preference, late diagnosis, and a cascade of preventable hospitalisations and deaths.

The economic arithmetic is equally damning. A single asthma-related hospitalisation costs a family far more than a full year of ICS therapy would have. We are making an irrational trade, at scale, and calling it treatment.

Who Is Responsible?

This is the question that sits at the centre of every conversation about India’s respiratory crisis — and it deserves a direct answer.

Responsibility is shared, but not equally. Physicians carry the largest share. The prescription is the decisive intervention point, and prescribing habits have persistently favoured convenience over evidence. Continuing medical education must go beyond conference attendance — it must produce measurable change in prescribing behaviour, particularly around paediatric asthma and ICS initiation.

The pharmaceutical industry has a role it rarely acknowledges openly. Driving oral molecule volumes at the expense of ICS adoption is commercially understandable. It is also ethically indefensible when the human cost can be traced and quantified. The industry that has the distribution networks, the medical science teams, and the physician relationships to shift this conversation needs to decide what kind of market it actually wants to build.

Policymakers have allowed ICS awareness to remain a niche concern rather than a public health priority. National asthma management guidelines exist — but their implementation in primary and secondary care settings remains inconsistent at best, invisible at worst.

Patients and caregivers are the last in the chain, but they too are part of the solution — through better access to plain-language information, culturally intelligent communication, and physician conversations that treat them as intelligent adults capable of understanding the difference between an inhaled corticosteroid and a systemic steroid.

What Needs to Change

India’s respiratory disease burden will not resolve itself. The patients are there. The disease is real. The consequences are quantified. And the solution — in the form of safe, effective, affordable inhaled corticosteroid therapy — has been sitting in the evidence base for thirty years.

What is missing is not a molecule. What is missing is the collective will to change a system that has found it easier, more profitable, and more culturally palatable to manage symptoms than to actually control disease.

That is the real diagnosis. And unlike asthma, it does not respond to Montelukast.