New York City
- That siren you hear is an ambulance rushing another non-compliant asthmatic to the ER. According to the Journal of Allergy and Immunology
, 58 percent of Americans with asthma are uncontrolled, and the costs rise every year, not just in cash but days lost at school and work are in the billions of dollars.
The fault lies largely not in external factors but in the patients themselves. Year in year out, American asthma patients fail to renew their prescriptions for inhaled corticosteroids an astonishing 70 percent of the time.
The same pattern holds for other countries, even those with mainstream socialized medical systems. For example, a recent study of children in the Toronto area by Canadian doctors showed, "A highly significant finding in the sub-group of drug plan holders was that for every one percent increase in family income spent out-of-pocket on a child's asthma medications, there was a 14 percent increase in the number of severe asthma attacks resulting in an emergency room visit or hospital admission."
And a British newspaper reported, "Asthma UK says 27 percent to 50 percent of asthma patients fail to take their treatment correctly. Incredibly, 80 percent of the 1,200 deaths a year from the disease can be blamed on poor adherence to therapy."
The excuses fall into a few basic categories: "It's a pain in the neck." "If I'm not wheezing, it's controlled." "I don't want to shell out for the co-payment." "I'm afraid of steroids."
This challenge of getting good little boys and girls of all ages to take their medication for diseases like asthma and allergic rhinitis has always figured in my belief in immunotherapy, which for now in this country refers pretty much to allergy shots, known technically as subcutaneous immunotherapy. This involves injecting a small amount of allergen under the skin, and gradually retraining the immune system so it doesn't produce an allergic reaction. (In Europe a newer method, sublingual immunotherapy, in which the allergens are placed under the tongue, has gained wider acceptance than it has here). While immunotherapy is not suitable for everyone, and doesn't work for food allergies, where avoidance is still important, it has served a very important purpose because it helps reinforce good adherence for patients whose asthma is triggered by things like pollen. When patients come into our office once a week for their shots, we always ask how they are doing and whether they are taking their preventative medication or relying on their "rescue" medication.
Of course they can lie, but as they get to know the people giving their shots, they become more conscientious. Often it appears they don't want to let the nurses down. Whatever the reason (and I don't discount their wanting to feel better) they take their asthma medications.
But that's among the older patients. Until they are in the habit of taking their medication, children are only as compliant as their parents make them, so we need to give them reasons to ride herd. Long-term control is usually achieved by using inhaled corticosteroids, or ICS, and for allergic rhinitis, intranasal steroids. But parents don't want their kids on steroids, even if, as most doctors believe, they are safe for long-term use. These parents often push for getting the children off these medications as soon as possible. If fear of steroids provides the impetus for long-term change in behavior that is the essence of asthma treatment, I'm not going to argue about their safety too strenuously. I will make "deals" with patients that allow them to decrease the dosage or stop it altogether. In the case of asthma, using an Asthma Action Plan, including using a peak flow meter to measure pulmonary function, gives patients and/or their caregivers something to shoot for.
As with grown-ups, a personal bond with the medical professionals also helps. For years I have worked with kids in disadvantaged public schools, seeing them every week or two. These kids are from homes where supervision varies. Those kids use their inhalers so that I won't be disappointed. The nurses and I become friends with the children, and they didn't want to disappoint their friends.
And what happens if they still lie? We have ways of finding out who's naughty or nice through pulmonary function tests or a fractional exhaled nitric oxide test, which measures airway inflammation and thus indicates who's compliant; children know that numbers don't lie. Day in day out, however a doctor's admonishment and cajoling only work up to a point because we can't see them all the time. The best tools of all are a peak flow meter and a conscientious mother.