Medical adherence to intranasal corticosteroids in adult patients

General practitioner and patient perspectives on intranasal corticosteroids for allergic rhinitis: Treatment duration and obstacles to adherence, findings from a recent survey

Background and objective

Currently, there are no guideline recommendations for the duration of intranasal corticosteroid (INCS) treatment for allergic rhinitis (AR). We aimed to catalogue real-world AR-INCS prescription patterns.

Materials and methods

This multicenter, non-interventional, cross-sectional study used online general practitioner (GP) and patient surveys from 4 countries. Eligible GPs had 3-35 years of practical experience, regularly prescribed INCSs for AR treatment, and had managed ≥5 patients with AR per month according to Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines in the previous year. Eligible patients with AR were non-pregnant females or males, aged 18-65 years, previous AR-INCS users (≥12 months), and receiving GP-prescribed AR therapy. Survey participants were from countries with 15-50% AR prevalence and mostly prescription-only INCS use of ≥100 million units annually (Brazil, Mexico, Spain, Thailand). GP surveys and GP-completed patient record forms (PRFs) gathered AR-care and INCS-use data over 10 months; each GP completed patient record forms (PRFs) for 3 patients with AR under their care. The patient survey reflected actual AR-INCS experience, treatment duration, and adherence factors from patient perspectives. The target sample size was 75 GPs, 75 patients, and ≥30 respondents per country.

Results

From 900 GP-PRFs, the mean GP-recommended AR-INCS durations reported were 8.4 (Brazil), 8.3 (Mexico), 5.4 (Spain), and 6.4 (Thailand) weeks. From 300 patient surveys, mean reported INCS recommended durations were 6.4 (Brazil), 5.1 (Mexico), 4.0 (Spain), and 4.9 (Thailand) weeks; reported actual use durations were 6.2, 4.8, 3.6, and 6.4 weeks, respectively. The most frequent GP-PRF-reported factors influencing AR-INCS treatment duration were symptom severity (76-85%), symptom recurrence (49-73%), and existing comorbidities (33-57%). The most frequent GP-PRF-reported obstacles to adherence included forgetting to take medication regularly (54-100%), subsiding symptoms (42-91%), and being unable to continue activities (33-51%). Subsiding symptoms (36-53%) and reaching the prescription duration end (20-51%) were most frequent obstacles reported by the patient survey. Patients from all surveyed countries indicated that they visited the GP, a different physician, or a pharmacy for assistance with symptom recurrence; some patients also self-medicated.

Conclusions

Real-world AR-INCS prescription durations vary between countries and actual use tends to be shorter than prescribed. Understanding underlying factors may support appropriate AR-INCS use. The study was not powered to statistically compare intercountry differences; hence, comparisons have not been drawn, and the small sample may not reflect a complete picture of clinical practice and patients with AR in each country.

Predicting Adherence to Topical Medications in Chronic Rhinologic Disease: A Systematic Review

OBJECTIVE

To determine risk factors of medical adherence and describe strategies to increase adherence in patients with chronic rhinologic disease.

DATA SOURCES

PubMED, SCOPUS, CINAHL, and Cochrane.

REVIEW METHODS

Systematic review of 4 databases (PubMED, SCOPUS, CINAHL, Cochrane) from inception of databases to September 1, 2022 to identify studies that evaluated factors related to and affected by medical adherence in patients with chronic rhinologic disease.

RESULTS

Of 1491 studies screened, 25 studies met inclusion criteria. Of these, 7 studies described how sensory attributes of intranasal sprays affect adherence, including odor, taste, aftertaste, and side effects. Five studies described record keeping diaries/notification systems to improve adherence, with demonstration of web-based platforms to send reminders as well as keep record of medication usage to improve adherence. Eight studies described patient-specific risk factors to nonadherence, with demonstration of increased age and conscientious personalities correlating with medical adherence. Five studies looked at pediatric patients specifically, with adherence rates in children parallelling that of adults. Additionally, nonadherence in children may have greater implications for school performance.

CONCLUSION

Overall, adherence to topical medical therapy in patients with chronic rhinologic disease is affected by patient-related and medication-specific factors which should be considered when counseling patients. Web-based diary or notification systems may help increase adherence. Additionally, children are equally adherent to topical medical therapy as adults and nonadherence may have negative implications for school performance.

