Poor adherence
to inhaler therapy in patients with bronchial
asthma: Rates and causes
......................................................................................................................................................................
Sultan K. AlSureehein (1)
Rakan M. Haddad (1)
Ghaith Abu Alsamen (1)
Khaled M. Alnadi (1)
Wafa S. Alsyoof (2)
(1) MD, Department of Internal Medicine, Respiratory
Medicine Division, King Hussein Medical Center(KHMC),
Amman, Jordan
(2) Department of Nursing, King Hussein Medical
Center(KHMC), Amman, Jordan
Correspondence:
Dr.S. Alsureehein
Department of Internal Medicine, Respiratory Medicine
Division,
King Hussein Medical Center(KHMC),
Amman, Jordan
Email: Dr.sultan75@yahoo.com
ABSTRACT
Objective: To assess adherence rates
to inhaler therapy in bronchial asthma patients,
and to find out the most common causes of
non-adherence.
Method: prospective study of 295
patients diagnosed to have bronchial asthma
in King Hussein Medical Center (KHMC) in
the period between March 2014 and January
2015. Patients were followed up for 15 weeks,
after which adherence to their inhaler therapy
was assessed, and the causes of non- adherence
were investigated.
Results: It was found that 138 patients
from the 295 patients included in our study
were non-adherent to their inhaler therapy,
which equals 47% of the patients in this
study. The most common cause for non-adherence
was the patients' fear that using inhalers
would be habit forming, and would be associated
with a social stigma. This cause accounted
for 46% of the causes for non-adherence
in our study group.
Conclusion: Non-adherence rates to
inhaler therapy in bronchial asthma were
shown to be significant in our study. The
fact that the most common causes for non-adherence
in our study were found to be due to non-drug
related causes, and mainly caused by poor
patient understanding of their condition
and treatment, makes patient's education
very important, and emphasizes the significance
of doctor-patient communication to answer
all the questions that might cause non-adherence
to inhalers.
Key words: Bronchial asthma, Inhaler
therapy, Adherence, Jordan
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Bronchial asthma is one of the
most common chronic diseases in the world. The
incidence and prevalence of bronchial asthma is
increasing, and studies show that bronchial asthma
affects 5-10% of the population worldwide. (1,2)
Being a chronic and common medical condition,
proper management of bronchial asthma is a very
important goal to achieve. Inhaler therapy is
the cornerstone in bronchial asthma management.
(3,4) Inhalers have the advantage of delivering
high concentration of the medications to the airways
with minimal systemic side effects. (5) A common
issue which is usually faced and prevents proper
management of bronchial asthma is non-adherence
to the inhaler therapy. Some studies show adherence
rates of around 50% in bronchial asthma patients.(6)
This means that about half the patients diagnosed
to have bronchial asthma are non-adherent to their
inhaler therapy.
Poor adherence to inhaler therapy increases the
risk of morbidity and mortality from bronchial
asthma.(7,8) It was shown that poor asthma control
is a frequent cause of Emergency Department (ER)
presentation and hospital admission.(9)
Another important aspect that shouldn't be overlooked
is the economic burden of uncontrolled bronchial
asthma to the health care system. This aspect
has been studied and documented in industrialized
countries.(10) It was shown that 1/3 of all asthma
costs in the United States of America come from
ED use for managing bronchial asthma.(11)
In our study, the aim was to follow up patients
diagnosed with bronchial asthma for 15 weeks,
for whom inhaled therapy was given. We assessed
the rates of adherence to these inhalers by the
end of the 15-week period. The causes of non-adherence
were also investigated in these patients, hoping
that by knowing the causes of non-adherence we
can maximize our efforts to target these causes
and increase adherence rates to inhaled therapy
in bronchial asthma patients.
In our study, 295 patients who
were diagnosed to have bronchial asthma in KHMC,
Respiratory Medicine Division, between March 2013
and January 2015, were enrolled for the study.
