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HOW TO IMPROVE ADHERENCE TO ASTHMA TREATMENT

E-bulletin No. 2: June 5, 2007

Christine A. Sorkness, PharmD
Professor of Pharmacy and Medicine
University of Wisconsin School of Pharmacy
Madison, WI
Denver, CO

Poor adherence to asthma treatment is a common problem, with less than half of patients adhering to prescribed therapy. Recognized as an important contributor to asthma treatment failure, poor adherence can result in increased morbidity, mortality, and health care costs.1

Text Box: Key message: Poor adherence to asthma treatment is a common problem, an important contributor to increased morbidity, mortality, and health care costs. Multiple interventions, both objective and subjective, tailored to the individual patient improve adherence and help maximize the benefits of treatment. Understanding the barriers. Patients may not adhere to treatment for many, often complex, reasons. Some have concerns about adverse effects, taste, cost, lifestyle changes; a fear of “dependency on medication”; or certain beliefs, perceptions, and attitudes about the disease or the therapy.2 Many remain unaware of the importance of using inhaled corticosteroids on symptom-free days, based on a belief that asthma is present only when there are symptoms. A 2006 study showed that better adherence was associated with a stronger belief in the benefits of treatment and trigger avoidance.2

Improving adherence. Because so many factors can contribute to adherence, there is no “typical” nonadherent patient and no single intervention appropriate for everyone.3 However, some general guidance may help:


  • Partner. The physician–patient relationship has a more powerful influence on adherence than almost any other factor.3, 4 Treatment success results when the physician develops a partnership, answers all the patient's questions, and communicates clearly and positively.3
  • Investigate. Patient and physician must identify and discuss fears and worries in order to select an appropriate strategy for intervention. Careful interviewing and active listening can improve medication use, as many studies have shown.5 For some patients, self-report questionnaires or a visit with an asthma counselor or educator might feel less threatening than a physician interview.
  • Monitor. Patients are more adherent when they know they are being watched. Monitoring adherence and giving feedback can improve adherence without any other intervention.5, 6 Encourage patients to schedule regular visits to reinforce messages and goals—even when they think they are symptom-free.
  • Screen. Identify patients at risk for nonadherence. A common misconception is that patients with severe asthma have a lower risk for nonadherence than those with less severe disease.5 Psychiatric diagnoses, particularly depression and anxiety, are also common risk factors.5
  • Simplify. Simple treatment regimens with fewer medications are associated with better adherence.1 Adherence tends to decrease as the number of medications, the dosing frequency, and the duration of treatment increase.5 In a recent study, adherence was significantly better when patients received fluticasone and salmeterol combined in a single inhaler rather than given separately.1
  • Write it down. Clearly write out the treatment plan–including action plans for worsening symptoms–and make sure that the patient or family member can read it and understand it.

Looking ahead. The future will bring an increasing reliance on multiple interventions–both objective and subjective–to improve adherence. Several electronic monitoring devices are in development and may become less costly and more readily available as health systems recognize the benefits of addressing poor adherence.5 Computerized medical records may also allow for better monitoring by physicians or pharmacists. Future strategies will focus on identifying which patients to monitor and how to individualize interventions–particularly for hard-to-reach populations such as the urban and rural poor.

References


1. Stempel DA, Stoloff SW, Carranza Rosenzweig JR, Stanford RH, Ryskina KL, Legorreta AP. Adherence to asthma controller medication regimens. Respir Med. 2005;99:1263-1267.
2. De Smet BD, Erickson SR, Kirking DM. Self-reported adherence in patients with asthma. Ann Pharmacother. 2006;40:414-420.
3. Bender BG, Rand C. Medication non-adherence and asthma treatment cost. Curr Opin Allergy Clin Immunol. 2004;4:191-195.
4. Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J. 1995;152:1423-1433.
5. Weinstein AG. Should patients with persistent severe asthma be monitored for medication adherence? Ann Allergy Asthma Immunol. 2005;94:251-257.
6. Onyirimba F, Apter A, Reisine S, et al. Direct clinician-to-patient feedback discussion of inhaled steroid use: its effect on adherence. Ann Allergy Asthma Immunol. 2003;90:411-415.

 


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