Abstract
For a physician, the final step of a consultation consists of developing a treatment plan and prescription. For the patient, this is the start of a process. First, their role in the treatment plan must be clarified, then they may have to obtain an alternative prescription from their general practitioner. Next, they must have the prescription filled and dispensed from the pharmacy and, finally, they must take the treatment on time and for the required duration. For people with chronic conditions, this requires repeatedly returning to the pharmacy for the prescription to be renewed and dispensed. Given that many patients are on multiple treatment regimens and may have poor health literacy, this becomes a complex process and it is not surprising that this can, and frequently does, go wrong. Research shows that when a patient does not adhere to standard asthma or COPD treatment, they report poor control and overuse of rescue β-agonists, experience frequent exacerbations and are often prescribed add-on treatments such as biological agents. In short, poor treatment adherence can manifest in the same way as a refractory condition. These clinical features should prompt a clinician to investigate poor adherence as they might investigate a new blood or radiological finding. Examining a patient's prescription refill records or a digitally enabled inhaler can demonstrate a number of patterns of inhaler use. A small minority regularly use their treatment as prescribed but many appear to be "cluster users": a group of patients who use their treatment correctly when they are unwell, but once some level of personal control is attained, they cease or reduce their use. Others may cease using their treatment because they are not perceiving a benefit or because an alternative condition accounts for their symptoms. In other words, clinicians can consider that treatment adherence is like a clinical sign: something to be investigated so that they may understand the patient's condition better. EDUCATIONAL AIMS: To highlight the clinical consequences of poor adherence to standard treatments for airways diseases.To describe how poor treatment adherence manifests as complications of the condition.To highlight that when a patient does not benefit as might be expected from a treatment, poor adherence should be considered and evaluated for, before more treatment is added.