Asthma Management: The one size fits all approach
Introduction. Asthma management continues to be a significant challenge for both patients and healthcare providers. The number of patients suffering from asthma continues to increase and asthma sufferers are at risk for increased morbidity and mortality.
The Asthma Society of Canada states that goal of asthma management is to “…reduce airway inflammation through environmental control measures and the use of regular controller medication, rather than intermittent therapy that is focused on short-term relief of symptoms”.
Additionally, it has long been recommended that treatment of asthma requires an individual approach. This is due in part to the fact that asthma symptoms tend to vary not only from patient to patient, but often from episode to episode. Patient education tools, such as the Asthma Action Plan can help patients and providers create an individualized program. Additional screening tools, such as the Asthma Control Test, can help in the long term management as it helps identify poor, or adequate, control of asthma symptoms at each visits. This test should be routine practice for all healthcare practitioners who see patients with asthma on a regular basis.
Choose your device carefully. Choosing the right inhaler is a critical component of helping patients control their asthma. While it may be challenging to know each device and its advantages intimately, it is important to acknowledge that patients will be more adherent if they have confidence in their inhaler and are using it appropriately. Successful control of asthma depends on proper deposition of the medication into the airways, therefore, ongoing education, instruction and communication on correct technique and overall satisfaction with a particular device can go a long way to improving adherence and adherence improves outcomes.
Metered Dose Inhalers (MDIs) and Dry Powder Inhalers (DPIs) are the two most common medications used for controlling asthma. Each device has its advantages and its challenges. MDIs have been around for a long time and physicians have grown comfortable with their use. However, the use of spacers is often required to get optimal deposition of the drug in the airways and may therefore affect adherence and efficacy.
DPIs, on the other hand, do not require spacers for optimal drug delivery. But even here there are considerations. First and foremost, there are numerous different DPIs on the market including, but not limited to: Turbuhalers, Diskus, Handihalers, Twisthalers and more. Studies have demonstrated that not all DPIs are created equally. 1These devices vary considerably in design, operational technique and drug delivery. Finally, not all DPI’s have the same indications for use which is another key consideration when choosing the right device for the right patient.
Different patient populations may also find individual types of DPIs easier to use.1Therefore, selecting the right DPI on an individual basis can contribute significantly to improved adherence. However, while DPIs may be generally considered as easier to use compared with MDIs, as many as one in three patients still use their device incorrectly.
Since asthma affects each patient differently, no single inhaler satisfies the needs of all patients. Careful consideration should be given to choosing an inhaler for each individual patient including assessing patient preference and competence in using a particular device. One way to achieve this is to have MDI and DPI sample devices (placebo) and Spacers and allow patients to examine and evaluate which device they see as preferable for themselves. Other factors to consider include:
- Delivery mechanism (not all inhalers are created equally)
- Medication type – LABA’s and ICS have different effect on patient response
- Potential for side effects
- Cost considerations/3rd party reimbursement coverage
Choosing the right medication for the right patient poses a challenge to healthcare practitioners. Habit and comfort often lead to narrowing our choice of medication. Newer therapies may have certain advantages over established therapies. Regardless of the device chosen, ongoing education is a critical factor in improving outcomes. It is estimated that more that 80% of asthma deaths could be prevented with proper education.2 In the end, no medication has the chance to work if patients won’t take it.
Join me for webinar on September 22nd or September 23rd at noon where we will examine these issues in more detail and provide you with information on how to access educational resources for you and your patients.
- 1. Chrystyn H. The DiskusTM: a review of its position among dry powder inhaler devices. International Journal of Clinical Practice. 2007;61(6):1022-1036. doi:10.1111/j.1742-1241.2007.01382.x.
- 2. Institute for Clinical Evaluative Services in Ontario (ICES) 1996. ICES Practice Atlas (second edition), June 1996