Adherence to Intranasal Steroids in Chronic Rhinosinusitis with Nasal Polyposis Prior to and during Biologic Therapy: A Neglected Matter

Adherence to treatment is essential in chronic rhinosinusitis with nasal polyposis (CRSwNP). Intranasal corticosteroids (INCS) are the first-line therapy, followed by systemic corticosteroids and surgery if needed. In cases of refractory disease, biologics are added to conventional treatment, making adherence to INCS crucial in assessing eligibility for these targeted therapies. The purpose of this review is to examine INCS adherence assessment and rate, before starting and during biologic therapy. We conducted a comprehensive literature review focusing on INCS adherence in CRSwNP treated with biologics, including randomized controlled trials and real-life studies. The search extended to studies on allergic and non-allergic rhinitis to provide broader insights into tools to assess the INCS adherence. The result was that adherence to INCS in CRSwNP is underexplored, with only a few studies addressing it directly. Various tools for adherence assessment have been identified, but none are universally accepted as standard. The review also highlights the complexity of factors influencing adherence rates. Effective CRSwNP management requires a paradigm shift to prioritize adherence in treatment guidelines and clinical practice. The review advocates for improved adherence assessment tools, a deeper understanding of influencing factors, and the integration of personalized medicine approaches, especially for biologic therapies.

Knowledge, attitudes, and practice towards allergic rhinitis in patients with allergic rhinitis: a cross-sectional study

BACKGROUND

The knowledge, attitude, and practice (KAP) of Chinese patients with allergic rhinitis (AR) on AR is poorly known. This study investigated the KAP towards AR in patients with this disease and explored the factors associated with KAP.

METHODS

This cross-sectional study enrolled patients with AR in Zhangjiagang Hospital of Traditional Chinese Medicine between October 2022 and March 2023.

RESULTS

This study included 656 valid questionnaires. Most participants were 26-35 years old (36.13%) and were female (55.18%). The knowledge, attitude, and practice scores were 5.70 ± 2.88 (possible range: 0-12), 29.51 ± 3.52 (possible range: 9-45), and 34.13 ± 7.55 (possible range: 9-45), indicating poor knowledge, unfavorable attitudes, and proactive practice. AR history of 3-5 years (adjusted odds ratio (adjOR) = 1.62, 95% confidence interval (CI): 1.03-2.54, P = 0.037), AR history of > 6 years (adjOR = 1.64, 95%CI: 1.06-2.54, P = 0.027), and know their own allergens (adjOR = 2.34, 95%CI: 1.28-4.25, P = 0.005) were independently associated with the sufficient knowledge. AR history of ≥ 6 years (adjOR = 0.60, 95%CI: 0.37-0.96, P = 0.035), and liking sports (adjOR = 1.58, 95%CI = 1.07-2.33, P = 0.020) were independently associated with the positive attitude. The knowledge scores (adjOR = 1.14, 95%CI: 1.05-1.22, P = 0.001), attitude scores (adjOR = 1.24, 95%CI: 1.17-1.32, P < 0.001), age 36-45 (adjOR = 2.13, 95%CI: 1.19-3.82, P = 0.011), employed (adjOR = 0.59, 95%CI: 0.37-0.94, P = 0.026), and liking sports (adjOR = 2.11, 95%CI: 1.43-3.14, P < 0.001) were independently associated with the proactive practice.

CONCLUSIONS

Patients with AR have poor knowledge and unfavorable attitudes but good practice toward AR. Continuous quality teaching interventions and education on patients for AR were recommended.

Knowledge of, Attitudes towards, and Practices of Intranasal Corticosteroids Usage among the Allergic Rhinitis Patients of Northern Saudi Arabia: A Cross-Sectional Study

Intranasal corticosteroids (INCS) are generally safe and effective treatments for allergic rhinitis (AR). The improper use of INCS may not alleviate AR symptoms, and it could lead to complications and an impaired quality of life. We evaluated the knowledge of, attitudes towards, and practices of INCS usage and associated factors among AR patients using a pretested Arabic questionnaire. Of the 400 participating AR patients, 39.3%, 29.0%, and 36.5% had poor scores for knowledge, attitude, and practice, respectively. We found a significant association between knowledge and education (p < 0.001) and follow-up facilities (p = 0.036). The attitude category was significantly associated with age (p = 0.003), marital status (p = 0.004), and type of allergic patients (p < 0.001), and the practice category was significantly associated with education (p = 0.027), type of allergic patients (p = 0.008), and follow-up facilities (p = 0.030). Smoking status was significantly associated with all three categories. Furthermore, we found a positive correlation between knowledge and practice scores (Spearman's rho of 0.451, p < 0.001). We recommend improving AR patients' knowledge of the proper practices of INCS through health education programs. Furthermore, we recommend an exploratory mixed-method survey on the INCS usage among AR patients that involves other provinces in the KSA.