All of these patients were prescribed inhaler
therapy according to the GINA guidelines. Initially,
proper education about their disease, the types
of inhalers to be used and proper technique were
explained to the patients. Follow up every 3 weeks
for the next 15 weeks was done in the clinic.
By the end of the 15 weeks, adherence to the inhaler
therapy was assessed.
Adherence day was defined as a day in which the
exact number of puffs of the prescribed inhalers
was taken. Patients were labeled as adherent if
they fit the above definition for more than 80%
of the days of the study (>84 days).
During each visit to the clinic, the patients
were asked about their adherence to inhalers during
the 3 week period preceding their appointment,
and the number of adherent days was recorded in
their files. By the end of the 15 weeks, the number
of adherent days was calculated by reviewing the
patients' files.
In the non-adherent group, the cause for non-adherence
was investigated by asking the patients about
the major reason that prevented them from adhering
to their inhaler therapy.
From the 295 patients with bronchial
asthma who were enrolled in our study, 138 patients
were found to be non-adherent to their inhaler
therapy. This represents 47% of the patients in
our study.
The cause was investigated in the non-adherent
group. 63 patients (46% of the patients in the
non-adherent group) stated that the major cause
was that they were afraid that by using their
inhalers regularly they will form a habit, which
will be associated with a social stigma according
to them. 54 patients (39% of the patients in the
non-adherent group) said that they were non-adherent
because they had doubts regarding the efficacy
of inhalers, and they thought that oral treatment
is superior to inhalers in treating bronchial
asthma. 13 patients (9%) said that the cause was
their fear of side effects. The remainder of the
non-adherent patients (8 patients, 6%) gave other
causes such as forgetfulness, difficulty in using
their inhalers and refusing the concept of being
asthmatics.
Figure 1: A comparison
between the number of adherent and non-adherent
patients to inhaled therapy from the 295 patients
in our study
Table 1: Causes of non-adherence to inhaled therapy
in bronchial asthma
*Other causes
such as forgetfulness, difficulty in using their
inhalers and refusing the concept of being asthmatics.
Bronchial asthma is a common
chronic medical condition. Adherence to bronchial
asthma treatment, of which inhaled therapy forms
the cornerstone, decreases morbidity and mortality
caused by this disease, and adherent patients
are less likely to experience exacerbations than
less adherent patients.(12)
However, adherence rates to inhaled therapy in
bronchial asthma have been shown to be less than
satisfactory. The WHO recorded adherence rates
to treatment in chronic diseases to be around
50 %.(13) Many other studies assessing adherence
to inhaled therapy in bronchial asthma specifically
showed non-adherence rates between 20-80%. (14)
In our study, it was found that 138 patients from
the 295 patients with bronchial asthma enrolled
in the study were non-adherent to their inhales
therapy, with non -adherence percentage of 47%.
This high percentage of non-adherence is worrisome
and the causes of which should be investigated
thoroughly.
In our study, it was found that the main causes
for non-adherence were not related to the drugs
per se, rather it was due to poor understanding
by the patient about their disease and treatment
choices and strategies.
We found that 46% of non-adherent patients were
not adhering to their inhaled therapy because
they were afraid that using the inhalers will
form a habit, which is associated with a social
stigma according to these patients. 39% of the
patients in the non-adherent group stated that
they were non-adherent because they preferred
to use oral treatments because they thought it
was superior to inhaled therapy. Other less common
causes included fear of side effects of the inhaled
therapy ( 9%), and forgetfulness, difficulty in
using their inhalers and refusing the concept
of being asthmatics (6%).
As it is clearly shown in our study, the main
causes for non-adherence stem from poor understanding
by the patient about bronchial asthma as a chronic,
non curable disease, that needs lifelong treatment,
and the significant role that inhaled therapy
plays in managing bronchial asthma.
