Attitude changes needed to foster treatment adherence in patients with asthma

Although asthma is a disease that cannot be cured, it can be treated and controlled.1,2 A series of studies published between 1985 and 1990 demonstrated that asthma is a chronic inflammatory disease,3-6 and shortly after this it was shown that patients on long-term antiinflammatory therapy could remain free from symptoms and maintain normal lung function.7 The different guidelines on the diagnosis and treatment of asthma include simple protocols for correct patient treatment.1,2 All these developments gave rise to the general impression among physicians that asthma was an easy illness to control whereas, paradoxically, epidemiological studies have shown that in practice asthma is inadequately controlled in most patients. In the AIRE8 study for example, asthma was fully controlled in only 35% of patients. The ASES9 study showed that, even when apparently correct treatment was implemented, the illness was poorly controlled in over half of all patients. It is clear, therefore, that while in theory asthma is easy to control, in practice it is poorly controlled in many patients. The most commonly cited explanation for this paradox, particularly when the treatment prescribed is appropriate, is that patients do not adhere to the treatment plan.9-11 Given the low levels of adherence found among patients with asthma, it is not surprising that nonadherence is a determining factor in this lack of control. Asthma patients take their medication only 50% of the time,12 even less often than patients with hypercholesterolemia13 or hypertension,14 who take their medication 60% and 70% of the time, respectively. Numerous studies have confirmed this low rate of adherence, although the range is very broad (from 15% to 65%) owing to differences in the populations or treatment regimens studied, and the parameters measured.15-23 It is, therefore, clear that in clinical practice the patient’s failure to adhere to the prescribed treatment limits the success of therapy. When faced with therapeutic failure, medical professionals tend to choose easy but usually erroneous solutions, such as increasing the dose, prescribing additional medication, or changing the treatment regimen. Since the most common cause of therapeutic failure is nonadherence, none of these strategies leads to success. The reason such solutions are often used is that many physicians believe that patient nonadherence is not their problem and consequently do nothing to address it directly. A change of attitude on the part of medical professionals would have a considerable impact on the therapeutic decision because adherence, while depending mainly on the patient, is also influenced by the physician’s attitudes and interest in changing the patient’s behavior by way of advice. Medical professionals must implement strategies aimed at fostering adherence. The medical literature does not yield any studies showing that simple interventions are effective in improving overall adherence. Some such interventions may perhaps improve adherence in certain specific situations.24 While the discovery of a simple intervention effective in all situations would be the solution to all problems of adherence, it is not surprising that such a panacea has not been found since a universal remedy would only be possible if nonadherence were a straightforward problem. But it is, on the contrary, clearly a multifactorial problem involving a broad range of determining factors. In contrast to the thousands of clinical trials on the efficacy of different drugs, very few rigorous studies have been undertaken to study the problem of adherence to treatment.24 The studies that have been done show that the strategies currently in use are rather ineffective notwithstanding the considerable effort and resources they entail. Undoubtedly, this is in part due to the difficulty of designing a study that can demonstrate the efficacy of a non-drug intervention. Moreover, the methodology used tends to differ considerably from one REVIEW ARTICLE