Adherence in Asthma – a victim of the episodic nature of the disease
- Asthma is characterized by its episodic and unpredictable nature1.
- Inhalation therapy – the standard treatment of care – is not optimally adhered to by patients. The key barriers are unawareness, misconceptions, unaffordability, inaccessibility, and associated stigma1,2.
- Tracking adherence in asthma is also a considerable challenge. However, the upcoming smart technologies like the use of Smart-inhalers could help achieve higher adherence in the future3.
Every year, the first Tuesday of May is celebrated as World Asthma Day to spread awareness about asthma. Asthma is a non-communicable chronic respiratory condition. As per World Health Organization estimates for the year 2019, it affected roughly 262 million children and adults, in addition to causing 461,000 deaths worldwide4. Asthma is prevalent in both high and middle-income countries, resulting in a substantial impact on patient’s quality of life5.
Non-adherence to asthma medication is significant, ranging between 22-78%. The adherence rate differs across countries with higher rates in Brazil and Italy (52% and 43.8%, respectively) while lower adherence in the US (22.2%), France (24.9%), Saudi Arabia (27.4%), Ethiopia (18%), China (13.8%), Australia (19.4%) and New Zealand (30%)3. Poor knowledge about asthma disease and misbeliefs about consequences are among the most common barriers across nations. While social factors are the key barriers in countries with universal health care6, access to asthma medicines is the major limitation in low-income countries7. It results in a higher frequency of asthma attacks, hospitalization, treatment costs, and mortality rates. It also impacts patients’ quality of life, influencing their performance in personal, social, and professional capacities8.
Why are asthmatic patients reluctant to take medicines
In the past asthma was treated using anti-cholinergic, non-anticholinergic, and corticosteroids delivered systemically through oral administration9,10. However, the current standard treatment for asthma care is inhalation therapy, which uses corticosteroids, short/long-acting beta-2 agonists, and anticholinergic agents administered using an inhalation device11. Other than being effective in treating asthma, they are safe and economical. The oral medications used in past had a negative impact on overall immunity and their long-term use was associated with adverse events like risk of infections, diabetes type-2, osteoporosis and psychiatric disorders12. In contrast, inhalers use a small portable device to efficiently deliver the medicine directly to the airways, without any systemic effects and also require lower doses than oral medicines10.
The long-term benefits of using inhaled corticosteroids far outweigh the minor side effects. The treatment has allowed children with persistent asthma – including those with severe asthma – to be free of symptoms and continue with an active lifestyle expected from them13. The daily use of these medications decreases the frequency of asthma symptoms, bronchial hyper-responsiveness, and risk of serious exacerbations14. The treatment is well-tolerated and inhalation of glucocorticoids rather than oral administration, eliminates the risk of serious adverse effects, especially at low dosages15.
Barriers to adherence
The reasons for non-adherence to asthma medication are multifactorial16. This includes asthma’s episodic nature, belief in alternative therapies, and disease-related various misconceptions. Patients also seem to have apprehension towards regular usage of inhalers and fear of getting addicted to steroids. The key factors that form barriers to non-adherence in asthma are:
- Episodic nature of asthma: Asthma is episodic and there often exists an irregular and significant gap between asthma attacks. Therefore, patients tend to take medicine only while they are sick and assume they do not need the medicines regularly17.
- Misconception about asthma: Patients believe in various misconceptions about asthma. Some believe that using alternative therapies can cure the disease without the use of Western medicines17. Patients have an inaccurate notion that inhalers could be addictive and that they can affect the growth of children. There are also ongoing concerns about the side effects of steroids in inhalers18,19.
- Improper use of inhalers: The misuse of inhalers has been correlated to increased hospital visits in asthma patients. The major reason for improper use of inhalers is irregular clinic follow-ups and lack of education about asthma medication including challenges in operating the inhaler20.
- Medication challenges: The high cost of medications, inaccessibility of pharmacies, underuse of inhaled corticosteroids, and over-reliance on short-acting β2-agonists for symptom relief are some of the major treatment challenges in asthma patients1,2.