These causes for non-adherence were investigated
thoroughly in various other studies. Gupta &
Gupta found in their study that up to 76% of bronchial
asthma patients consider inhaled therapy inferior
to oral medications.(15) Another study done by
Bedi found that 42% of the patients didn't adhere
to their inhaled therapy because they were afraid
that it would be habit forming.(16)
The fact that the majority of the non-adherent
patients stated causes which stemmed from poor
understanding of their disease and treatment choices,
makes patients' education and doctor-patient communication
of upmost importance in trying to improve adherence
rates of bronchial asthma patients to inhaled
therapy.
Non-adherence to inhaled therapy
in patients with bronchial asthma is common. This
emphasizes the need to regularly assess patients'
adherence to their inhaled therapy during their
regular clinic visits.
The fact that non-adherence in bronchial asthma
patients is mostly caused by non-scientific ideas
by the patients about their disease and treatment
methods, makes an informative doctor-patient relation
very important, where patients should be educated
about their disease, and the therapeutic strategies,
of which inhaled therapy forms the cornerstone,
discussed in detail with them.
1. Gupta
RS, Weiss KB: The 2007 national asthma education
and prevention program asthma guidelines: accelerating
their implementation and facilitating their impact
on children with asthma. Pediatrics 2009, 123(Suppl
3):S193-8.
2. Al Frayh AR, Shakoor Z, Gad El Rab MO, Hasnain
SM: Increased prevalence of asthma in Saudi Arabia.
Ann Allergy Asthma Immunol 2001, 86(3):292-6.
3. G. Crompton A brief history of inhaled
asthma therapy over the last fifty years Prim
Care Respir J, 15 (2006), pp. 326-331
4. M.G. Cochrane, M.V. Bala, K.E. Downs, et al.
Inhaled corticosteroids for asthma therapy. Patient
compliance, devices and inhalation technique Chest,
117 (2000), pp. 542-550
5. Broeders ME, Sanchis J, Levy ML, Crompton GK,
Dekhuijzen PN: The ADMIT series-issues in inhalation
therapy. 2. Improving technique and clinical effectiveness.
Prim Care Respir J 2009, 18(2):76-82.
6. J.A. Coults, N.A. Gibson, J.Y. Paton, Measuring
compliance with inhaled medication in asthma,
Arch. Dis. Child. 67 (1992) 332-33
7. National Institutes of Health, National Heart,
Lung, and Blood Institute.1997. Expert Panel Report
II: Guidelines for the Diagnosis and Management
of Asthma. Public Health Service, Bethesda, MD.
Publication No. 97-4051.
8. National Institutes of Health, National Heart,
Lung, and Blood Institute.1991. Expert Panel Report:
Guidelines for the Diagnosis and Management of
Asthma. Public Health Service, Bethesda, MD. Publication
No. 91-3042
9. Adams RJ, Smith BJ, Ruffin RE: Factors associated
with hospital admissions and repeat emergency
department visits for adults with asthma. Thorax
2000, 55(7):566-73.
10. Barnes P, Jonsson B, Klim JB. The costs of
asthma. EurRespir J 1996: 9:636-642.14. Rand CS,
Wise RA. Measuring adherence to asthma medication
regimens. Am J Respir Crit Care Med 1994;149:69
-78
11. Weiss KB, Gergen PJ, Hodgson TA: An economic
evaluation of asthma in the United States. N Engl
J Med 1992, 326(13):862-6.
12. Stern L, Berman J, Lawry W, et al. Medication
compliance and disease exacerbation in patients
with asthma. Ann Allergy Asthma Immunol 2006;
97:402- 408.
13. World Health Organization, Adherence to long-term
therapies: Evidence for action, 2003.
14. Rand CS, Wise RA. Measuring adherence to asthma
medication regimens. Am J Respir Crit Care Med
1994;149:69 -78
15. Gupta PP, Gupta KB. Awareness about the disease
in asthma patients receiving treatment from physicians
at different levels. Indian J Chest Dis Allied
Sci 2001;43:91-5.
16. Bedi RS. Knowledge about asthma and its management
in asthmatics of rural Punjab. Indian J Tub 1993;
40:153-5.
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