A patient who keeps having asthma exacerbations can be frustrating to manage. It is easy to assume that the patient simply needs a stronger inhaler or additional medications. But before escalating therapy, it is important to figure out why the patient is not getting adequate control in the first place.
Poor inhaler technique
One of the first things I would assess is how the patient is actually using their inhaler. A prescription for an inhaled corticosteroid does not help much if the patient is not getting the medication into their lungs. Patients may inhale too quickly, fail to coordinate actuation with inhalation, skip the breath-hold, or use a dry powder inhaler incorrectly. Some patients have been using the same technique for years without ever having someone watch them use the device. Have the patient demonstrate their inhaler technique rather than simply asking, “Do you know how to use your inhaler?”
Adherence problems from multiple daily doses
The more complicated the regimen becomes, the easier it is for patients to miss doses. A patient taking medications multiple times throughout the day may do well for a few days and then gradually start missing doses. This is especially problematic with controller medications because patients may not immediately notice a consequence from missing one or two doses. Over time, however, inconsistent use can contribute to worsening airway inflammation and an increased risk of exacerbations. When possible, simplifying the regimen can make a meaningful difference.
Cost-related nonadherence
Sometimes the patient isn’t taking the medication because they simply cannot afford it. This can be overlooked when reviewing an asthma medication list. The chart may show an inhaled corticosteroid as an active medication, but that does not necessarily mean the patient is actually using it. Ask directly: “Are any of your asthma medications too expensive?” Patients may stretch out doses, skip doses, stop filling prescriptions, or rely heavily on an albuterol inhaler because of cost. If cost is the problem, consider whether there are less expensive alternatives, generic products, insurance formulary options, manufacturer assistance programs, or a different device that the patient can realistically afford.
A difficult home environment with frequent exposure to triggers
Medication therapy can only do so much if the patient is repeatedly exposed to asthma triggers. A patient may be exposed to cigarette smoke, vaping, pets, dust, mold, strong fragrances, cleaning products, or other irritants at home. Some patients may know exactly what triggers their symptoms but have limited ability to change their environment. This is where asking about the patient’s living situation becomes important. If someone is repeatedly exposed to a trigger every day, simply increasing the corticosteroid dose may not completely solve the problem.
Inadequate corticosteroid dosing
Finally, the patient may simply not be receiving enough anti-inflammatory therapy to control their asthma. Inhaled corticosteroids are a key component of asthma management because airway inflammation is a major part of the disease process. If the corticosteroid dose is inadequate for the severity of the patient’s asthma, the patient may continue to experience symptoms and exacerbations despite apparently good adherence and technique. Before increasing the dose, however, make sure the other factors have been addressed. There is little value in increasing the corticosteroid dose when the patient is using the inhaler incorrectly, cannot afford the medication, or is constantly exposed to environmental triggers.
The next time you see a patient who keeps having asthma exacerbations, don’t immediately assume they need another medication.
Ask five questions:
Are they using the inhaler correctly?
Are they actually taking it as prescribed?
Can they afford it?
What are they being exposed to at home?
Is the corticosteroid dose adequate?
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