|Year : 2019 | Volume
| Issue : 1 | Page : 59-62
Adherence to therapy in adult patients with bronchial asthma
Sharmila Sinha1, A Tejus2
1 Department of Pharmacology, Command Hospital, Lucknow, Uttar Pradesh, India
2 Department of Pharmacology, Army College of Medical Sciences, Delhi, India
|Date of Submission||26-Apr-2019|
|Date of Acceptance||29-Apr-2019|
|Date of Web Publication||19-Jun-2019|
Lt Col A Tejus
Army College of Medical Sciences, Delhi - 110 010
Source of Support: None, Conflict of Interest: None
Background: The global prevalence of bronchial asthma according to the WHO is 235 million and adherence to therapy is now becoming one of the main issues in its effective management all over the world. In developing countries such as India, easy accessibility to drugs and inadequate health services results in increased use of self-medication. Over-the-counter drugs though meant of self-medication, their inappropriate use can be potentially hazardous, and there is always a risk of interaction with other prescription drugs. Very few studies have been published regarding self-medication pattern in India and hardly any studies regarding their interactions with prescription drugs in asthma, hence this study was proposed. Methods: One hundred adult ambulatory patients aged above 20 years were randomly selected from the respiratory outpatient department of a tertiary care government teaching hospital in Pune. The participants were subjected to a semi-structured interview with the help of a questionnaire. Results: Ninety-one percent were adherent to therapy. The main reasons for not adhering to therapy as suggested by the questionnaire and interview were old age and difficulty in using the inhaled medications appropriately. Self-medication was in 16% of the patients and the most common drugs being proton-pump inhibitors, H2 blockers, and antihistaminics, but no significant interaction was observed. Conclusions: In our study, the adherence was well above the global figures. Nonadherence to therapy is estimated to be 50% for chronic illnesses. A multidimensional approach by proper management and increasing interaction time with the patients will go a long way in improving the management of such conditions. Elderly people should be specially targeted as they have multifactorial reasons for not adhering to therapy. Effective but simple and uncomplicated regimens, convenient dosing and route of administration, less expensive, and safer drugs should be the aim in the treatment of bronchial asthma.
Keywords: Adherence, bronchial asthma, self-medication
|How to cite this article:|
Sinha S, Tejus A. Adherence to therapy in adult patients with bronchial asthma. J Mar Med Soc 2019;21:59-62
| Introduction|| |
Bronchial asthma, a chronic disorder of the airways, that is characterized by increased responsiveness of the tracheobronchial tree and its symptoms include dyspnea, wheezing, and cough. The global prevalence of bronchial asthma according to the WHO is 235 million and adherence to therapy is now becoming one of the main issues in its effective management all over the world. The common drugs used for bronchial asthma include bronchodilators (beta-2 agonists, anticholinergics, and methylxanthines), leukotriene antagonists, mast cell stabilizers, corticosteroids (inhaled and systemic), and immunoglobulin E monoclonal antibodies.,
Adherence to therapy is the extent to which patients follow treatment instructions and not following it leads to nonadherence. There can be different types of nonadherence to medication such as failure to obtain medicines, failure to take medicines as prescribed, prematurely discontinuing the medication, or taking medicines inappropriately. Furthermore, not adhering to therapy can be intentional (deliberate) or unintentional (accidental). Nonadherence to therapy is one of the major hurdles to effective delivery of health care the world over. Problem is much more in developing countries where it is estimated that only 50% of patients in developing countries with chronic diseases such as asthma, diabetes, and hypertension follow treatment instructions. Noncompliance in asthma which is estimated to be 28%–70% worldwide leads to a higher risk of severe attacks requiring institutional management. The main causes of nonadherence in bronchial asthma are low education status, low socioeconomic status, poor doctor–patient interaction or not being able to correctly comprehend the advice, problem with usage of inhaler devices, mixing of drugs, complexity of the treatment regimen relief of symptoms only for a short duration on taking drugs, self-medication, psychological factors, and other comorbidities.,,,
Over-the-counter (OTC) drugs are meant of self-medication, but their inappropriate use can be potentially hazardous, and there is always a risk of interaction with other prescription drugs. Many self-prescribed drugs may interact with antiasthmatic agents and may cause idiosyncratic reactions which are especially dangerous in an asthmatic patient. Almost 5%–10% of asthmatics can be sensitive to aspirin (a very commonly used OTC) leading to severe bronchoconstriction and symptoms of histamine release such as flushing and abdominal cramps. Common drugs which induce episodes of asthma are mainly aspirin, coloring agents (tartrazine), and β-adrenergic antagonist. There is a lot of concern the world over about compliance and self-medication in asthma, but very few studies in this field have been conducted in India. Hence, this study was conducted aimed to assess the magnitude, reasons, and pattern of nonadherence to therapy and self-medication and its potential interaction with antiasthmatic drugs.,
Aims and objectives
The aim is to assess the adherence to therapy in adult patients of bronchial asthma and to determine the amount of self-medication in these patients and potential clinically significant interactions with prescription drugs.
| Methods|| |
This was a questionnaire-based, cross-sectional study that involved assessing compliance to therapy, self-medication, and the risk of potential interactions with prescription antiasthmatic drugs. One hundred adult ambulatory patients aged above 20 years, diagnosed as a case of uncomplicated bronchial asthma were randomly selected (computer-generated random numbers) from the respiratory outpatient department of a tertiary care government teaching hospital in Pune. The study was started after taking clearance from the institutional ethical committee. Prior to recruitment into the study, informed consent was obtained from each patient, and only patients who volunteered were interviewed. Adherence to therapy was determined by the extent to which patients followed treatment instructions and not following it was considered nonadherence. Self-medication was defined as “medication taken on the patient's own initiative or on the advice of a pharmacist or lay person”, and included medicines obtained without prescription, refilling of old prescriptions, sharing medicines with relatives or friends, or using leftover medicines. Herbal medications, food supplements, and alternative medications taken by the patient were also included. The participants were subjected to a semi-structured interview, and their medical records were also evaluated.
