Download Perception of the Role and Potential Side Effects of

Perception of the Role and Potential
Side Effects of Inhaled Corticosteroids
Among Asthmatic Patients*
Louis-Philippe Boulet, MD, FCCPf
and fear of untoward side effects
Background: Misunderstanding of the role of asthma medication
in
to
reduce
compliance therapy, potentially resulting poor asthma control and increased
may
risk of severe asthma events.
Methods: We report the results of a recent Canadian survey of 603 asthmatic patients recruited
from the general population, aimed at determining their perception of the role and potential side
effects of inhaled corticosteroids (ICS).
Results: The survey revealed that a large proportion of asthmatic patients do not understand the
role of their medications and have many misconceptions and fears in regard to ICS, reducing
their willingness to use them. Among the most common fears are those concerning troublesome
side effects, particularly in regard to corporeal image, bone density, and a reduction in efficacy
of medication over time. More than half of the population said they were very or somewhat
concerned using ICS on a regular basis; two thirds of patients had not discussed their concerns
about ICS with their physicians or other health-care professionals. Finally, in a large number of
asthma patients, asthma was not adequately controlled, according to recent asthma consensus
guidelines.
Conclusions: These observations stress the importance for those involved in asthma care of
questioning patients about their understanding of the role of asthma medications, particularly
ICS, their fears and misconceptions, and what they consider to be adequate asthma control, in
order to provide appropriate education and counseling.
(CHEST 1998; 113:587-92)
Key words: asthma; asthma treatment; compliance; education; inhaled corticosteroids; patients' perception
disease, still responsible for
Asthma
Canada
significant morbidity and mortalityconsidered
that
other countries.13 It
is
a common
in
is
in
as
generally
untoward consequences of asthma could be
avoided by preventive measures, individualized
therapy, and education, as indicated
pharmacologic
in recent national and international guidelines on
asthma management.46
Unfortunately, asthma is still often insufficiently
controlled, resulting in increased health-care use
and morbidity. Two of the factors involved in poor
asthma control are deficiency in recognizing
asthma severity and suboptimal treatment, this last
often related to reduced compliance.78 Adherence
most
to
therapy
varies
widely according
to
studies,
*From the Centre de Pneumologie de l'Hopital Laval, Universite
Laval, Sainte-Foy, Quebec, Canada.
Copies of the questionnaire used in this study are available from
the author on request.
Glaxo Wellcome Canada.
Supported byreceived
February 27, 1997; revision
Manuscript
tember 10.
accepted Sep¬
Reprint requests: Louis-Philippe Boulet, MD, FCCP, Hopital
Laval, 2725, Chemin Sainte-Foy, Sainte-Foy, Quebec, Canada
G1V 4G5
ranging from about 20 to 70% in different chronic
conditions such as asthma.812 Nonadherence to or
misuse of therapy often results from inadequate
knowledge or understanding of the disease and its
treatment, psychosocial and economic factors,
of side
complexity of the treatment, occurrence commu¬
insufficient
and
effects,
patient/care giver
nications.1013
A poor understanding of asthma and the role of
medication may lead not only to insufficient intake of
drugs, such as bronchial anti-inflamma¬
tory agents, but also to overuse of others, such as
P2-adrenoceptor agonists.141516 Asthma is an airway
inflammatory disorder, and inhaled corticosteroids
are considered to be the mainstay of its treatment,
while P2-adrenoceptor agonists primarily play a role
in the control of intermittent symptoms.461718
Doses of inhaled corticosteroids 1,000 fxg daily of
beclomethasone in adults and 400 to 800 fig in
children are considered safe, and even higher doses
are preferable to poor control of asthma.18 Never¬
have different views on
some
of the
<
theless, patients
p2-adrenoand
and
corticosteroid
use,
persisting
ceptor agonist
CHEST/113 73/MARCH, 1998
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587
corticophobia may be at least partly responsible for
reduced compliance to this therapy.19
To better understand how to provide adapted and
efficient counseling to asthmatic patients, we should
of asthma therapy, particu¬
analyzein their perception
to
medications
such as inhaled corti¬
larly regard
costeroids, and understand their fears and concerns
about these agents. There are still, however, few
studies addressing these particular issues. A Cana¬
dian survey of asthmatic patients was recently con¬
ducted to assess perceptions regarding the role and
potential side effects of asthma medications. The
primary objective of this research was to under¬
stand the asthma patient's attitude pertaining to
inhaled corticosteroids. A secondary objective was
to obtain a general profile of the Canadian
asthmatic population.
