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Low inhaler compliance in secondary school children despite poor asthma control

Pearl Toh
19 Apr 2017

Almost half of secondary school children who had been diagnosed with asthma had suboptimal asthma control, yet over half of those surveyed did not use their inhalers as prescribed, a recent study found.

“Young teenagers don’t always fully appreciate the long-term consequences of not taking their medicine, and often reject medication because they want to be seen as normal like their peers,” said Dr Michael Lim, a consultant of the Division of Paediatric Pulmonary and Sleep in National University Hospital, Singapore, who is unaffiliated with the study.

Among 689 asthmatic students in London, 342 (49.6 percent) reported suboptimal asthma control, defined as scoring ≤19 out of a maximum of 25 in an asthma control test (ACT), while 39 (5.7 percent) reported consistent condition without asthma symptoms (ACT score of 25). [J Asthma 2017;doi:10.1080/02770903.2017.1299757]

Of the 528 students who needed a short-acting β2-agonist (SABA) inhaler at school, 224 (42.4 percent) claimed that they felt “somewhat/hardly/not at all comfortable” using their inhalers at school. Almost one third of them (29.2 percent) reported not using an inhaler even when they needed it, “at least some of the time”.

For the 390 students who had been prescribed with an inhaled corticosteroid (ICS) inhaler with or without long-acting β2-agonists (LABA), more than half (56.4 percent) reported not using the inhaler according to prescription “at least some of the time”, 19.2 percent did not use “most of the time”, and 9.5 percent “all of the time”.

The most common reason for noncompliance to ICS±LABA inhaler was “forgetfulness”, claiming “it was sometimes difficult to remember to take their [inhalers] due to distractions including getting ready for school in the mornings, homework, and extracurricular activities.”

Also, 41.7 percent of the students did not know what an ICS±LABA inhaler was for, giving a wrong answer for a multiple-choice question on the inhaler. Over one third (42.4 percent) of students with suboptimal control perceived their asthma to be “well/completely controlled”.

Compared with those who had optimal asthma control, more students with suboptimal control felt “somewhat/hardly/not at all comfortable” using their SABA inhalers at school (29.1 percent vs 52.7 percent; p<0.01) and forgot their ICS±LABA inhaler (55.5 percent vs 57.0 percent; p<0.01).

Similarly in Singapore, only about a quarter of patients were fully compliant to their asthma therapy in a small survey of adolescent patients, according to Lim, who observed that the reasons behind noncompliance among Singapore adolescents include forgetfulness, perceived wellness, and inconvenience.

“Ongoing patient education is important about the long-term consequences of poor asthma control, [including an] increased risk of difficult-to-treat asthma when older, and a poorer quality of life and increased risk of severe asthma attacks when older,” said Lim.

“Having a good doctor-patient relationship reduces the chances of patients defaulting on their clinic appointments. We maintain a so-called ‘high-risk’ register of patients who have bad asthma control, and actively get in touch with the child and family whenever a clinic appointment is missed,” he added, suggesting that having an asthma diary can help monitor compliance, and medications requiring fewer dosing may help increase patient’s compliance.

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22 May 2017
Chronic obstructive pulmonary disease (COPD) is currently the 10th commonest cause of death in Singapore, with a disease burden of 5.9 percent according to a 2015 population-based survey (EPIC-Asia survey) in Singapore. Pearl Toh spoke with Dr Augustine Tee, chief and senior consultant of the Department of Respiratory and Critical Care Medicine at Changi General Hospital (CGH) in Singapore, on how COPD is often underdetected in the primary care population as symptoms are not specific and diagnosis requires a combination of clinical risk factors, symptoms and spirometry testing.
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