By Dr. Paul Ehrlich
That siren you hear is an ambulance rushing another non-compliant asthmatic to the ER. We return again and again to the subject of compliance because of the health and financial costs associated with patients who fail to take their medication as directed. Year in year out, American asthma patients fail to renew their prescriptions for inhaled corticosteroids an astonishing 70% of the time.
The same pattern holds for other countries, even those with mainstream socialized medical systems. For example, a recent study of children in the Toronto area by Canadian doctors showed, “A highly significant finding in the sub-group of drug plan holders was that for every one per cent increase in family income spent out-of-pocket on a child’s asthma medications, there was a 14 per cent increase in the number of severe asthma attacks resulting in an emergency room visit or hospital admission.”
And a British newspaper reported, “Asthma UK says 27% to 50% of asthma patients fail to take their treatment correctly. Incredibly, 80% of the 1,200 deaths a year from the disease can be blamed on poor adherence to therapy.”
There are many reasons for not taking the medications we prescribe, none of them good. “It’s a pain in the neck.” “If I’m not wheezing, it’s controlled.” “I don’t want to shell out for the co-payment.” “I’m afraid of steroids.” We have heard them all before.
This challenge of getting good little boys and girls of all ages to take their medication for diseases like asthma and allergic rhinitis has always figured in my belief in immunotherapy. (For more on immunotherapy, see this excellent piece by Dr. Harold Nelson.) While it is not suitable for everyone, it has served a very important purpose in addition to the protection it provides; it helps reinforce good adherence. Those who come into our office once a week are always asked how they are doing and whether they are taking their preventative medication or relying on their “rescue” medication.
Of course they can lie, but as they get to know those who give them their shots these patients become more forthcoming. Often it appears they take their medications so that they won’t disappoint their shot-givers. Whatever the reason (and I don’t discount their wanting to feel better) they take their medications.
Compliance among actual children does not seem to be as big an issue for obvious reasons, but when inhaled corticosteroids or intranasal corticosteroids are thrown into the mix, parents often push for getting the children off these medications as soon as possible. If fear of steroids provides the impetus for long-term changes in behavior that will help their children, I’m not going to argue about their safety too strenuously. I will make “deals” with patients that allow them to decrease the dosage or stop it altogether. In the case of asthma, using an Asthma Action Plan gives patients and/or their caregivers something to shoot for.
When we prescribe and tell them to return in six months that arrangement just isn’t good enough. So often when I am discussing things with these children or with those in my practice there is a bond which they don’t want to break. They take their inhalers so that I won’t be disappointed. This was certainly the case when I was seeing the same kids routinely in public schools as part of Project ERASE. The nurses and I became friends with the children, and they didn’t want to disappoint their friends.
We have ways of finding out who’s naughty or nice through pulmonary function tests or a fractional exhaled nitric oxide test, which measures airway inflammation and thus indicate who’s compliant; children know that numbers don’t lie. Day in day out, however a doctor’s admonishment and cajoling only work up to a point because we can’t see them all the time. The best tools of all are a peak flow meter and a conscientious mother.