Controlling Asthma Requires Constant Vigilance

GAINESVILLE, Fla.---Modern medicine can control most cases of asthma, but so many children don't take their prescriptions as directed that health-care professionals and parents must constantly be alert forfailure to follow doctor's orders, a University of Florida physician warns.

The stakes are high: Millions suffer attacks of wheezing and shortness of breath that are more frequent and severe than they need to be, putting them at risk for permanent lung damage and even death.Furthermore, patients may wind up on increased doses or more toxic medications because doctors mistakenly believe the original treatment plan had been ineffective.

"No one should have to die from asthma," said Dr. James Sherman, a professor of pediatrics and chief of the pediatric pulmonary division in UF's College of Medicine. "Yet studies have shown that 30 percent to 70 percent of people with the disease do a poor job of keeping up with the medication, which results in increased emergency room visits, hospitalizations and deaths.

"So when physicians have patients whose asthma is out of control, they need to think first about whether the person is really taking the medicines properly," said Sherman, whose article on the topic was published earlier this year in the journal Contemporary Pediatrics.

An estimated 15 million people in the United States-about a third of them children--have asthma, a chronic condition characterized by inflamed airways that occasionally flares into severe breathingdifficulties. The incidence of the disease has been rising steadily during the past two decades. In 1995, more than 1.5 million emergency department visits, 500,000 hospitalizations and 5,000 deaths were attributed to asthma, according to the National Institutes of Health.

For all but the most mild cases, daily "controller" medication, which can be taken in pill or inhaled form, is required to keep inflammation of the air passages in check. When an attack does occur, a "rescue" medicine is to be taken. Also, with the aid of a handheld meter,patients with more severe disease are directed to take a daily or twice-daily measure of their ability to push air out of their lungs.

"It may not sound like the most difficult regimen," Sherman said. "But on the other hand, the majority of people in the United States know they're supposed to exercise four times a week and floss their teeth every day. How many of us do that? In general, preventative kinds of measures seem to be difficult for people."

Complicating the picture is the fact that many of those with asthma are young children unable to be responsible for their own health.

"Many of the patients we see don't have a family structure that can handle a chronic illness," Sherman said. "The medications also can be expensive, and some patients cannot afford them."

People with asthma often don't have symptoms every day, Sherman noted.

"So there's not that 'sick' reminder that you have to take your medicine. And if you fail to take your controller medicine, the consequence of that can be delayed for days or even weeks, whichlimits the incentive to take it," Sherman said.

Physicians should emphasize to patients and their families the potentially life-threatening risks of uncontrolled asthma, Sherman said. They should work with families to find medicines and a daily treatment schedule that is realistic and acceptable.

"If you prescribe a medication and the patient tells you he is so frightened of it that he doesn't think he can take it, then letting him walk out with it is a prescription for nonadherence," he said.

But if education and negotiation don't work, and patients still aren'tdoing well, doctors must become steadily more aggressive at monitoring medication use.

Leslie Hendeles, a UF professor of pharmacy and a clinical pharmacist in the pediatric pulmonary clinic, suggests physicians call pharmacists to see how frequently prescriptions are being filled. If the patient doesn't order refills at regular intervals, it is unlikely thatthey are taking the medicine regularly.

Health-care providers also can check on patients by counting the number of pills left since the last visit, or weigh inhaler canisters to see how many puffs have been taken. Commercial products are available that record the date and time pill bottles are opened or the number oftimes an inhaler has been activated.

To encourage proper medication use, physicians can arrange for home visits by a nurse or work to identify an "asthma partner" - a relative, neighbor or other volunteer who will help a family stay ontrack with the treatment plan.

Sherman and Hendeles sometimes develop contracts with their patients, laying out what is expected, and agreeing to be available to the family at any time for questions.

"In very rare circumstances, if adherence is still a problem and thechild has life-threatening asthma, we have sometimes gone to court to have the child placed in a circumstance where medication will be provided regularly," Sherman said.

"But most of the time, it doesn't come to that," Sherman said. "We have often been able to take patients who are on high doses of multiple medications, none of which are taken as prescribed, and helped them control their asthma with much smaller doses of fewer medications byimproving their adherence."

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