Information related to adherence was documented, and reasons for not adhering to therapy were also noted. Information regarding the type of self-medication, illness for which medication was taken, and the reason for not consulting a doctor were also collected. All the prescription drugs that the patients were taking were noted and also if they had suffered from any adverse effects.
| Results|| |
Of the 100 ambulatory adult (over 20 years of age) patients suffering from bronchial asthma, 38 were female and 62 were male [Figure 1]. The most used antiasthmatic medication being used was leukotriene antagonist (montelukast), which was prescribed to 73 of the patients. Beta-2 agonists (both long acting and short acting), methylxanthines, and steroids (both inhaled and oral) were being used. No significant adverse effects were reported by any patient except mild gastritis [Figure 2].
Most patients were adherent to therapy. Only 11 patients were not adherent, of which 7 were male (11.92% of all males recruited in the study) and 4 were female (10.52% of all females recruited in the study) [Table 1]. Their difference in adherence rates between males and females was similar [Figure 3]. The main reasons for not being adherent to therapy as suggested by the questionnaire and interview were old age and difficulty in using the inhaled medications appropriately [Figure 4].
Self-medication was found in 16% of patients and was not related to age, sex, or socioeconomic status. The most common drugs being used were proton-pump inhibitors (PPIs) and H2 antihistamines [Figure 5]. Other prescription drugs for comorbidities being used were H1 antihistamines (levocetirizine), antimicrobials (levofloxacin, amikacin, amoxicillin + clavulanic acid), antidiabetics (insulin, metformin), cardiovascular drugs (amlodipine, verapamil, losartan, and indapamide), sildenafil, calcium, Vitamin C, domperidone, methotrexate, hydroxychloroquine, and alprazolam [Figure 6]. None of these patients reported any history of adverse effects, aggravation of symptoms, or hospitalization.
| Discussion|| |
Nonadherence to prescribed therapy in bronchial asthma medical is a major hurdle in its effective management. Despite significant advances in the pharmacotherapy of bronchial asthma, it appears that the treatment remains unsuccessful due to low compliance rate. Optimal results are not achieved even by adequate medication prescribed due to the lack of adherence to the prescribed medication. The question of how much adherence is enough is difficult to answer. Obtaining 100% adherence would be the ideal situation; it may be difficult to achieve. Adherence to a level that keeps the patient's symptom-free and lets then enjoy a good quality of life would be a more achievable goal.
In our study, adherence was quite good (91%), and the reasons for nonadherence to therapy were mainly difficulty in understanding the correct method of using the inhaler devices. One of the common reasons for nonadherence, i.e., availability and cost of medication was not an issue in our study as medication was provided by the hospital free of cost.
In our study, the number of patients on self-medication was 16% and was not related to age, sex, or socioeconomic status. Most of the drugs taken were PPIs, ranitidine, or anti-histaminics. None of the patients reported any significant adverse event during the treatment. There were 15 patients with comorbid conditions such as hypertension, diabetes, and rheumatoid arthritis. None of these patients reported any adverse events or worsening of symptoms. The analysis of the drugs prescribed also did not reveal any combination that could carry a potential risk of interactions.
| Conclusions|| |
Teamwork is necessary for managing complex chronic diseases such as asthma, to make health-care strategy succeed. The correct method of usage of the various devices used in the management of asthma should be demonstrated to the patients/caregivers. In elderly patients, the education of the caregiver is very important. Children, though not included in this study, are a group in whom interaction with the caregivers is of utmost importance. Overcoming the barriers that reduce adherence and propagating appropriate self-care will improve the management of such conditions. Not adhering to prescribed medication is an emerging as a major health-care issue that needs to be addressed to improve the treatment outcomes and the quality of life of the patients.
Drug interaction is another issue that affects the pharmacotherapy of chronic illnesses such as asthma. Interactions may be with prescription drugs, as well as self-medications including OTC drugs, herbal remedies, and alternative therapies. In our study, we did not find any significant drug interactions.
Health-care providers should improve their communication skills and increase interaction with patients so that they comprehend the doctor's instructions. While advising the patients about their disease and its management and also while dispensing the medications, their comprehension capacity, their language, cultural background, and age need to be taken into cognition. Elderly people should be specially targeted, as they have multifactorial reasons for not adhering to therapy. Effective but simple and uncomplicated regimens, convenient dosing and route of administration, and less expensive and safer drugs should be the aim in the treatment of bronchial asthma.
Financial support and sponsorship
This study was part of the Indian Council of Medical Research.
Conflicts of interest
There are no conflicts of interest. Short Term Study Project.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]