Materials
and
Methods
Subjects
A national
telephone
survey
was
conducted
throughout
Canada, aiming at interviewing adults with asthma, with each
province or region represented at its true proportion of the
Canadian population. Within each province, half of the interviews
were
conducted in urban
areas
and half in rural
areas.
Partici¬
study if they were 16 years or older and
had a physician's diagnosis of asthma, reactive/hyperreactive or
irritable airways.
To recruit approximately 600 patients fulfilling the inclusion
criteria and completing the interviews, a total of 11,315 people
were interviewed; 137 were disqualified based on employment in
a market research or pharmaceutical organizations, 10,095 did
not have asthma, 328 had asthma but were younger than 16 years
of age, and 155 qualified but refused to participate in the study.
Overall, initial refusal to take part to the interview was 24% and
only 1% decided not to complete the interview part way through.
pants qualified for the
The questionnaire included questions about various aspects of
corticosteroid therapy, particularly relating to the perceived
modes of action and side effects of those agents. The general
profile of the enrolled asthmatic patients was assessed in regard
to years diagnosed with asthma, medication usage and dosing,
physician managing asthma, severity of asthma, frequency of
Emergency Department visits due to asthma, and sources of
patient information.
Data
Results are described as means for the whole group of patients
and, in some cases, for subgroups, such as those currently using
inhaled corticosteroids. Differences were considered significant
at the 95% level of confidence. Results reported for the whole
sample are correct to ±4% margin of error, 19 times out of 20.
Results
The average patient's profile is shown in Table 1.
They usually had suffered from asthma for many
years (mean, 13 years) and most took inhaled salbutamol on demand. Thirty-nine percent (n=235) had
used regular or intermittent inhaled corticosteroids
in the past 12 months. Of those, 75% had used
inhaled beclomethasone (42% high-dose formula¬
tion, 33% low-dose formulation or unspecified) and
25% had used inhaled budesonide. Half (48%) con¬
sidered their condition to be mild, 38%, moderate,
and 14% severe. Inhaled corticosteroid users tended
to consider their condition to be more serious.
Fifty-six percentin said that asthma was related to
allergies (57% corticosteroid users). Overall, each
had visited an Emergency Department on (mean) 15
occasions since asthma was diagnosed (Table 1).
Table 1.Patient Population Profile (n=603)
Methods
Interviews were conducted from mid- to late-September,
Characteristic
1995,
English or French. Camelford Graham was the research firm
commissioned for the study. They were supported by Telepoll
Canada Inc, which specializes in data collection. Camelford
Graham developed the questionnaire, supervised all fieldwork,
processed the data, and were involved in data analysis. The
in
Analysis
questionnaire was pretested twice: once formally with field staff
and again live with qualified respondents. This process allowed
the questionnaire to be checked for proper flow or any potential
problem areas regarding possible misinterpretation or respon¬
dent confusion. Based on the pretest, necessary adjustments were
made to produce the finalized version of the questionnaire to be
used in field. Continuous monitoring of each interviewer as¬
signed to the study was conducted. Approximately 20% of
interviews were randomly monitored. All interviewers were
briefed in advance and read the questions exactly as they were
worded but did not read the list of possible responses that are
shown. They listened to the response and determined which code
best fitted their response. If there was not a good fit with any of
the precodes provided, the interviewer recorded the partici¬
pant's response verbatim.
% of Subjects*
Men/women
34/66
Age, yr
16-30
30-60
60+
Asthma reported
Time since
<5
6-10
>11
37
44
19
56
as allergy induced
diagnosis, yr (mean, 13 yr)
36
22
42
Self-assessment of asthma severity
Mild
Moderate
Severe
No. of visits to the emergency
was
diagnosed
48
38
14
dept since asthma
1 to 9
10-19
20+
^Percent of the total
66
10
24
population studied.
