Friday, February 19, 2010

The Doctor Will See You... Sooner Than You Thought? Why Asthma Patients Need Frequent Follow-Up.

At the end of every patient visit, I let my patients know when I would like to see them again. For some patients, the visits are infrequent- once a year for a well-controlled patient with nasal allergies. However, for asthmatics, I recommend more frequent visits.

Lately, I've begun noticing that my chronic asthma patients occasionally look at me sideways when I tell them that I expect to follow-up with them every 3-4 months to document asthma control and adjust medications. There have been a few disgruntled phone calls after a patient learns that only 3 months worth of refills have been submitted to the pharmacy, instead of the standard 6-12 month supply. It has occurred to me that my patients are not alone in their confusion as to why their physician can not bear to be apart from them for more than 12 weeks at a time, so let me explain myself:

1. I am not secretly in love with you.
2. I am not trying to get paid for shooting the breeze with you quarterly.
3. I am not in cahoots with big pharma, or trying out new drugs on you. (If there's a new drug, I'll try it out on myself first, thank you very much.)

The real reason, albeit dull, is an important one. CONTROL.

No, not my inane need to control every aspect of your life (although my hubby and kids might tell you otherwise).

I'm on an endless search for asthma control. It is unacceptable to me to have my patients walking around puffing on their rescue inhalers (>2x/week) when what they really need is a more optimal dose of controller medicine. It is equally unacceptable to have my patients walking around symptom-free on higher-dose controller medicine, when a lower amount of medication might adequately control their disease.

So, how do I decide how often is often enough, when it comes to asthma follow-up?

Inhaled corticosteroids, when taken regularly as prescribed, generally take around 2 weeks to begin exerting their beneficial effects, but take around 6 weeks to reach maximal efficacy. So, after changing a patient's asthma controller medicine dose or regimen, I will wait at least 6 weeks before deciding if the new dose is working adequately. If it is working well, I will continue the dose for at least 3 months before attempting to decrease the dose, per asthma guidelines published in 2007 by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. But, I always attempt to decrease, as long as the patient has done well for the past 3 months. Asthma severity is fluid, and changes over time. Just because a patient required a certain dose in January 2005, doesn't mean that they should be on the same dose in August of 2010. It is my responsibility as an asthma specialist to keep pushing the dose of medication as low as tolerated.

To find a dose that works and just keep it there for years on end without trying to limit cumulative medication dosage is just laziness, in my opinion.

In light of the recent FDA recommendations regarding long-acting beta agonist medications in asthma, it seems even more important to keep pushing these doses down. Read more: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm200923.htm

So when your doctor asks to see you sooner that you anticipated, don't worry that you're the object of an inappropriate crush- she may actually have your best health in mind.

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