a SLACK Incorporated newspaper
March 1998
SAN DIEGO - Practitioners may not appreciate the negative consequences of encouraging their asthma patients to make sacrifices that affect their personal enjoyment of life.
"Life events and psychosocial disruptions may adversely affect patients' subjective impression of the control of their asthma and influence their attitudes and approach to therapy," said Andrew P. Greening, MD, of Western General Hospital in Edinburgh, United Kingdom. "Appropriate recognition of this by the clinician and the use of effective inhaled steroids and long-acting b-agonists will lead to better asthma control and quality of life."
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An example of good asthma management may be for patients to get rid of their pets, said Greening, who spoke here at the Allergy, Asthma and Immunology Annual Meeting. "But the child might be kind of devastated. Physicians may not be aware of the psychological impact of some of their advice."
In a survey of 200 consecutive attendees at Greening's asthma clinic, he found that only 8% had given away their pet because of recognized aggravation to their asthma. But more startling was the fact that 20% "kept their pets, believing that while allergic to other people's pets, they were not to their own," he related. "So there are false patient perceptions. For example, most people believe that with hairy pets - cats and dogs - the allergen responsible is on the hair, when in fact it is on the saliva."
Greening also observed that a much higher proportion of patients who kept cats and dogs were using high doses (>1,000 mg/day) of inhaled corticosteroids vs. those without pets.
In essence, practitioners need to ponder whether patients would be "better off without their pet and with fewer asthma symptoms and less drug therapy, or with their pet and more drug therapy," he said.
Greening strongly recommends fluticasone propionate (Flonase, Glaxo Wellcome.) for reducing asthma exacerbation rates and reducing the need for systemic steroid therapy. "It is an extremely effective inhaled steroid," he said. "Once you have gained control, you may be able to reduce the dose." In addition, "the introduction of fluticasone means that many patients who previously were required to use regular prednisone or frequent courses of prednisone, may be much better controlled by using fluticasone alone."
Greening is acutely aware of the link between drug therapy and psychosocial factors. "When time is spent talking to patients rather than simply modifying their drug therapy, it is abundantly clear that they have substantial personal, family or social problems," he said, noting that in children this might entail being bullied at school or enduring an unhappy home life.
"Persistent asthma symptoms and reduced activity lead to increased anxiety and depression levels. It is easy to see how vicious circles may be established, with poorly controlled asthma leading to anxiety and depression, which in turn leads to a worsening perception of asthma," he said. "Therefore, it behooves the clinician to establish simple but effective therapy for asthma control, as well as being alert to life events that may influence patients' asthma."
Greening emphasized that a doctor should always be alert when a patient's previously well-controlled asthma becomes increasingly difficult to manage. Instead of just giving more treatment, asking the right questions may result in social-worker intervention or counseling that may help the patient. "For instance, addressing the issue of bullying at school may be a better way of sorting out the asthma than just saying `Take more tablets and take more inhalers,'" said Greening. "If you don't ask the right questions, people won't tell you."
Greening said it is even possible to downgrade a patient's asthmatic classification if certain psychosocial factors are addressed and rectified. "The patient may say he has to use his rescue puffer eight or 10 times a day. He feels symptoms that he otherwise wouldn't actually experience if all these unpleasant life events weren't going on. Because subjective symptoms can have an influence on the grading of severity of asthma, this might change people's management plans."
Exercise, dust, temperature changes, chemicals, drugs, laughter and emotions are all non-specific factors that can contribute to asthma symptoms.
"With appropriate time spent with the patient, along with sensible application of modern drugs, virtually all patients with troublesome asthma ought to be able to be well controlled and maintain a very good quality of life," said Greening.
For more information:
- Greening AP. Impacts on quality of life: recent advances in asthma management. Presented at the Allergy, Asthma and Immunology Annual Meeting. Nov. 7-12, 1997. San Diego.
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