IIn 2017, an expert committee organized by Lancet Examine the current status of Asthma care. That committee identified poor adherence to medication as one of the major barriers between people with asthma and improving disease outcomes. Compliance, the committee wrote, was “the biggest elephant in the room”. “Although rants are paid to improve basic management, in practice little is done other than asking the patient if they are receiving treatment.”
According to research in European Respiratory JournalMore than half of asthma patients fail to take their medications as directed. Some other surveys have put that figure as high as 80%. Doctors who treat people with asthma confirm that many do not follow their treatment plan. “Personally, I would say adherence is an issue for at least 50% of patients,” says Dr. Rushi Gupta, a professor and asthma specialist at Northwestern University’s Feinberg School of Medicine.
The problem of poor adherence is so common that experts aren’t sure what percentage of asthmatics actually have severe asthma. That’s because the condition is defined by its inability to control it; If more people with severe asthma took their medications as instructed, it is likely that a significant portion of them would have their asthma under control, and as a result would not qualify for a diagnosis of severe asthma.
But more adherence to treatment is much easier said than done. Part of the problem, Gupta says, is that even those with severe asthma can often feel well. Asthma is called a “fluctuating disease” because its symptoms ebb and flow. Treatment often requires a person to take several oral or inhaled medications on a daily basis, even when they are not experiencing symptoms. “It’s difficult for anyone to take a medication, let alone multiple medications, every day,” says Gupta. Having to do this for years on end, as it is for many patients with severe asthma, is very challenging. Even a single missed dose can contribute to a flare, but there is often a delay between a missed dose and a worsening of symptoms. So people don’t necessarily associate the risk of poor adherence with asthma attacks.
Missing a dose is one of the reasons people with severe asthma don’t take their medications as prescribed. In some cases, adherence problems may result from caregiver lapses. In other cases, the patient may consciously decide not to take their medications. “The reasons for suboptimal adherence are multifactorial,” says Dr. Vanessa McDonald, a professor and pulmonologist at Newcastle University in Australia.
The consequences of poor commitment are often serious, sometimes disastrous. Besides flare-ups of symptoms, medication lapses increase a patient’s risk of trips to the emergency department. Some estimates suggest that 60% of asthma-related hospital visits result from poor adherence to medication. Medication lapses also increase a patient’s risk of asthma-related death. The World Health Organization estimates that 250,000 people die prematurely each year from asthma.
Here, McDonald and other asthma specialists break down the different factors that contribute to poor medication adherence. They also detail the latest measures to improve adherence, including new technologies, advances in treatment, and improvements in provider-patient interactions.
Solve the problem of poor commitment
Sometimes people with asthma simply forget to take their medication. When you consider that inhaled corticosteroids (one of the most common treatments for severe asthma) sometimes have to be taken twice daily, it’s easy to see how even hardworking patients can forget a dose every now and then.
Another barrier to full compliance has to do with operator error; Inhaling asthma medication is not as simple as swallowing a pill. “inhalation [asthma] Medicines require great skill and practice,” the authors of a 2015 paper wrote in the European Respiratory Journal. “Even if the medication is taken daily, deposition in the lungs will be low with incorrect inhalation technique.”
Doctors say they often encounter these types of problems. “Do they hold their breath after inhaling a corticosteroid for 10 seconds to make sure the drug reaches deep into the lungs?” asks Dr. Jonathan Gavin, co-director of the Severe Asthma Program at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School. These are the types of technical errors that can lead to flares. This is also one area where failure may fall in part on the patient care team. Researchers have found that when people with severe asthma receive more prior training and medication education, adherence rates improve.
Poor communication between patient and provider can also reduce adherence. People with severe asthma who are younger or who have fewer years of formal education are more likely to experience medication declines, and there is evidence that some groups of patients may not fully understand a caregiver’s instructions or the rationale for a treatment plan.
Most of these are classified as unintentional forms of non-compliance. But in some cases, patients consciously choose not to take their medication. “There is intelligent or willful non-compliance, where patients make deliberate decisions to either stop treatment, change how they take it, or even neglect to start prescribed treatment at all,” McDonald says. There are several reasons why people may deliberately choose not to take their medication. Concern about side effects is one of them, McDonald says, and this is another area where better communication between patient and provider comes into play. If a person knows exactly what to expect from their medication, and also fully understands the risks of non-adherence—not just symptomatic episodes, but an increased risk of hospitalization and fatal complications—that knowledge can improve adherence.
