Research shows that substantial numbers of asthma patients don't take their medications as prescribed, contributing to poor control of the condition. CLAIRE O'CONNELLreports
IF A PATIENT’S asthma is not being well controlled by prescribed medication, could it be that they are just not taking the drugs properly?
It’s a complex issue, but a new study suggests that the simple answer in many cases could be yes, and several groups in Ireland are working to reduce such non-adherence, particularly around corticosteroids that can treat underlying inflammation and help prevent asthma attacks.
In some cases, patients can have “steroid phobia”, says asthma nurse specialist Jacqueline Gamble, lead author on a study that tracked 182 patients at Belfast City Hospital.
The study, published this month in the American Journal of Respiratory and Critical Care Medicine, found that 35 per cent of the patients filled half or fewer of their inhaled medication prescriptions, while 21 per cent overfilled their prescriptions and 88 per cent admitted poor adherence with inhaled therapy.
Meanwhile, 23 of 51 patients on oral steroids were not taking them appropriately to manage their condition.
“We were not unduly surprised at the figures as poor adherence has been identified as a problem in asthma patients previously,” says Gamble. “However, this group of patients had very high levels of asthma morbidity and often extremely poor quality of life, and indeed some had life-threatening asthma, so we were very concerned.”
Why do so many patients not adhere, despite the ill effects? Reasons can include lack of knowledge or information, misconceptions and confusion about corticosteroids and their effects or potential effects, explains Gamble, who has previously surveyed attitudes of patients with difficult-to-control asthma.
“They had either negative images of taking corticosteroids such as weight gain, osteoporosis, anxiety and irritability, or had previously suffered from their effects,” she says.
“Patients often subconsciously weigh up the pros and cons of taking or not taking treatment, often leading to intentional non-adherence. Or at times it was simply a lack of routine or forgetfulness or misunderstanding the regimen.”
The Belfast team has started to intervene by discussing the issue with patients who don’t take their asthma medication as prescribed, and offering more individual support if patients still fail to adhere.
The new study highlights the problem among patients with severe asthma, but the issue of treatment non-compliance is wider still, according to Dr Jean Holohan, chief executive of the Asthma Society of Ireland, which estimates that about 470,000 people in Ireland have the chronic condition.
Recent data from the Harp (Helping Asthma in Real Patients) study shows that more than 60 per cent of asthma patients here are uncontrolled if assessed by international criteria, says Holohan. “The majority of patients have mild to moderate disease and for this group non-compliance with inhaled steroid is a very significant problem.”
Patients need to understand the difference between the reliever (blue) inhaler for symptom relief and the inhaled steroid for sustained control of asthma, she explains. “Many patients stop taking controller medication after a few months and rely solely on their blue inhaler – this is poor asthma control.”
The cost of controller medication and poor inhaler technique can contribute to patients not getting the appropriate medication into their airways, and parental concerns over the possible side effects of inhaled steroids also need to be addressed, notes Holohan.
“Parents reassured about the benefits of low-dose inhaled steroid in controlling their child’s asthma, the excellent safety profile of these medications and the dangers of relying on reliever inhalers alone.”
As well as the impact on individual patients, poor control of the condition contributes to the average of 5,500 asthma- related hospital admissions and approximately 25,000 AE presentations here each year, says Holohan.
The society is funding a new asthma management demonstration project to help primary care practices and community pharmacists work with patients to control their asthma.
“Patients have a low expectation of how well their asthma can be controlled and they tolerate or expect to be symptomatic with their condition – this in itself reinforces poor compliance,” says Holohan.
“Asthma control is achievable for the majority of patients, but it requires educated patients participating responsibly with their healthcare professional in managing their condition.”
Monitoring the use of inhalers
Monitoring how people with asthma take their inhaled medication could soon get a whole lot easier, thanks to an approach being developed at Trinity College Dublin.
The idea is to improve disease management by providing data on medication use and effectiveness, explains Isabelle Killane, a biomedical researcher with the Enterprise Ireland-funded eBioTech project.
“A device is put on an inhaler so the patient is monitored as they are taking their inhaler – they don’t have to do anything else, they just open their inhaler and close it,” she says.
During a consultation, the doctor can download data from the chip and look at how the inhaler was used.
“The idea is that the consultant will open a graph and get information on compliance, that they followed the instructions for use. The doctor can diagnose with more information, and patients can also track themselves.”
The team, which is headed by Richard Reilly, professor of neural engineering at Trinity, and Dr Richard Costello, a respiratory consultant at Beaumont Hospital, is also developing technologies to remotely monitor other chronic conditions, including schizophrenia, multiple sclerosis and vocal palsy.
- See www.asthmasociety.ie
