Patient counseling is part of the revolution of the pharmacist. As pharmacists'responsibility has evolved from dispenser to a disseminator of information, patient counseling has become a cornerstone for pharmaceutical care. Research has proven that medication adherence ranges from 20% to 70% for chronic conditions, such as asthma.¹ Pharmacist-provided education can improve adherence rates and patient understanding.^2-4 The National Asthma Education and Prevention Program recognizes the need for pharmaceutical care and recommends that asthma education be integrated throughout asthma care.⁵ Even though patient education is perceived as important by pharmacists⁶ and other health care professionals,⁵ in a 1990s study researchers reported that between 40% and 67% of patients do not talk with their pharmacist about their medications.⁷ Even though pharmacists are specifically trained to provide medication education, patients may lack an understanding about the expanded counseling function that pharmacists possess.⁷ Because patients lack awareness of this skill, it is up to pharmacists to open the door of communication when providing counseling about asthmatic treatments.

Important Points to Cover

Most patients do not have a completely correct inhaler technique, which may lead to less than optimal delivery and suboptimal efficacy of the medication. The majority of retail pharmacists who provide patient counseling are very busy and are being pulled in several different directions; quick and concise counseling techniques are necessary.

DIPS [Dosage, Instructions, Priming, Special Instructions] is an easy-to-remember acronym that covers most of the important parts regarding correct use of inhalers.

DIPS

D. Is the patient going to be using 1 or 2 inhalations? Will the dosage be scheduled or as needed? This is also an easy transition to discuss the indication of the medication—rescue, longterm control, or combination product. If a bronchodilator and maintenance medications are prescribed, the patient needs to use the bronchodilator first, wait 5 minutes, and then use the maintenance inhaler.

I. The instructions can vary according to which delivery system is being used. Metered dose inhalers (MDIs) require coordination, which can be difficult for small children and the elderly. The patient needs to breathe out and press down on the canister while breathing in. Patients should hold this breath for up to 10 seconds, or as long as they are comfortable. The patient needs to shake the inhaler and wait approximately 1 minute between inhalations, if multiple inhalations are prescribed.⁸ Most companies can provide placebo versions of their inhalers upon request. The use of a placebo inhaler can be very helpful when demonstrating correct inhaler technique. The patient should subsequently be able to demonstrate the technique, as most people do not have questions or do not discover problems until the first use of a product.

Dry powder inhalers may be more patient-friendly and do not require the patient to coordinate breathing and product delivery. The patient does need to keep the inhaler parallel to the ground after the dose has been released to keep the powder in the delivery channel before inhalation. Be sure to warn the patient that humidity, including patient breath, can cause the powder to clump together. Patient exhalation into the device prior to inhalation can also cause that dose to exit the device.

P. MDIs require priming (ie, 2 to 4 sprays in the air) before use if the product is new or unused for a certain amount of time (Table). If the patient does not prime the device, less than the desired dose of active ingredient may be received. Educate patients that this is an important part of inhaler use, especially if they use their rescue albuterol inhaler infrequently. Dry inhalers require no such priming.

S. Inhalers are like no other delivery device and have special instructions for each type of device. Some relatively new inhaler devices require special instructions (eg, some are breath-actuated, and some require capsules to be inserted into the device). For inhalers that require capsules, patients need to be aware that the capsule is not to be ingested and needs to be replaced with each use. For MDIs, the correct amount of medication in each canister is measured in a certain amount of actuations. After that specific number of actuations, even though the canister does not feel completely empty, the canister should be discarded. Placing an inhaler in water to see if it floats does not indicate if the canister is empty—this is no longer considered appropriate or accurate. Patients need to rinse and spit following the inhalation of corticosteroids, because MDIs may also lead to oropharyngeal deposition, which can cause hoarseness and thrush. Cleaning of inhalers is not necessary; wiping with a moist, clean rag is sufficient.

Areas of Patient Confusion

"My asthma medication isn't working" is a common statement pharmacists should expect to hear. This statement should lead pharmacists to check patient inhaler technique and use open-ended questions to discover the problem.⁹

Language Barrier

Patients and health care providers have different definitions for commonly used medical terminology.¹⁰ A patient may define controller or longterm controller as a medication that controls symptoms, and he or she will use this medication when symptoms occur that need to be controlled. Rescue medication can have different meanings to the patient and provider. The phrase "rescue medications open the airways" is often used to describe the mechanism of action of the rescue medication. The patient may misunderstand that the force of the product exiting the inhaler inflates the lungs.

Expectations

Patients'expectations also affect how they view the efficacy of their medication. Patients may expect to feel or taste the medication when they inhale, and if correct technique is used this should not occur. Patients may anticipate feeling systemic side effects, such as heart palpitations or excitation.

To correct or prevent incorrect inhaler technique, ask patients to describe under what circumstances they use each medication, provide verbal and written education, and demonstrate proper techniques.

Dr. Knudsen is a clinical pharmacist at Arizona Medical Clinic in Peoria, Ariz.

References

1. Boulet LP. Perception of the role and potential side effects of inhaled corticosteroids among asthmatic patients. Chest. 1998;113:587-592.

2. De Tullio PL, Corson M. Effect of pharmacist counseling on ambulatory patients' use of aerosolized bronchodilators. Am J Hosp Pharm. 1987;44:1802-1805.

3. Self TH, Brooks JB, Lieberman P, Ryan MR. The value of demonstration and role of the pharmacist in teaching the correct use of pressurized bronchodilators. Can Med Assoc J. 1983;128:129-131.

4. Stiegler KA, Yunker NS, Crouch MA. Effect of pharmacist counseling in patients hospitalized with acute exacerbation of asthma. Am J Health Syst Pharm. 2003;60:473-476.

5. National Asthma Education and Prevention Program. Expert panel report: guidelines for the diagnosis and management of asthma: update on selected topics—2002. J Allergy Clin Immunol. 2002;110(suppl 5):141-219. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthmafullrpt.pdf.

6. Schommer JC, Wiederholt JB. Pharmacists' perceptions of patients' needs for counseling. Am J Health Syst Pharm. 1994;51:478-485.

7. Schommer JC. Patients' expectations and knowledge of patient counseling services that are available from pharmacists. Am J Pharm Educ. Winter 1997:61;403-406.

8. Proventil HFA [package insert]. Kenilworth, NJ: Key Pharmaceuticals Inc; 1996, 1999. Available at: www.spfiles.com/piproventilhfa.pdf. Accessed February 5, 2007.

9. Lewis RK, Lasack NL, Lambert BL, Connor SE. Patient counseling—a focus on maintenance therapy. Am J Health Syst Pharm. 1997;54:2084-2098.

10. Rubin BK. What does it mean when a patient says, "My asthma medication is not working?" Chest. 2004;126:972-981.