JACI In Practice: Is Albuterol Overuse a Marker of Psychological Distress?

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NIH, ALA funded study reminds clinicians to consider depression when patients are quick to refill rescue inhalers

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There are many factors which can influence rescue-inhaler overuse but an asthma study funded by the National Institutes of Health (NIH) and the American Lung Association (ALA) has just highlighted a commonly overlooked one: depression.

“How patients take their prescribed asthma medications is an important predictor of asthma control and exacerbation risk,” first author Joe K. Gerald, MD, PhD, from the University of Arizona, explained. Overusers in this study consumed more than twice the amount of albuterol as expected, approximately four canisters per year. Prior studies have previously associated this amount of albuterol use with higher exacerbation risk among adults and children. In general, patients who exceed two or more refills in a year for adults (and three or more refills in a year for children) have a twofold risk of an asthma-related hospitalization.

416 adults with mild asthma participated in this study and completed multiple questionnaires and submitted baseline visit information. They also recorded their albuterol use, montelukast or placebo use and asthma symptoms on daily diary cards. Participants were then categorized as expected users, overusers or underusers of albuterol.

Of the 416 participants, about half (212 or 51%) used their albuterol correctly, meaning on most symptom days and rarely on symptom-free days. Of those remaining, 114 (27%) were overusers and 90 (22%) were underusers. Of the 114 overusers, 51 (45%) used albuterol every day as if it were a controller medication.

Gerald and his colleagues found that in a given month, overusers had approximately 53 more albuterol actuations than expected users. More frequent symptom days (about 3.5 more symptom days a month) accounted for 15% of overuse and greater use on those symptom days accounted for 31% of overuse. Unexpectedly, most overuse (54%) was explained by use on days without asthma symptoms.

When surveyed, overusers reported lower asthma-related quality of life, worse physical functioning and worse mental functioning than expected users. Researchers also found that overusers were at a greater risk of clinical depression than expected users (32% vs 17%).

“Emotional affect, particularly depression, can influence disease perception and medication behaviors among those with chronic illness. Among patients with asthma, depression has been associated with greater symptom reporting, lower quality of life, and lower adherence to controller medication,” Gerald said.

This research is a reminder for clinicians to gain a better understanding of the multiple factors of overuse, including the psychological factors, so physicians can intervene appropriately. In fact, Gerald’s team found that expected users had somewhat higher scores in asthma-related knowledge, attitudes and efficacy – suggesting that asthma-specific knowledge is an important mediator and educational interventions could be helpful.

“We know that appropriate use has been previously identified with accurate knowledge of asthma medications, higher self-reported health status, prior consultation with a specialist and thoughtful budgeting of medications,” Gerald said.

More information on asthma is available at the AAAAI website. This study was published in The Journal of Allergy and Clinical Immunology: In Practice on September 1, 2015.

The AAAAI represents allergists, asthma specialists, clinical immunologists, allied health professionals and others with a special interest in the research and treatment of allergic and immunologic diseases. Established in 1943, the AAAAI has more than 6,800 members in the United States, Canada and 72 other countries. The AAAAI’s Find an Allergist/Immunologist service is a trusted resource to help you find a specialist close to home.


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Megan Brown, Senior Media & Member Communications Manager
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