Drug aversion is another cause of intentional non-compliance. “Not wanting to be dependent on daily medication is a common trigger,” MacDonald says. She says financial constraints are another. Some asthma medications are very expensive, and the patient’s insurance may not cover enough of the cost to make the medications affordable for them.
The variety of factors that lead to poor adherence is one reason why it remains such a common and intractable problem. But there are solutions.
New tools and techniques to improve adherence
Clearly, traditional approaches to starting treatment for severe asthma—a doctor telling a patient what to take and how to take it, followed by an occasional check-in—doesn’t get the job done. The newer, research-backed approach gives patients more control and more input in creating their own medication plan.
For example, a 2010 randomized controlled trial found that when clinicians and patients discussed together the benefits, risks, and costs of different treatment plans—not just to relieve symptoms, but to fit the patient’s own priorities—adherence after one year was significantly higher when compared to a traditional top-down relationship. Down where the doctor alone chooses the treatment plan. “Involving people with severe asthma in shared decision-making can help improve adherence to treatment,” MacDonald says.
There is also evidence that patients with severe asthma who are treated by a multidisciplinary team of specialists, as opposed to just primary care, are more likely to adhere to their medication plans. “This team could include a pulmonologist, an allergist, a specialist nurse, and some type of mental health support,” says Gavin. Through the lens of their different disciplines, this team can help discover and address issues that lead to medication lapses. This team can also ensure that a person’s medication plan is part of a more comprehensive approach to controlling asthma — an approach that may also include lifestyle and environmental modifications — that may be more effective.
Internet or smartphone-based reminders are another solution that is supported by some preliminary research. According to a 2021 study in Scientific reports, pairing a medication self-administration app with an inhaler-mounted electronic medication monitoring device (or EMM, which tracks whether a person has taken their medication) led to strong improvements in adherence. The app not only alerted the patient when to take their medication, but also provided feedback on their medication Use of inhalers and continuing education materials. Newer “smart” drug delivery devices are also useful. According to research in the journal asthmaSmart nebulizers are able to adapt to a person’s unique breathing pattern and respiratory capacity to ensure the right amount of medication is deposited deep in the user’s lungs.
Last but not least, new forms of treatment are reducing patient dependence on inhaled medications. Biology is the big story in this space. These drugs, given every few weeks by injection, work by targeting immune cells, the proteins, genes, or pathways that underlie them. Asthma symptoms. “These were complete transformations,” says Dr David Jackson, a respiratory medicine specialist at King’s College London. “Since 2017, new biologics have been added to our arsenal almost on a yearly basis, and the number of patients with uncontrolled asthma has gotten smaller and smaller.” Biologics are usually administered in the clinic. This extra layer of provider oversight, along with a relatively infrequent dosing schedule, makes adherence more likely. However, the cost of these drugs is still significant, and not all patients are good candidates.
According to the latest data from the US Centers for Disease Control and Prevention, approximately 6% of children and 8% of adults in the United States have asthma. The prevalence of the disease has been trending upwards since 2001, and while there are signs that this increase has leveled off, recent surveys have found that severe asthma may be more common now than in years past.
This may be due to gradual The aging of the American people. Older adults with asthma are more likely to suffer from severe, uncontrollable disease, and the median age and proportion of adults 65 or older in the country are steadily rising – and expected to rise even more for decades to come. All of this suggests that the number of Americans with severe asthma is likely to grow, not shrink, and thus resolving the problem of poor adherence is likely to gain greater importance in the coming years. “Advanced age correlates with intentional adherence better, but non-intentional non-compliance may be a problem in this age group due to problems with inhaler use and age-related factors such as poor vision, decreased manual dexterity in using inhalers correctly, and reduced ability to inhale medication.” deeply,” McDonald says.
She and other experts say there is no silver bullet for the commitment problem; It is a multifactorial challenge that requires a multifaceted response. But with further development, refinement, and implementation of the tools we have today—a combination of smarter tools, better medications, and improved communications between caregivers and patients—asthma specialists hope they can significantly improve adherence among people with severe asthma.
There is work to be done, but there is reason to believe that significant improvements are on the way – or already here.
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