Despite the presence of treatment guidelines many patients are not appropriately managed with drug therapy. Death rates for asthma are increasing, and patients report severe symptoms at alarmingly high rates. Both healthcare providers and patients are guilty of a lack of knowledge and adherence to guidelines. For example, patients at Michael Reese Hospital, an urban emergency department located on Chicago’s South Side, were surveyed regarding outpatient management and knowledge of their disease.
One hundred ninety-three patients were surveyed, of whom 96% were African-American. Seventy-nine percent had visited an emergency department in the previous 12 months. Despite this, only 88% currently had a prescription for an inhaled beta2 agonist and only 33% were receiving inhaled steroids. Twelve percent used a peak flow meter (PFM) to monitor asthma, with 61% reporting being educated on the use of a PFM. Surprisingly, only 83% of patients could recall ever being taught how to use a metered dose inhaler. Accordingly, pharmacists should take an active role in assessing patients and determining compliance to national guidelines for asthma therapy.
Patient compliance is important to assure disease control. Despite the fact that many patients are given appropriate therapy by their physicians, many do not comply with prescribed regimens. Medication noncompliance has been demonstrated in as many as 70% of patients. Pharmacists are at an optimal point of service to assess compliance. Pharmacy data can prove invaluable, often exposing noncompliance that physicians do not identify. Upon recognizing noncompliance, barriers to adherence can be assessed and corrected. Some barriers include that: asthma is episodic in nature; short-acting beta agonists provide fast relief; noncompliance has delayed effects; and medications are expensive, difficult to use, and have side effects. Breaking down these barriers can improve compliance and patient outcome. For continued success, instructions should be reinforced on every visit to the pharmacy to assure patient adherence.
National guidelines stress the need for anti-inflammatory therapy in those patients with mild-, moderate- and severe-persistent asthma. Treatment based on disease severity is outlined in TABLE 2.Concepts to be emphasized when working with patients include the use of two types of medications: quick-relief and long-term control medications. Short-acting beta2 agonists have a proven record as effective quick-relief medications. However, long-term controllers are often necessary to decrease the frequency and severity of attacks and reduce the need for quick-relief medication. The proven long-term controllers, anti-inflammatory agents, are the inhaled corticosteroids. Despite the need for long-term controllers, studies have shown the underuse of corticosteroids as anti-inflammatory agents.
Corticosteroid dosing is dependent on severity of illness. Because disease severity can change throughout a patient’s life, corticosteroid dosing should be reassessed every 1–6 months for dose adjustments.
Childhood asthma, including hospitalization rates, has been on the rise in the past several years. Despite advances in asthma therapy, clinicians may be reluctant to prescribe inhaled corticosteroids due to inherent risks involved with their use. As with any disease state, a risk/benefit ratio must be assessed when deciding on treatment regimens. Risks involved with systemic corticosteroid use are serious; however, the availability of inhaled therapy with lower overall doses and bioavailability lessen systemic absorption and side effects.
When inhalers are used, approximately 15%–30% of the medication reaches the lung, and the remainder is swallowed. All medication that reaches the lung is absorbed; however, absorption of swallowed medication depends on oral bioavailability. Oral bioavailability of inhaled steroids range from <1% for fluticasone to 23% for triamcinolone. Overall, doses of inhaled corticosteroids are minimally absorbed, leading to a decreased risk of systemic side effects.
|Table 2 NAEPP Guidelines for Management of Asthma in Adults and Children Older than Five|
|STEP ||LONG-TERM CONTROL||QUICK RELIEF|
|Step 4Severe Persistent||Anti-inflammatory: |
High-dose inhaled corticosteroid, assess long-term need for oral corticosteroidNighttime symptoms: Long-acting bronchodilator
|Inhaled beta2 agonist as needed|
|Step 3Moderate Persistent||Anti-inflammatory: |
Medium-dose inhaled corticosteroidNighttime symptoms:
|Inhaled beta2 agonist as needed|
|Step 2Mild Persistent||Anti-inflammatory:Low-dose inhaled corticosteroid||Inhaled beta2 agonist as needed|
|Step 3Mild Intermittent||No daily |
|Inhaled beta2 |
agonist as needed
|Step Down: Review treatment every 1–6 months; a gradual stepwise reduction in treatment may be possible|
|Step Up: If control is not maintained consider step up; first review patient medication technique, adherence, and environmental control|
Major side effects of inhaled corticosteroids are listed in TABLE 3. Systemic adverse effects of concern in children receiving inhaled corticosteroids include disturbances of growth, bone mineralization, and suppression of the hypothalamic–pituitary–adrenal axis. Some studies suggest inhaled steroids may decrease growth velocity.
Children grow at various rates and there is no conclusive evidence that inhaled corticosteroids have an effect on final adult height. In fact, evidence suggests that growth impairment in children with asthma is most likely due to poorly controlled asthma and not inhaled corticosteroids. The long-term benefits of inhaled corticosteroids far outweigh risks and their use should be considered at the earliest signs of inflammation. Children using inhaled corticosteroids should be observed for systemic side effects, including close monitoring of growth.
|Table 3 Side Effects of Inhaled Corticosteroids|
|Oral Thrush||Adrenal gland suppression|
|Dysphonia||Decreased bone mineralizationCataracts |