TUCSON—A recent study of asthma medication use in the United States has found that current asthma therapy is woefully inadequate, especially among minorities and socioeconomically disadvantaged populations.[1]

Theresa Guilbert, MD, one of the study’s principal investigators, told RESPIRATORY REVIEWS, “I see that many children and adults [remain] under-diagnosed and under-treated for many years.”

The Asthma in America survey was conducted specifically to measure the self-reported use of anti-inflammatory therapy according to severity of symptoms. Data were obtained from a national sample of adult patients and parents of children with asthma; these patients and parents were identified through a cross-sectional, random-digit-dial telephone survey of American households. Of 42,022 households sampled, 3,273 were found to have one or more persons who met the criteria for current asthma. A total of 2,509 persons completed the 30-minute telephone interview.

The survey, which was supported through a grant from GlaxoSmithKline, included questions about the following: sociodemographics, asthma symptoms, medications, health service use, health insurance and personal health care costs, patterns of care delivery (including types of provider and frequency of visits), ratings of patient-physician interactions, and attitudes and beliefs regarding asthma and its therapy.

ANTI-INFLAMMATORY USE OR NONUSE

The survey identified 721 children younger than 16 years and 1,788 adults with current asthma. Only 507 (20.1%) of all respondents reported having used an anti-inflammatory drug during the past four weeks. In 72.5% of these cases, the respondents had used inhaled corticosteroids; leukotriene antagonists were used in 11.4% of cases; and cromolyn or nedocromil, in 18.6%. When stratified by degree of long-term asthma symptoms, 21.3% of those with some asthma-related limitations and 26.4% of those with severe limitations reported current anti-inflammatory use.

Slightly more than half of the respondents (50.8%) reported having persistent asthma. Among those patients reporting persistent asthma, only 26.2% said that they had used anti-inflammatory drugs during the past four weeks.

Drugs that provide symptomatic relief (eg, short-acting inhaled ß2-agonists and inhaled anticholinergics) were used by 79.7% of patients with persistent asthma. The extent to which reliever medications were used correlated directly with symptom severity. Only 4% of those who reported recent anti-inflammatory use said that they did not use drugs that provide symptomatic relief.

In bivariate analyses, people reporting lower income, less education, nonwhite race, and present unemployment were significantly less likely to report current anti-inflammatory use than were other populations. Among individuals who reported persistent short-term asthma symptoms and who had been hospitalized, visited the emergency department, or made two or more urgent care visits in the past year, less than half reported current use of anti-inflammatory medication.

A NEED FOR EDUCATION …

According to this study, only one quarter to one third of those who—as designated by the National Asthma Guidelines—should be using anti-inflammatory medications are actually using them. “I believe both patient and health care provider education is needed,” said Dr. Guilbert, who is an Assistant Professor of Pediatrics in the Respiratory Center at the University of Arizona in Tucson. “Many patients continue to receive rescue medications (ß2-agonists) rather than effective controller medications (inhaled steroids) from their physicians.”

The socially and economically disadvantaged are at increased risk for suboptimal care, and the factors involved are many and complex, including cost of and access to care, patient attitudes, and physician-patient relationship. Dr. Guilbert noted that this population tends to rely on emergency care, which usually involves episodic treatment with rescue medication. Also, she said, “Many patients do not understand that asthma is a chronic disease, not an intermittent disease.”

… AND FOLLOW-UP

The current procedures for asthma management are not adequate for a large proportion of the population. “I advocate that two to three screening questions be employed in well-child and well-adult visits [because] asthma is one of the most common chronic disorders,” Dr. Guilbert said. People with asthma should be started on effective controller medications and closely followed to see if they respond to treatment.

Dr. Guilbert added that long-term management regimens can be prescribed during urgent care or emergency department visits. “If a history of persistent asthma is elicited from patients, they should be placed on controller therapy, shown how to use it, and given a written asthma management plan and follow-up visits with their primary care physician.” Unfortunately, said Dr. Guilbert, many physicians are unable to devote the time needed for effective asthma education when their patient visits last only 10 to 15 minutes.

THE TREATMENT GAP

Although this study was based on self-reported information, the authors believe that objective lung function measurements would probably only increase the number of people in higher symptom burden categories. This would only lower the proportion of people with persistent asthma who report using anti-inflammatory medicine.

“I think this study underscores the need for improved diagnosis and treatment of patients with asthma,” concluded Dr. Guilbert. “Only 30% of persistent asthmatics … were on effective asthma medications as defined by the National Asthma Guidelines. Compare this to other chronic diseases that can lead to mortality, such as diabetes or heart disease.”

—Gale Jurasek