588
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Clinical
Investigations
From the whole group, 293 were followed up by a
general
practitionner, 51 by a specialist, 65 by both,
and 194 had no regular follow-up. Patients followed
up by a specialist or both had more severe asthma
patients believed that inhaled corticosteroids could
cause weight gain, build huge muscles, cause infec¬
tions, make bones susceptible to fractures, or affect
growth. Inhaled corticosteroid users had a more
positive attitude toward corticosteroids, recognizing
that they were useful to treat asthma. They harbored
fewer misconceptions or fears than did the nonusers.
Agreement with most of the attributes concerning
safety and specific side effects increased with sever¬
ity of asthma.
One of the common misconceptions or fears was
the impression that higher doses would have to be
used over time to match the effectiveness previously
experienced (38%). This is in keeping with answers
to other questions related to the perception that
inhaled corticosteroids could become less effective
when used on a long-term basis (36%). Misconcep¬
tions regarding possible loss of efficacy after longterm use remained constant across mild, moderate,
and severe sufferers.
Forty-six percent of patients agreed with the state¬
ment indicating a reluctance to take inhaled cortico¬
steroids on a regular basis. Among those claiming
that they were not using inhaled corticosteroids,
when asked about their willingness to fill a prescrip¬
tion of corticosteroids, 18% indicated that they
would definitely fill this prescription, 38% said def¬
and 37% would probably or
initely or not
probably,
fill
this
definitely
prescription. The positive
intent to fill the prescription increased slightly with
age (33% between 16 and 19 years old and 40% older
than 40 years old). Men expressed a greater likeli¬
hood to use inhaled corticosteroids than women
(64% vs 46%). Sixty-five percent of patients (80% of
those using inhaled corticosteroids within the past 12
months) mentioned that they would be interested in
using a newer and safer inhaled corticosteroid.
Most patients claimed that they had not discussed
their concerns about inhaled corticosteroids with
their physician or other health-care professionals
(75%). Thirty-one percent of asthmatic patients in¬
dicated that they were not aware that inhaled corti¬
costeroids existed for asthma treatment, as a reason
for not discussing them with their physician. When
they had discussed those concerns, most of them had
than those followed by a general practitioner.
Respiratory Symptoms
Roughly two thirds of asthmatic patients stated
some of the following symptoms
they experienced
once a week or more often: coughing, wheezing,
breathlessness, and early morning chest tightness.
Most of these symptoms were considered to be more
than mild in close to two thirds of the subjects (Table
2). Coughing and wheezing were the symptoms
experienced most frequently. Respiratory symptoms
were regularly present in at least half of the subjects;
26% experienced nighttime awakenings once a week
or more and 38%, early morning chest tightness
3 and
(Table
4).
Understanding the Role of Asthma Medications
Table 5 provides a summary of the answers to the
key questions on perception of the role of inhaled
corticosteroids.
of the main
One
observations of this
that
asthma
sufferers
confused the
survey
many
two chief categories of agents, bronchodilators and
anti-inflammatory agents. They did not correctly
understand the role of inhaled corticosteroids in the
treatment of asthma or how to use them properly;
the most common misconception was reflected by
the fact that 43% believed that corticosteroids
opened the airways and relieved constriction as do
bronchodilators while only 22% mention that they
reduced inflammation or swelling of the airways.
was
Concerns About Inhaled Corticosteroids
Table 6 summarizes the primary concerns expressed about inhaled corticosteroids. More specifi¬
cally, 53% of the patients (47% of inhaled cortico¬
steroid users) said they were very or somewhat
concerned about using inhaled corticosteroids. Their
concerns included the fear of side effects (59%),
althoughif 39% recognized that they were usually
minor the drugs were used as prescribed. Many
Table 2.Evaluation of Asthma
Symptom Severity
Mild
Moderate
Severe
*
Percent of subjects
Coughing
Symptom Severity*
Chest
Coughing
Up Phlegm
Tightness
Breathlessness
Wheezing
Nighttime
Wheezing
35
36
45
18
26
50
21
30
45
23
33
45
19
26
43
28
46
17
rating the various reported symptoms as mild, moderate, or severe.
CHEST / 113 / 3 / MARCH, 1998
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589
Table
3.Frequency of Symptoms*
Breathlessness
Without
Coughing Wheezing
Once a week or more 51 44
Between once a week and once every 2 wk 9 8
Between once every 2 wk and once every 4 wk
Between once a month and once every 3 mo
Less frequently than every 3 mo 11 12
Do not experience that symptom 11 11
^Percent of patients
11
36
9
8
6
11
30
1310
9
37
7
6
10
13
26
38
6
9
33
26
5
5
7
11
46
reporting this frequency for a given symptom. Numbers may not exactly equal 100 as decimals are omitted.
with their family physician (81%) and most
felt
(75%) that their concerns were eased through
those discussions.
