Vol. 12 •Issue 9 • Page 20
Allergy & Asthma
Searching Out the Causes of Nonadherence in Asthma Care
Picture yourself in a typical doctor’s office. A teenager with asthma comes in for a routine visit. All is going fine, until the conversation turns to medication.
Doctor: So what medicines have you been using since our last visit?
Patient: I’ve been using my albuterol, but only two or three times a day.
Doctor: What about the controller med that I gave you?
Patient: Oh yeah, I’ve been using that just like you told me to.
Doctor: Then why hasn’t it been refilled?
Patient: Because I still got plenty at home.
Patient-doctor conversations like this can be frustrating experiences, especially when it comes to asthma and adhering to medications. Patients may get their medications mixed up, they may not have the proper inhaler technique, or they might not even understand the importance of adhering in the first place.
Considering that feeling better rapidly is a great positive reinforcement, adherence to emergency asthma relievers usually is easy. But maintaining adherence to long-acting controller medicine is much more of a challenge. After all, who wants to use medicine when feeling well?
Recent studies have found that up to two-thirds of persistent asthma patients are nonadherent to the regular use of inhaled corticosteroid controller medication, which is unfortunate.1,2 The regular use of asthma controller medication — especially the inhaled corticosteroid medications — is one of the most potent interventions for improving asthma control and reducing risk of asthma hospitalizations and mortality.3,4
Many factors can contribute to nonadherence. The next time you find yourself in a baffling patient conversation about asthma medications, find out why the patient isn’t adhering. If you know the obstacles to adherence, you can work together with the patient to design an asthma management strategy that overcomes them.
UNDERSTANDING THE MISUNDERSTANDINGS
Doctor: What does your controller med do?
Patient: It’s like my other inhalers, but it doesn’t seem to work as well as albuterol.
Misunderstanding the role of asthma controller medication is a common contributor to nonadherence. In one survey, which questioned parents of Medicaid-insured children in managed care programs, 23 percent of children with persistent asthma who had an asthma controller medication mixed up its role, thinking it was for symptom relief rather than prevention.2 Not surprisingly, adherence to its daily use was much lower among these children.
The role of medications is a key educational message in the National Asthma Education and Prevention Program guidelines.5 It’s critical that patients understand what to expect of their asthma medications and when to expect it.
Doctor: When do you take your asthma medications?
Patient: Well, to be honest with you doc, sometimes when I get real busy, I forget all about them.
Taking medicine regularly is difficult when life is busy or chaotic. That’s why developing a routine is important. It helps to link taking medicine to an established routine. Patients can take asthma controller inhalers just before brushing their teeth, before mealtimes, or before getting dressed in the morning and/or undressed at night.
Simplification of the medication regimen also is critical. Lower the dosing frequency, and you will improve adherence.6 Sure, the use of inhaled corticosteroid medication twice daily may be slightly more effective, but for some patients, once daily use is much less burdensome.7,8 A large decrease in burden may be well worth the small decrease in effectiveness. If an easier medication regimen is something patients want and feel they can do, it’s more likely that they will abide by it.
Doctor: Do you like your asthma controller medicine?
Patient: Actually, I don’t. I can’t feel it working. I don’t have the time to take it so many times a day. I hate that bulky spacer that you make me use. And it tastes nasty.
Taste shouldn’t be ignored. Sometimes it’s inconsequential, but a taste perceived as unpleasant can block adherence. In those cases, inhaled corticosteroid dry powder inhalers can have a more pleasant taste for some patients than the same type of medicine in its metered dose inhaler formulation. For patients who need both an inhaled corticosteroid and a long-acting bronchodilator, the combination dry powder inhalers may help by both making the regimen more convenient and by making the taste less offensive.
Other strategies to lessen the impact of taste can help, such as rinsing the mouth and/or brushing the teeth right after inhaler use. Use of a spacer or holding chamber can decrease taste by reducing oropharyngeal deposition.
Adherence rates for pills are better than for inhalers because pills are quick and easy to take.1 However, the asthma controller medications available in pill form (leukotriene modifiers and theophyllines) aren’t as effective in preventing asthma flare-ups as the inhaled corticosteroid medications.9
PROBLEMS WITH PARENTS
Sometimes, frustrating conversations don’t just happen with patients. They can occur with patients’ parents as well.
Doctor (to parent): How do you know that he’s taking his medicine?
Parent: Truthfully, I don’t. I feel it’s his responsibility. I leave it in his hands. Besides, I’m too busy to be checking up on him all the time.
Inadequate parental guidance can affect adherence, so supervision needs to be age appropriate. A toddler or early school-aged child needs direct supervision. Allowing an older child to have more responsibility is certainly important, but the parent must make sure that the child is worthy of it.
Have detailed conversations with patients and grill them about all sorts of adherence issues — likes and dislikes, routines for taking medicine, beliefs about the medications, and goals of asthma care. Ask parents if they think the child’s asthma is in good control. Review pharmacy refill histories; if the child’s quick relievers are being refilled frequently but the asthma controllers aren’t, something is amiss.
What really can make parents’ jobs easier is if children understand what’s happening in asthma and what the asthma controller medication is doing for them. If children believe the medication is important, then they may put up less resistance to using it.
Asthma education programs aimed at children can help improve asthma management behaviors. Sources for education include asthma camps, video games, Internet sites, pharmaceutical companies and respiratory device manufactures.10-12 Local health education centers also may have useful information. Different children may learn in different ways, so it’s important to adapt an individualized approach.
Dr. Farber is a pediatric pulmonologist at the Kaiser Permanente Medical Center in Vallejo, Calif. He’s the author of “Control Your Child’s Asthma: A Breakthrough Program for the Treatment and Management of Childhood Asthma.” His Web site is www.permanente.net/doctor/harold_farber.
For a list of references, please call Sharlene George at (610) 278-1400, ext. 1324, or visit www.Respiratory-care-sleep-medicine.advanceweb.com.
ASTHMA EDUCATION INTERNET RESOURCE
• What’s Asthma All About: www.whatsasthma.org
This is an interactive, Internet-based, flash video tutorial about asthma. Development was funded by a grant from Merck.