By Dr. Larry Chiaramonte
In an excellent editorial called “Asthma in the Real World” in the Journal of Allergy & Clinical Immunology, Paul M. O’Byrne, MB from McMaster University in Canada paints a bleak disconnect between the efficacy of asthma medications as demonstrated in clinical trials and the effective control rate based on how people actually use these meds. O’Byrne says there are people who don’t respond to the standard medication among the uncontrolled population, but they “represent 5% to 10% of all asthmatic patients, a relatively small proportion.” The big problem? ”The numbers of asthmatic patients who continuously take their medication as recommended is vanishingly low.”
What in my opinion can be done in this regard? Patient perception of their illness affects their compliance with medication. Most asthmatic patients think they are better than they really are and do not take their medication. Home peak flow monitoring can give them a “reality check.” This will help those who comply. But sadly, we are creatures of convenience. It is generally the most seriously ill who have kind of discipline it takes to monitor themselves regularly. For those with intermittent symptoms, it’s a question of out-of-sight, out-of-mind.
Ease of use is a big factor. QD—once a day dosing—is easier than Bid (twice a day dosing), which is why, as O’Bryne points out, in real world trials, a QD pill like montelukast (Singulair) may look as effective as twice-a-day puffs of inhaled corticosteroids like Flovent, or a combination steroid, long-acting beta agonist like Advair (as I have written previously), which are bronchodilators. These provide immediate relief of symptoms, which can reinforce compliance. If a patient gets positive reinforcement [by feeling better quickly after taking medication] the more likely they will comply. That is why I like to start patients on combination medication until their asthma is controlled. Finally group support can help.
Do we need better drugs? O’Byrne doesn’t think it’s necessary for now. He seem to believe we need better patients, concluding: “There is little doubt that the greatest opportunity to further improve outcomes in asthmatic patients is to develop ways to enhance adherence to the effective treatments that are currently available.”
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