By Dr. Larry Chiaramonte
Tough Tony was an asthmatic before he became a weight lifter and football player. He told me that he chose these sports in part because when he was a sickly little asthmatic kid, the big boys used to pick on him.
“Doc, fuhgedabout that new asthma drug you gave me. It just does not work like my albuterol. One hit of that clears me up right away.”
“Tony remember last year in the ER? The more of albuterol you took the less it worked. That’s because it does not work on your thickened mucous or damaged airway lining, only on the muscle spasm.”
“Yeah,you gotta point-but it is a steroid and they’re banned in sports.”
“It is a different kind of steroid and is only inhaled.”
“But, Doc, you want me to take it every day I only wheeze a couple of times a week.”
“You sleeping okay?”
“Not so good. I wake up at night.”
“You checking your lower peak flows like I taught you?”
“Here, take a look at your fractional exhaled nitric oxide levels (FeNO). Your lungs are badly inflamed. You want to pass your physical for the team this year, you’d better get your act together.”
This story is made up, but it’s representative of hundreds of encounters with patients and their parents over many years, and according to the latest information we have, it could be ripped from the health records even now. Same excuses, same rationalizations, same misunderstandings.
A study by Ann Chen Wu, M.D., M.P.H., of the Harvard Pilgrim Health Care Institute in Boston published in JACI paints a bleak picture of asthma compliance. As reported in Health Day, just half of parents of asthmatic children with asthma fully understand the use of their child’s asthma medications. A survey of the parents of 740 children, 29 percent of children prescribed inhaled corticosteroids weren’t taking them as directed. For 202 children who were supposed to use the inhaled corticosteroids every day, 27 percent of parents said they weren’t. Of 263 children who were to use inhaled corticosteroids daily when symptomatic, more than half of parents (54 percent) said otherwise.
My experience tells me:
1) That a parent’s perception of the medication and their estimation of the severity of the asthma strongly influences if the child asthmatic takes what the doctor has prescribed. Not only does the parent have to believe the medication is safe and effective, but also that the child’s asthma is severe enough to make it necessary to take the medications. Many parents believe the worst on the first point and the best on the second.
2) It is very difficult and time consuming for the physician to change a parent’s established belief system. Most of us are assaulted daily by media stories of the harmful effects of steroids especially as used in sports. Now doctors want to use them to treat asthma. Those impressions aren’t dispelled by mere facts. Most parents are in a state of denial of the severity of their child’s asthma. Look, I’m a parent and a grandfather. I know that it’s easier to take the line of least resistance on these things, but my medical training convinces me I’m right on this one.
The facts are: the inhaled asthma steroids are only going to the lungs not everywhere in the body. They are in the metabolic class not the anabolic class used to enhance performance in sports. Finally, as Tony observed, they do not give the instant relief supplied by bronchodilators. Inhaled steroids work over a long period of time. Unfortunately, we doctors do not always take the time to deliver these messages, and we haven’t for a long time.
A parent’s estimation of the severity of their child’s asthma must be brought more closely to reality by monitoring the inflammatory status of the airways. The asthma control test score, FeNO scores, and home peak flow monitoring all demonstrate the silent lead up of inflammation in the airway before a violent asthma attack. Sadly they are underutilized because of poor insurance reimbursement.
Are there problems with steroids, combination inhalers, and leukotriene agonists? Yes. They can alter moods and affect resistance to infection. These effects are worse for some people than for others. But the treatment for most of us is not worse than the disease, which afflicts 300 million people worldwide and costs 3500 Americans their lives, most of which could be prevented if the patients were conscientious about complying with the medication.
Asthma myths have nine lives, but people do not.
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