Finally, overall, there were no significant differ¬
ences in the answers to the various questions on
inhaled corticosteroids between patients from rural
areas and those from urban areas.
done
Exertion
Early Morning Coughing
Chest
Up Phlegm Nighttime
or Mucus
Tightness
Awakenings
so
Discussion
There are few observations in the medical litera¬
on the perception of asthma medication, partic¬
ularly in asthmatic patients recruited from the gen¬
eral population. Those attending asthma clinics may
have had additional information through their regu¬
lar follow-ups or participation in studies. It is there¬
fore of interest to look at the results of such an
extensive survey of the general population.
This survey demonstrated that knowledge of
asthma medications by asthmatic patients is often
poor, with many confusing what is currently consid¬
ered to be the two main categories of drugs, bron¬
chodilators and anti-inflammatory agents. Further¬
more, fears and misconceptions about inhaled
corticosteroids are quite frequent among the asth¬
matic population, the two most common being about
untoward side effects and a reduction in efficacy
with time. Most of the subjects questioned had not
discussed those fears with their physicians or other
health-care professionals. Furthermore, although
this was not specifically addressed, answers to the
ture
questionnaire suggested that evaluation of asthma
by the asthmatic patient was frequently
control
inadequate, and that asthma-related morbidity was
significant.
We may question the validity of the diagnosis of
asthma in the present study, although in all cases it
was made by the physician, and a large part of the
studied was young, so that confounding
population
asthma with COPD was unlikely. Furthermore, a
large proportion of subjects had chronic symptoms
typical of asthma (mostly cough, wheezing, chest
and breathlessness) and had had asthma
tightness,
medication prescribed.
Even when environmental measures are appropri¬
ate, many asthmatic subjects still required some
form of asthma medication. Inhaled corticosteroids
are considered the mainstay of pharmacologic treat¬
ment of asthma, and in most asthmatic subjects,
asthma is controlled by doses that are considered
safe and likely induce no or minimal side effects.18 It
has been well established that inhaled corticoste¬
roids, used judiciously at the minimal dose required
in association with
are
preventive measures,
Table
among
5.Perception of the Role
of Inhaled
*
Corticosteroids
Ever Used
Past 12
mo
Inhaled
Corticosteroid
Corticosteroids
Users
X
Opens the airways- -relieve
(n=272)
(n=235)
43
41
22
24
14
16
constriction
Table 4.Frequency of Respiratory
Symptoms
Coughing
Wheezing
Breathlessness without exertion
Coughing up phlegm or mucus
Early morning chest tightness
Nighttime awakenings
Symptoms
% of Patients Experiencing Those
Symptoms Once a Week or More
51
44
38
37
36
26
/ Reduces inflammation/swelling
of the airways
/Prevents asthma attacks
11
12
asthma attack
7
/Gets asthma symptoms under
control
3
3
X Builds up/strengthens lungs
11
12
Don't know
*Checkmark (/) is considered a good answer; "X" is considered a
false answer. Answers are respectively true or false according to
X Relieves
current
an
knowledge.
590
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Clinical
Investigations
Perception of the Role and Potential
Side Effects of Inhaled Corticosteroids
Among Asthmatic Patients*
Louis-Philippe Boulet, MD, FCCPf
and fear of untoward side effects
Background: Misunderstanding of the role of asthma medication
in
to
reduce
compliance therapy, potentially resulting poor asthma control and increased
may
risk of severe asthma events.
Methods: We report the results of a recent Canadian survey of 603 asthmatic patients recruited
from the general population, aimed at determining their perception of the role and potential side
effects of inhaled corticosteroids (ICS).
Results: The survey revealed that a large proportion of asthmatic patients do not understand the
role of their medications and have many misconceptions and fears in regard to ICS, reducing
their willingness to use them. Among the most common fears are those concerning troublesome
side effects, particularly in regard to corporeal image, bone density, and a reduction in efficacy
of medication over time. More than half of the population said they were very or somewhat
concerned using ICS on a regular basis; two thirds of patients had not discussed their concerns
about ICS with their physicians or other health-care professionals. Finally, in a large number of
asthma patients, asthma was not adequately controlled, according to recent asthma consensus
guidelines.
