An article published in the November 1 issue of the American Journal of Respiratory and Critical Care Medicine suggests that difficult-to-treat asthma often may have more to do with patients who do not take their medication as instructed than ineffective medication.
"[A] significant proportion of patients with difficult asthma are poorly adherent to inhaled and oral corticosteroid therapy," said PI Dr. Liam Heaney.
Why is this important? I mean, beyond the fact that patients aren't taking medication as prescribed and could be putting themselves at risk for future health problems, as well as driving up health care costs from ancillary consequences of not adhering to prescribed regimens. Heaney says defining "the scale and identifying non-adherence in this population is important given currently available and other imminent expensive biological therapies."
That makes sense - if patients aren't adhering to a regimen that is well-understood and relatively affordable, why would you take a chance prescribing a new and expensive medication?
The researchers studied 182 patients who were referred to a tertiary referral clinic that specializes in treating difficult asthma. Initially, patients denied poor medication adherence. So, to find out whether they really were compliant with inhaled corticosteroid therapy (ICT), the researchers compared patient prescriptions to the patient's actual refill usage and used blood plasma prednisolone and cortisol levels to evaluate oral medication adherence.
Of the 182 consecutive patients, 35 percent filled fewer than half of their prescribed ICT, 21 percent filled more than they were prescribed and 45 percent filled between half and all ofthe medication they were prescribed. In patients who were on a maintenance course of oral prednisolone, blood levels of cortisol and prednisolone showed that nearly half (45 percent) were not taking the medication as prescribed. In follow-up conversations with the researchers, most admitted that they were inconsistent in the use of their medications.
Oops, that's embarrassing for the patient - caught red-handed. Now, a few patients still insisted they were taking their meds as prescribed, and that's possible - perhaps these were the few for whom the medication really didn't work. Interestingly, women were more likely to be non-compliant than men, but there wasn't a trend by age.
"Non-adherence is a common problem, which is often hard to detect," Heaney said. "In general, asking the patient or relying on clinical impression is useless, and objective or good surrogate measures should be utilized." That's my favorite quote of the story - asking the patient is useless. Why should we rely on patient reported data, since they're just going to lie? Awesome.
My first question was, why are they non-adherent? The only article that addressed this even tangentially was OnMedica, which hypothesized that "patients may be reluctant to take steroid therapy, especially systemic steroids, 'with their greater and more readily attributable side-effects.'"
I think this is one of the biggies - and something physicians really need to think about when making prescription decisions. Are the patients willing to take a steroid? If not, it's probably not a good idea to prescribe it. Some other thoughts on why patients aren't compliant:
- insurance: whether they're covered, whether their insurance covers the medication, whether they can afford it even with coverage
- cost: can they afford the medication?
- willingness to take the medication: is it a drug they are uncomfortable taking, like a steroid? Are they tired of inhalers? What if a medication is injectable - that's a pain, both literally and figuratively. Do they just not want to take any medication at all?
- symptoms: do they have any? If not, they may not feel they need to take medication (which is why so many people erroneously stop taking antibiotics before the course is up).
- side effects: does the medication cause side effects? Are they of a nature that patients would rather deal with the disease than the side effects from the medication taken to treat the disease?
- ability to remember to take meds: do they have a system for keeping track of when they need to take meds? Or are they in a situation where they easily forget to take drugs?
So yes, the patient has some responsibility here. If you don't take your drugs, there are consequences. But physicians need to consider these points if they want the prescribed regimen to be as successful as possible.
Eureka press release here.
Science Codex article here.
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