Europe and the United States differ on many things including how we look at war and how often we pick our noses…yes it’s true about rhinotillexomania (nose picking). Perhaps this is why Europeans will reach for a nose spray FIRST to treat allergies and then go for antihistamines. Yes, there’s even a Dr Oz video on the subject: http://www.oprah.com/oprahshow/Dr-Oz-on-Health-and-Hygiene
So what is the point of all this nonsense? Treatment of asthma also differs between the United States and Europe.
The Misuse of Asthma Drugs
Gene L Colice Expert Rev Resp Med. 2013;7(3):307-320.
There are three major problems with asthma care in the USA today and misuse of asthma drugs contributes to each.
First, multiple sources document that symptom control of most Americans with asthma in the general population does not meet standards established in the National Asthma Education and Prevention Program Expert Panel Report III (EPR3). In the CHOICE survey, 1000 patients with asthma randomly chosen across the USA were asked about their care and burden of disease. Almost half of these patients (49%) reported that they did not use asthma controller medications, although 79% had evidence of persistent disease. Of the 51% of the patients reporting the use of asthma controller medications in this survey, 85.7% had not well controlled or very poorly controlled disease. Numerous previous surveys of asthma patients in the USA and Europe, using either telephone interviews or questionnaires, have reported similarly high levels of uncontrolled disease. In the Exercise-Induced Bronchospasm Landmark Survey, 78.8% of the children with asthma and 83% of adults with asthma described respiratory symptoms with exercise. Children and adults with asthma commonly described being limited in their ability to perform sports and outdoor activities by their disease in this survey.
I know most patients would like to stop their asthma medications ASAP, but it comes at the cost of losing asthma control. I’ve previously discussed when to stop asthma medications…I’d like to know what you think? Are doctors prescribing unneccesary medications?
Second, in addition to difficulties with symptom control on a daily basis, patients with asthma in the USA frequently suffer exacerbations.
In the CHOICE survey, 5% of the patients reported being hospitalized and 14.4% described either an emergency department (ED) or urgent outpatient visit for an asthma exacerbation in the past year. Patients interviewed in this survey with more severe, persistent or uncontrolled asthma were more likely to have suffered asthma exacerbations. Previous surveys have reported similarly high rates of asthma exacerbations resulting in ED visits and hospitalizations. Data from the US CDC confirm that nationwide rates of ED visits and hospitalizations for asthma exacerbations remain unacceptably high.
So what are parents to do? The choice between giving your child steroids and having to rush to the emergency room for an asthma flare can be a “no win” proposition.
Third, asthma is an expensive disease.
The CDC has recently estimated that asthma costs the US economy approximately US$56 billion annually. On average, an asthma patient has been calculated to generate approximately US$2000–$4000 more in healthcare costs per year than a nonasthma control patient. Indirect costs due to work loss, school absenteeism, reduced productivity and so on, further contribute to the economic impact of asthma. Healthcare costs of asthma increase in patients with more severe disease. In patients with moderate and severe persistent asthma, exacerbations will further substantially increase healthcare costs.
I know the most common reason that patients stop their medication is simple: medications are too expensive. Here are some tips to reduce the cost of your prescribed medications for asthma:
- Make sure the medications you are picking up at your pharmacy are needed year round. Some patients need asthma inhalers only during the cold winter months.
- Educate yourself…know your triggers for asthma attacks to keep you out of the ER and better yet to use inhalers as prevention! (I have links to the American College of Allergy and the American Academy of Allergy, Asthma, and Immunology)
- Monitor your symptoms with a peak flow meter and pay attention to how much exercise you can do, and how well you sleep. Both of these indicators will tell you several days in advance if your asthma is flaring.
- Use coupons for your inhalers. In years past, pharmacy reps would leave samples for us to hand out to get patients started on asthma prevention. This is no longer the case because of health care reform. But….coupons are available for a similar value. Just don’t forget to take the coupon in to your pharmacist when you pick up your inhaler.
In summary, having reviewed the data, the EPR3 predisposes to under treatment of asthma. The tendency is for healthcare providers to underestimate asthma severity and to correspondingly undertreat the disease. In most asthma patients, the result will be persistent asthma symptoms. In important subsets of asthma patients, particularly smokers, the efficacy of ICS seems impaired. For a given categorization of asthma severity (even if accurately calculated by the healthcare provider), the corresponding recommended treatment with ICS in the EPR3 might be insufficient in smoking and obese asthma patients. Again, the consequence will be persistent asthma symptoms. Asthma tragedies occur all the time…let’s make sure it doesn’t happen to someone you know!