The Drug Needed for Noncompliant Asthma Patients

A Tragic Misunderstanding

Years ago, a patient told me about the death of her brother from asthma in the 1970s. He had a history of multiple hospital admissions and emergency department visits for his asthma.

One day, his doctor prescribed a new type of inhaler. The patient, who worked overnight alone as a security guard, was found dead one morning with the new inhaler by his side.

From her story, I surmised what had likely happened. This occurred around the time that inhaled corticosteroids (ICSs) first became available in the United States, and probably his new inhaler was an ICS. (Beclomethasone was, in fact, the first ICS available in the United States). He was either not told, or did not understand, the difference between the two types of inhalers (steroid/controller vs bronchodilator/rescue). This saga of the consequences of inadequate patient understanding still haunts me.

Before the advent of combination long-acting bronchodilator/ICS, another drug of its kind was studied. It was a combination inhaler, a short-acting beta agonist (SABA) with an ICS (budesonide) that was compared with budesonide and a SABA separately.^[1]

It seemed like a brilliant idea—a way for asthmatics to self-regulate. The more they needed their bronchodilator, the more ICS they also took. Yet the authors found that in a study of 102 asthmatics that there was little difference between outcomes, compliance, and pulmonary function tests.

A Missed Opportunity?

The conclusion was simply that "other ways of improving patient self-management need further investigation." This is an example of how a study misses the point. Public health is about populations, but medicine is about treating the patient in front of you and an understanding that every patient is different. Some patients, no matter how hard one tries, do not understand or just do not follow instructions.

Of course, now we have long-acting beta agonist (LABA)/ICS combinations, which enhances compliance and reduces severe exacerbations.^[2] The ICS/LABA has led to greater ICS use but overall lower use of systemic corticosteroids^[3] and a reduction in severe exacerbations. More than a decade after the initial SABA/ICS study, a study published in The New England Journal of Medicine evaluated mild persistent asthmatics treated with rescue use of a combination of a beclomethasone inhaler with rescue albuterol vs beclomethasone and albuterol in a single inhaler PRN (as needed) vs beclomethasone/albuterol vs albuterol rescue alone.^[4]

The key results of the study were that patients on the PRN ICS/SABA combination did just as well as those taking ICS regularly. Furthermore, the as-needed ICS/SABA group had a lower cumulative dose of ICS and, interestingly, fewer asthma exacerbations than those taking ICS/SABA regularly (another reminder that regular beta agonist use is not safe). The as-needed ICS/SABA group also did not even receive an asthma action plan because this inhaler is in a way its own asthma action device.

The combination of an ICS and short-acting reliever in a single inhaler is not going to be useful for all asthmatics, but it should be available as a tool for select patients. We know that ICSs reduce asthma mortality^[5] and that many patients do not comply with asthma maintenance therapy despite our best efforts.

A combination ICS/SABA should be available to emergency departments and asthma specialty clinics for patients who do not follow medical advice. Had such a device been around decades ago, countless lives probably would have been saved, including my patient's brother. I dedicate this article to his memory.