Original article
Asthma, lower airway diseases
Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients

https://doi.org/10.1016/j.anai.2009.11.024Get rights and content

Background

Complementary and alternative medicines (CAM), such as herbal remedies, are widely used by patients with chronic diseases, such as asthma. However, it is unclear whether use of the herbal remedies is associated with decreased adherence to inhaled corticosteroids (ICSs), a key component of asthma management.

Objective

To examine the association among use of herbal remedies, adherence to prescribed ICSs, and medication and disease beliefs.

Methods

We surveyed 326 adults with persistent asthma who received care at 2 inner-city outpatient clinics. Patients were asked about CAM use (teas, herbs, and rubs) for the treatment of asthma in the prior 6 months. Medication adherence was assessed using the Medication Adherence Report Scale, a validated self-report measure. Univariate and multiple regression analyses were used to assess the relationship among herbal remedy use, adherence to ICSs, and medication and disease beliefs.

Results

Overall, 25.4% (95% confidence interval, 20%–30%) of patients reported herbal remedy use. Univariate analyses showed that herbal remedy use was associated with decreased ICS adherence and increased asthma morbidity. In multivariable analysis, herbal remedy use was associated with lower ICS adherence (odds ratio, 0.4; 95% confidence interval, 0.2–0.8) after adjusting for confounders. Herbal remedy users were also more likely to worry about the adverse effects of ICSs (P = .01).

Conclusions

The use of herbal remedies was associated with lower adherence to ICSs and worse outcomes among inner-city asthmatic patients. Medication beliefs, such as worry about ICS adverse effects, may in part mediate this relationship. Physicians should routinely ask patients with asthma about CAM use, especially those whose asthma is poorly controlled.

Introduction

Asthma is a common chronic illness, affecting 6% to 7% of the US population.1 Minority inner-city populations have disproportionately higher rates of asthma and increased asthma-related morbidity.1, 2, 3, 4 Appropriate self-management (ie, adherence to controller medications, peak flow monitoring, asthma action plans, and environmental control practices) is critical for achieving adequate asthma control. There have been sustained national efforts to improve asthma management, emphasizing regular use of long-term controller medications, such as inhaled corticosteroids (ICSs).5, 6 Despite these efforts, asthma self-management remains suboptimal.7, 8, 9, 10 Studies11, 12, 13, 14 have shown poor medication adherence among patients with persistent asthma as the result of a number of different reasons, such as medication beliefs (including patient concerns about adverse effects), and poor access to medical resources. It is important to understand the factors associated with appropriate self-management among high-risk asthmatic patients to improve disease outcomes.

Many patients with chronic illnesses, such as asthma, use complementary and alternative medicine (CAM) to treat their conditions, and use of CAM is becoming more widespread in the United States.15 A review of CAM use among adults with asthma reported that 20% to 80% use CAM.16 Although use of CAM may be acceptable for some patients, a potential concern is that CAM may be used in place of prescribed ICSs. There are limited data regarding use of CAM and patient adherence to prescribed medications, with inconsistent results.17, 18, 19 An important unanswered question is whether use of CAM, a common practice among asthmatic patients, is associated with decreased adherence to ICSs, a critical component of asthma self-management. The purpose of this study was to examine the association among CAM use, adherence to prescribed ICSs, and medication and disease beliefs.

Section snippets

Patient Population

We analyzed data collected as part of a cohort study of adult asthmatic patients receiving care at 2 hospital-based clinics located in East Harlem, New York City, and New Brunswick, New Jersey.20, 21 Study participants were enrolled during a 33-month period, from June 2004 to March 2007.

The computerized registration systems were screened to identify potential participants with a physician diagnosis of asthma (International Classification of Diseases, Ninth Revision [ICD-9] code 493.XX).

Results

Between June 2004 and March 2007, 1,435 patients diagnosed as having asthma were identified. Of these patients, 1,054 were excluded for the following reasons: no history of asthma (316 patients [30.0%]), mild intermittent asthma severity (232 patients [22.0%]), history of smoking for 10 pack-years or longer (180 patients [17.1%]), other chronic lung diseases (179 patients [17.0%]), cognitive impairment (42 patients [4.0%]), and other reasons (105 patients [10.0%]). (These percentages may not

Discussion

Asthma is a common chronic illness that causes considerable morbidity among minority inner-city populations.1, 2, 3, 4 Suboptimal medication adherence is 1 of the main factors contributing to poor outcomes.30, 31 This study examined the association between herbal remedy use for asthma and ICS adherence among inner-city adults. We found that 1 in 4 inner-city asthmatic patients used herbal remedies and that these users had lower rates of adherence to ICS and worse asthma-related morbidity and

Acknowledgments

We thank Nicky O'Connor, BSN, MPH, Amy Badler, BA, Jessica Lorenzo, BS, MPH, Julian Baez, BS, and Jessica Segni, BS, for their invaluable help to this study: Nicky O'Connor, BSN, MPH, Amy Badler, BA, and Jessica Lorenzo, BS, MPH, for being project managers; and Julian Baez, BS, and Jessica Segni, BS, for being research assistants and helping recruit and interview patients. All 5 individuals were affiliated with Mount Sinai School of Medicine during the study period.

References (33)

Cited by (43)

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    Other studies found no association between CAM use and controller medication adherence,40,42 or even positive associations within some subgroups, such as NLWs.40 CAM use does appear to be more common among those with severe disease or poorly controlled asthma (eg, see Shen and Oraka,37 George et al,39 and Roy et al42), and among patients who experience cost barriers to obtaining medications.37,40 These findings suggest CAM is not necessarily a replacement for conventional medications solely due to preference, but that it may be used to supplement traditional care for those with severe disease, or as an alternative when medications are not easily obtained, highlighting the importance of asking patients and families about CAM use and its role in asthma management.

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    For example, negative ICS beliefs (e.g., skepticism about the need for ICS, concerns about side effects or addiction risk) have been found to partially mediate the association between minority status and ICS use.15 In addition, lower rates of ICS adherence have also been identified in patients endorsing integrative medicine (IM) for asthma.16–18 IM includes “the array of health care approaches with a history of use or origins outside of mainstream medicine”19 commonly referred to as alternative (in place of) or complementary (in addition to) medicine.

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Disclosures: Dr Li is 45% owner of Herbal Springs, LLC; Dr Leventhal has received reimbursement for travel expenses (related to presenting his research at national and international meetings) from the American Diabetes Association and the National Heart, Lung, and Blood Institute; and Dr Wisnivesky is a member of the research advisory board of EHE International and the recipient of a research grant from GlaxoSmithKline.

Funding Sources: This study was supported by a grant from the Food Allergy Initiative (Dr Li), a grant from the National Center for Complementary and Alternative Medicine (Dr Li), the National Institutes of Health (Dr Leventhal), grant K08 HS013312 from the Agency for Healthcare Research and Quality (Dr Wisnivesky), grant RO1 HS09973 from the National Institute on Aging, grant P01 AT002625-01 from the National Center for Complementary and Alternative Medicine, and Research Training Grant in Environmental Pediatrics 5T32 HD049311 from the National Institutes of Health.

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