Asthma and COPD patient adherence: the right inhaler
Large numbers of hospital admissions, along with poor adherence and the prescribing of inappropriate inhalers mean that asthma and chronic obstructive pulmonary disease (COPD) are a huge burden on the NHS. However, by considering patients' individual circumstances and taking the time to ensure that they use the appropriate inhaler and technique, everyone can benefit.
Asthma and COPD have a huge impact upon the individual and upon the NHS in general. There are over 5.2 million people with asthma in the UK. In COPD, 900,000 people have been diagnosed, while another 2.1 million have the disease, but remain undiagnosed. These are termed the 'missing millions'.
Recent studies, conducted throughout Europe and with a large UK database of 8,000 patients, show about 50 per cent of people with asthma are poorly controlled with their asthma. In terms of COPD, it is more difficult to describe what poor control looks like, because most people with the condition have symptoms every day. However, COPD kills. It kills 28,000 to 30,000 people each year in the UK. This, and the fact that approximately 130,000 hospital admissions each year are for COPD – the second highest cause of hospital admissions – indicates that control is not good.
Poor treatment of asthma and COPD puts a huge burden on the NHS. For example, £1 billion is spent on asthma treatment in the UK each year and represents 60,000 to 65,000 hospital admissions.
In terms of treatment for asthma and COPD, there are guidelines on the right sort of treatment to give. But, increasingly, these emphasise the need for a personalised approach to treatment, especially in relation to finding an inhaled therapy that the patient can actually take. In other words there is a correct inhaler technique: the right inhaler for the right person.
There are various problems in administering asthma and COPD treatment to patients. In asthma, for example, people don't necessarily perceive that they have to take their treatment every day. Some have the attitude: 'When I feel well, I don't need to take my treatment'. The second problem is that the inhaler they've been prescribed may not suit them; they haven't been shown how to use it properly and the health care professional (HCP) hasn't necessarily thought, 'Is this the right inhaler for this particular person?'
That question also applies in COPD, but there are additional problems like dexterity: can the person actually use that inhaler? They may struggle because they have arthritis, for example. Many frail, elderly people have problems with cognitive functions too. They may not be able to perceive the right technique to use or cannot understand how to use that inhaler: have they got the right instructions?
It is vital to get the correct inhaler technique. If the medication doesn't reach the right places, of course it's not going to work. But we can't generalise; what is a good inhaler for one person may not be right for another. So it is important to have a range of different inhaler devices and to find the one that suits that individual person.
When prescribing an inhaled therapy it is essential to take into account the suitability of the delivery device. And indeed both the National Institute for health and Care Excellence (NICE) guidelines for COPD and the British Thoracic Society SIGN guidelines for asthma emphasise this.
Often when HCPs prescribe inhalers they don't take the time to show the patient how to use it properly. Users may need to be shown several times, sometimes over several visits, before they get it right. And sometimes they don't get it right at all. So it needs to be easy to explain and to use.
Patients may never have been shown what the correct inhaler technique is, so they don't know whether they are doing it right. Also, some expect to feel an effect when they shouldn't with the right technique. With a metered dose inhaler, if you inhale too quickly, it hits the back of the throat, you feel it and you get the 'cold freon effect' and think the treatment is working. But actually, with the proper method, taking a slow breath inwards over 5 to 10 seconds, users may not feel it reaching the lungs and think that it hasn't worked.
With a bewildering number of new drugs available for asthma and COPD, HCPs are increasingly making their decisions based on the cost and the inhaler device. They need to consider which inhaler device is easy to teach and which is easy to use for the patient.
Tackling these problems can help patients and the NHS. Better instruction on inhaler technique, and regular reminders, will have an impact on COPD and asthma admission figures, which are so costly for individual patients and the health system.
About the author:
Dr Kevin Gruffydd-Jones, is a GP principal and Royal College of General Practitioners respiratory clinical lead. He speaks regularly on asthma and COPD issues.
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