Key Point

Physicians underestimate the prevalence of oropharyngeal symptoms among asthma patients who use inhaled corticosteroids and often do not manage the symptoms adequately. Asthma patients frequently do not tell their physician when they experience oropharyngeal symptoms and may alter therapy on their own to avoid these symptoms.

SAN DIEGO—Physician awareness and management of oropharyngeal symptoms caused by inhaled corticosteroid therapy for asthma could be better, suggested a telephone survey presented in two posters at the annual meeting of the American Thoracic Society.¹,² The 250 Canadian primary care physicians responding to the survey estimated that 15% of their asthma patients have had inhaled steroid–related oropharyngeal symptoms and that 14% have told their physician.

However, a corresponding survey of 1,003 Canadian asthma patients showed an oropharyngeal symptom rate of 24%. These patients experienced sore throat, hoarseness, and/or mouth sores during treatment with inhaled corticosteroids alone or together with an inhaled long-acting ß-agonist.

"Physicians appear to believe that almost all patients who suffer [oropharyngeal symptoms] report them to their physician," remarked the survey authors. "They remain unaware of the significant number of patients with [oropharyngeal symptoms] who choose not to mention them."

SAMPLES REFLECTED POPULATION

The patients and physicians surveyed were chosen at random to reflect the geographic distribution of the two groups in the Canadian population. Physicians were eligible for the survey if they treated asthma patients who were 18 or older and if they wrote at least 25 prescriptions for inhaled corticosteroids per week and at least three prescriptions for inhaled steroid/inhaled long-acting ß-agonist therapy per week.

The patients in the survey were identified through a nationwide consumer database of about 2.5 million Canadian households. Patients were eligible if they were 18 or older, had physician-confirmed asthma, and were currently using an inhaled corticosteroid or had stopped taking one in the previous 12 months (former users).

Of the physicians, 89% had received complaints about oropharyngeal symptoms from patients using inhaled corticosteroids. They said that there was no difference in the prevalence of such symptoms between patients taking inhaled steroids alone and those taking inhaled steroids in combination with an inhaled long-acting ß-agonists.

Overall, adherence to therapy worsened in 22% of the patients who reported oropharyngeal symptoms, the physicians estimated. The most common approach to symptom management was to advise patients to rinse their mouth after using their inhaler or to use a mouthwash or gargle.

Infrequently, the patients were switched to another therapy or advised to continue treatment as prescribed (ie, wait and see), to stop therapy for a while and then restart it, to reduce the daily dosing frequency but to maintain the number of puffs per dose, or to reduce the number of puffs per dose without decreasing frequency. The authors described the management of the patients’ oropharyngeal symptoms as "suboptimal."

EDUCATION INFLUENCED ASTHMA CONTROL

Among the patients surveyed, 943 were currently using inhaled corticosteroids and 60 were former users. The patients had suffered from asthma for a mean of 17.5 years. Asthma was uncontrolled in 58%.

"Patients whose highest level of education was primary or high school were significantly more likely to [have uncontrolled asthma] than those with higher education," noted the authors. "Oropharyngeal side effects were significantly more common in uncontrolled (28%) than controlled (18%) asthma patients."

Of the patients who experienced oropharyngeal side effects, 67% reported them to their physician. Eighty percent of that group said they were instructed to rinse after inhaler use or to use a mouthwash or gargle, and 23% said they were told to wait and see. "Among the patients who did not speak to their physicians about their oral symptoms, 25% stopped or reduced their dose of medication," the study authors pointed out.

Surprisingly, in patients who received combination asthma therapy, asthma was no better controlled than in patients who were taking an inhaled corticosteroid as monotherapy. The authors were unable to provide a firm explanation for that finding, however.

—Timothy Begany

Reference
1. Boulet L-P, FitzGerald JM, Chan CK. Physicians’ perception and management of oropharyngeal symptoms in asthmatic patients using inhaled corticosteroids. Presented at: annual meeting of the American Thoracic Society; May 19-24, 2006; San Diego, Calif.
2. FitzGerald JM, Chan CK, Boulet L-P. Medication use, asthma control and oropharyngeal side effects in a population of Canadian asthma patients. Presented at: annual meeting of the American Thoracic Society; May 19-24, 2006; San Diego, Calif.

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