Patient Education, Patient Compliance

DR. SOPHOCLES: How do you explain managing the disease to your patients?
DR. COX: Using the National Heart, Lung, and Blood Institute guidelines recommendations, which I follow fairly closely in my practice, I explain to the patient the emphasis is on normalizing your lifestyle and lung function. We provide a written asthma action plan that may be based either on their peak flow readings, if they’re doing this, or their symptoms. This is a guideline for them to use at home for when they start having increased asthma symptoms. I have them follow-up in the office at least every 1-6 months depending on the stability of their symptoms and I explain to them the goal of treatment is to prevent chronic and troublesome symptoms.

They should be requiring their rescue medication less than two times a week. Ideally, I want them to tell me “I can’t remember the last time I used my rescue medicine.” The goal is to keep or maintain normal pulmonary function tests. It is recommended that we measure lung function at the time of initial evaluation, later to assess response to the treatment we initiate, or when there is an exacerbation, and then every 1 to 2 years throughout their lifetime. And this recommendation applies to adults and children 5 years and older. This is very stressed in the new guidelines—that we should be measuring lung function even in children. The goal for the the patient is to maintain normal activity levels at school, at work. We also have to really sit down and talk to the family and the patient and make sure we meet their expectations and they are satisfied with their care. That also includes being satisfied with the medications they are taking because if they’re having unsatisfactory side effects, that is going to interfere with compliance and that is going to certainly impact on their care.

We want to reduce the risk of having asthma exacerbations and needing emergency room visits and hospitalizations. We want to try to prevent progressive loss of lung function if we can, and in children to minimize medications so we don’t affect height, but we also want to prevent loss of lung function that we’ve seen in some studies occur early. We want to provide the optimal pharmacotherapy but with minimal or no adverse effects.

And on a practical point, I think it’s very important for the asthma specialist or the primary care office to assess the patient’s compliance and their inhaler technique frequently, and to discuss what the medications are and what they do, not only on initial visit but on follow-up visits.

DR. SOPHOCLES: How do you handle non-compliant patients?
DR. COX: Non-compliant patients can be difficult and they could be non-compliant for several reasons. Some patients have difficulty tolerating medications - inhaled steroids can cause yeast infections or hoarseness, beta-agonists can cause stimulation that’s uncomfortable for some patients. I do spend a fair amount of time explaining airway inflammation and the dangers and the risk; and that does help patients get over the concern and anxiety about these medications. Some patients who are non-compliant, and this was actually recommended as a possible indication though it doesn’t sound like the right way to do it, but Omalizumab for allergic asthmatic patients may be a consideration because it’s an injection that’s given every 2 or 4 weeks and you may help knock out a significant component of their allergic asthma and that may help gain better control. Minimize medications to once a day if possible. Give medications that have numerical trackers - some of the inhaled medicines have a numerical counter so the patient can keep track of how much they have left. That is a real problem with inhalers that don’t because patients may not be using a inhaler that still has active medication, and that may be the sole reason for their asthma poor control that they have been for the past two weeks—inhaling an inhaled steroid with no medication. Those are simple things that one should assess for on follow-up visits. Basically, educating the patient on the disease and the dangers of the disease if not treated to try to get them to want to be more compliant. Also discuss with them their concerns and anxieties about using the medications.

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DR. SOPHOCLES: What are the goals in managing asthma in 2008?
DR. COX:Well, I don’t think they have changed dramatically from 2007 or even our previous guidelines: we want a patient that has a normal lifestyle and normal lung functions on minimal medications. That remains the goal. Ideally, we would like to have a drug that takes care of all the components of asthma with a single puff or a pill, but right now we still have requirements for one or more medications in many of our persistent asthmatic patients. So the goal basically remains the same and that is a patient who has a normal lifestyle, minimal need for rescue medications, normal as possible lung functions, and requiring minimal medications that provide few side effects.