Improving Treatment Compliance Among Asthma Patients:
A physician’s response when a patient says, “My asthma medication isn’t working.”

by Bruce Rubin, M.D.
from Clinical Update, Winter 2004

Abstract: Pediatric pulmonologist Bruce Rubin, M.D., of Wake Forest University Baptist Medical Center, provides pointers to help identify causes of non-compliance to therapy, the chief cause of morbidity and mortality in asthma patients.

Morbidity and mortality in asthma patients have been strongly associated with non- adherence to therapy. However, little guidance is given to help caregivers understand why a patient won’t take therapy as directed or misuses medications. Without this understanding, the caregiver may compound the problem. In a busy office practice, when a patient says medications aren’t working, it may be easier to write a prescription for a different medication. But, in many cases, the problem is not the medication at all.

This article discusses some of the common reasons for “medications not working” and offers suggestions that may help to improve patient understanding and adherence. It focuses mainly on children, but is also applicable to adults.

1) The patient who thinks he’s not really sick. Often, these patients don’t understand or accept the need for chronic medications to improve lung function and prevent exacerbations. They don’t believe that they really have asthma and may minimize their symptoms.
Solution: These patients can benefit from asthma education and careful, objective measurement of pulmonary function to document the effectiveness of medications. Children, adolescents, or the elderly may benefit from monitored administration of medications.

2) The patient who benefits from being sick. There is sometimes secondary gain to having a chronic illness. During exacerbations of asthma, children are sometimes kept home from school and are given special attention. As a result, they may deliberately not take medication. Likewise, parents may use their child’s illness for secondary gain. In the most severe cases, Munchausen syndrome by proxy, children can suffer serious injury and even death. But even in milder cases, where a parent overstates the seriousness of their child’s illness for attention or personal gain, there is a risk that medication will not be taken as prescribed.
Solution: These children need to be identified so that they and their family can get appropriate intervention. Social services must be called if non-adherence threatens the health of the patient. Often, these problems can only be clarified with a monitored hospital admission and therapy.

3) The patient who cannot afford the medication. Sometimes medication is so expensive for a family that they only use it when they absolutely must. This problem can be made worse if their physician responds to this complaint of the “medication not working” by prescribing even more medication.
Solution: Costs can sometimes be decreased by changing the dosage form, such as using a pressurized metered dose inhaler or a dry power inhaler instead of a jet nebulizer. And, many pharmaceutical companies sponsor programs to provide medications at lower cost for patients who qualify on the basis of need.

4) The patient who does not understand how or when to use medication. The more different medications a patient uses, the more likely there is to be confusion and non-adherence.
Solution: Treatment plans need to be written out. It is important to ascertain whether the parent can read and understand the written action plan. Words and explanations must be chosen carefully. For example, control medications are defined as those treating underlying inflammation. However, patients may believe that controller medications control symptoms, not inflammation, and may use the wrong medication during attacks. When they get no immediate relief, they believe the medication is not working. Similar problems can occur with other terms, such as preventer medications. Inhaled corticosteroids, for example, prevent inflammation; however, inhaled bronchodilators can prevent exercise-induced asthma. Also potentially confusing is the term rescue medication. Many patients incorrectly believe that this term means that the medication should be used only when in need of emergency services.

5) The patient who is concerned about medication side effects. Although physicians know that that the chronic use of low-dose inhaled corticosteroids (ICS) is safe, effective and generally devoid of side effects, parents may be concerned about side effects based on information from newspapers, the Internet, etc. Some parents mistakenly think ICS are the same as the androgenic steroids used by some athletes and body builders. Others believe that any medication taken daily will lead to addiction.
Solution: Although education and good communication can often correct misconceptions, occasionally these are so ingrained as to be difficult to change. In cases where patients or parents put themselves or their child at great risk by refusing to take medications, social service or psychiatric intervention may be a necessity.

6) The patient who can’t feel the medication working. One of the advantages of some newer formulations of pressurized metered dose inhalers and dry powder inhalers is that patients no longer have to tolerate medication that irritates the back of their throats or tastes bad. But, some patients believe that for medication to be effective they have to feel or taste something.
Solution: Clear communication or treatment goals supported by regular monitoring of airflow at home can help to change these perceptions. In some cases it may be helpful to use a medication that has a distinct taste (e.g. flunisolide) to see if this will improve adherence.

7. The patient who really needs more medicine. Some patients are adherent to therapy and use medications appropriately, but have progressive worsening of their asthma. However, some of the causes of increasing asthma severity may be amenable to therapeutic interventions.
Solution: Physicians should be alert to possible causes of increased severity, such as exposure to new allergens or to irritants such as tobacco smoke or volatile inhalants (e.g. glue from a new hobby of model building). Infection can also exacerbate asthma, as can gastroesophageal reflux disease. Asthma has also been reported to increase in severity during menstrual periods in some women, a factor to consider in the adolescent girl with worsening asthma.

Editor’s Note: This information is summarized from an article by Bruce K. Rubin, MEngr, M.D., FCCP, in the August issue of Chest. Rubin is Professor and Vice-Chair, Dept. of Pediatrics. To view the complete article, go to www.chestjournal.org.