Conclusions: These observations stress the importance for those involved in asthma care of
questioning patients about their understanding of the role of asthma medications, particularly
ICS, their fears and misconceptions, and what they consider to be adequate asthma control, in
order to provide appropriate education and counseling.
(CHEST 1998; 113:587-92)
Key words: asthma; asthma treatment; compliance; education; inhaled corticosteroids; patients' perception
disease, still responsible for
Asthma
Canada
significant morbidity and mortalityconsidered
that
other countries.13 It
is
a common
in
is
in
as
generally
untoward consequences of asthma could be
avoided by preventive measures, individualized
therapy, and education, as indicated
pharmacologic
in recent national and international guidelines on
asthma management.46
Unfortunately, asthma is still often insufficiently
controlled, resulting in increased health-care use
and morbidity. Two of the factors involved in poor
asthma control are deficiency in recognizing
asthma severity and suboptimal treatment, this last
often related to reduced compliance.78 Adherence
most
to
therapy
varies
widely according
to
studies,
*From the Centre de Pneumologie de l'Hopital Laval, Universite
Laval, Sainte-Foy, Quebec, Canada.
Copies of the questionnaire used in this study are available from
the author on request.
Glaxo Wellcome Canada.
Supported byreceived
February 27, 1997; revision
Manuscript
tember 10.
accepted Sep¬
Reprint requests: Louis-Philippe Boulet, MD, FCCP, Hopital
Laval, 2725, Chemin Sainte-Foy, Sainte-Foy, Quebec, Canada
G1V 4G5
ranging from about 20 to 70% in different chronic
conditions such as asthma.812 Nonadherence to or
misuse of therapy often results from inadequate
knowledge or understanding of the disease and its
treatment, psychosocial and economic factors,
of side
complexity of the treatment, occurrence commu¬
insufficient
and
effects,
patient/care giver
nications.1013
A poor understanding of asthma and the role of
medication may lead not only to insufficient intake of
drugs, such as bronchial anti-inflamma¬
tory agents, but also to overuse of others, such as
P2-adrenoceptor agonists.141516 Asthma is an airway
inflammatory disorder, and inhaled corticosteroids
are considered to be the mainstay of its treatment,
while P2-adrenoceptor agonists primarily play a role
in the control of intermittent symptoms.461718
Doses of inhaled corticosteroids 1,000 fxg daily of
beclomethasone in adults and 400 to 800 fig in
children are considered safe, and even higher doses
are preferable to poor control of asthma.18 Never¬
have different views on
some
of the
<
theless, patients
p2-adrenoand
and
corticosteroid
use,
persisting
ceptor agonist
CHEST/113 73/MARCH, 1998
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21761/ on 04/28/2017
587
15
Spitzer WO, Suissa S, Ernst P, et al. The use of P-agonists and
the risk of death and near death from asthma. N Engl J Med
1992; 326:501-06
16 Ernst P, Spitzer W, Suissa S, et al. Risk of fatal and near-fatal
asthma in relation to inhaled corticosteroid use. JAMA 1992;
268:3462-64
17 Kay AB. Asthma and inflammation. J Allergy Clin Immunol
1991; 87:893-910
18 Barnes PJ, Pedersen S. Efficacy and safety of inhaled cortico¬
steroids in asthma. Am Rev Respir Dis 1993; 148(suppl):Sl-S26
19 Osman LM, Russell IT, Friend JAR, et al.
20
21
22
23
Predicting patient
attitudes to asthma medication. Thorax 1993; 48:827-30
Adelroth E, Thompson S. Advantages of high-dose inhaled
budesonide [letter]. Lancet 1988; 1:476
Becker MH, Maiman LA. Strategies for enhancing patient
compliance. J Community Health 1980; 6:113-15
Boulet LP, Chapman KR, Green LW, et al. Asthma educa¬
tion. Chest 1994; 106:184S-96S
Brewis RAL. Patient education, self-management plans and
peak flow measurements. Respir Med 1991; 85:457-62
592
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21761/ on 04/28/2017
Clinical
Investigations