- Social stigma– Patients are uncomfortable using inhalers in public or in front of their peers as it may make them look “unfit” or “sick”1,6
- Doctor-patient problems– Miscommunications between patients and their HCPs are a common problem. Patients’ discontent with the accuracy of their diagnosis, and their distrust in the effectiveness of the prescribed medications or the feeling that they are being ignored by HCPs affect adherence to therapy1.
Non-adherence in adolescents
The age of the patients also plays a role in non-adherence as lower adherence is observed in children (<50%) than in adults (30-70%)21. Adolescents in particular have lower rates of adherence as compared to younger children who rely on their parents for the administration of asthma medications. As these young children gradually grow up to be adolescents they claim more independence and responsibility for their medications, which in turn hampers their adherence as they deprioritize taking medicines over other activities resulting in forgetful behavior. Non-adherence also seems to stem from relentless peer pressure that stigmatizes the use of inhalers. Most children -and often adults – find it embarrassing to use inhalers around their friends. They fear being treated differently or stigmatized as an “ill person” or “an asthmatic”22.
Ways to improve adherence
This issue of non-adherence can be efficiently addressed with the support and efforts from both the HCPs and patients through the following measures:
- Effective patient-provider communication: Removing the communication barrier between the patients and their caregivers can play a big hand in improving adherence. Providing proper instructions on taking the medications or operating inhalers correctly will encourage patients to stick to their medications and refill their prescriptions. Routine visits, timely follow-up, and supervision of the patients will go a long way in improving the adherence rates23.
- Clarity about the episodic nature of the disease: Healthcare providers should educate the patients about the seriousness of their disease, its episodic nature, management of side effects, and implications of non-adherence to disease outcomes23.
- Self-management: Patients also need to put an effort to improve their adherence. This includes identifying factors that make asthma worse and avoiding it, monitoring symptoms by themselves, following an asthma action plan, using the correct technique for taking medication through inhalers, and taking appropriate action to prevent and treat symptoms in different situations24,25.
- Social support: Social support plays an important role in helping asthma patients cope with their condition. It helps the patients feel loved and cared for, which has an overall positive effect on their general health26. In adolescents, the support of their friends and peers has a major impact on their asthma control27.
Interventions to tackle non-adherence in asthma
Monitoring adherence in asthma patients is a challenging task. Usually, patient-reported questionnaires, pharmacy records, or prescription refill records are the measures relied on to monitor adherence, but they are not infallible due to being non-objective or non-granular3,16. Adherence is a variable behavior among patients and cannot be generalized as a trait characteristic. It needs to be monitored intermittently during the follow-up visits. Patients may begin with a high adherence rate, but become complacent with time. Interestingly, the adherence rate is also reported to vary in the same patient for different therapies at different time points, raising the challenge further16.
The development of innovative technologies like electronic monitoring of adherence has helped to overcome some of the limitations of conventional methods. Electronic devices like smart inhalers that are linked to mobile applications can track the time and date of medication usage in addition to sending notifications and reminders to the patients. It can also provide feedback about adherence, assess inhaler technique, and track symptoms, and exacerbations. Finally, the collected data can be shared with healthcare practitioners in real-time to help them organize specific and tailored responses for each patient3. Several such smart devices are undergoing clinical trial evaluations. They hold a promising future for an era of digital interventions that would help alleviate or minimize non-adherence to asthmatic medications28.
Poor adherence in asthmatic patients is an issue that can be effectively resolved if healthcare practitioners, caregivers, and patients work as a team. Together they can find the most appropriate treatment regimens and daily practices that can benefit the patients. Enhancing health literacy with frequent follow-ups will help in improving adherence and building a trusted partnership between the patients and their doctors. Increasing awareness of asthma in the general population will reduce the stigma surrounding the condition. It will also sensitize everyone about the care and support that asthmatic patients deserve24,28.
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