Factors affecting adherence to intranasal treatment for allergic rhinitis: A qualitative study

Objective

To determine the facilitators of and barriers to adherence to use of intranasal pharmacotherapy (daily intranasal corticosteroids and/or antihistamine, and nasal saline irrigation [NSI]), for allergic rhinitis (AR).

Methods

Patients were recruited from an academic tertiary care rhinology and allergy clinic. Semi-structured interviews were conducted after the initial visit and/or 4-6 weeks following treatment. Transcribed interviews were analyzed using a grounded theory, inductive approach to elucidate themes regarding patient adherence to AR treatment.

Results

A total of 32 patients (12 male, 20 female; age 22-78) participated (seven at initial visit, seven at follow-up visit, and 18 at both). Memory triggers, such as linking nasal routine to existing daily activities or medications, were identified by patients as the most helpful strategy for adherence at initial and follow-up visits. Logistical obstacles related to NSI (messy, takes time, etc.) was the most common concept discussed at follow-up. Patients modified the regimen based on side effects experienced or perceived efficacy.

Conclusions

Memory triggers help patients adhere to nasal routines. Logistical obstacles related to NSI can deter from use. Health care providers should address both concepts during patient counseling. Nudge-based interventions that incorporate these concepts may help improve adherence to AR treatment.

Level of Evidence

2.

Pharmacology, particle deposition and drug administration techniques of intranasal corticosteroids for treating allergic rhinitis

This review presents an overview of the available literature regarding intranasal corticosteroids (INCs) for the treatment of allergic rhinitis (AR). Various treatment options exist for AR including INCs, antihistamines and leucotriene antagonists. INCs are considered to be the most effective therapy for moderate-to-severe AR, as they are effective against nasal and ocular symptoms and improve quality of life. Their safety has been widely observed. INCs are effective and safe for short-term use. Local adverse events are observed but generally well-tolerated. The occurrence of (serious) systemic adverse events is unlikely but cannot be ruled out. There is a lack of long-term safety data. INC may cause serious eye complications. The risk of INCs on the hypothalamic-pituitary-adrenal axis, on bone mineral density reduction or osteoporosis and on growth in children, should be considered during treatment. Pharmacological characteristics of INCs (e.g. the mode of action and pharmacokinetics) are well known and described. We sought to gain insight into whether specific properties affect the efficacy and safety of INCs, including nasal particle deposition, which the administration technique affects. However, advances are lacking regarding the improved understanding of the effect of particle deposition on efficacy and safety and the effect of the administration technique. This review emphasizes the gaps in knowledge regarding this subject. Advances in research and health care are necessary to improve care for patients with AR.

Survey on Use of Local and Systemic Corticosteroids in the Management of Chronic Rhinosinusitis with Nasal Polyps: Identification of Unmet Clinical Needs

Background: Local and systemic corticosteroids have long been the workhorse in management of chronic rhinosinusitis with nasal polyps (CRSwNP), although there is no universally accepted modality of prescription. We carried out a survey in Italy to capture current trends in the use of topical and systemic corticosteroids in patients with CRSwNP. Methods: A survey was set up on Survey Monkey^®. Each author distributed the link to the survey in an ad hoc manner and a total of 437 participants filled out the survey. Results: Mometasone furoate (79.3%) was the most frequently prescribed, administered daily by 61.9% of participants; the remaining preferred to discontinue treatment for brief periods to reduce side effects or to modulate the therapy in mild cases. The majority believe that a short cycle of systemic steroids should be prescribed for re-exacerbation of symptoms and that the number of cycles in the previous year should be evaluated to define control of the disease even if international guidelines do not provide clear indications on this topic. A certain degree of divergence emerged from responses regarding how long and the maximal dose of systemic steroids which place patients at high risk for adverse events. Finally, systemic corticosteroids seem to offer only temporary benefit on recovery of smell without guaranteeing long-term control even if the patient is adherent to topical corticosteroids. Conclusions: Our results highlight the need for clear guidelines on oral steroids, which could help supporting the use of a precision medicine approach, including indications for new biological agents.

Effectiveness of mobile health interventions to improve nasal corticosteroid adherence in allergic rhinitis: A systematic review

BACKGROUND

Mobile health interventions (MHI) offer the potential to help improve nasal corticosteroid (NCS) adherence in allergic rhinitis (AR). The aim of this systematic review was to summarise the current evidence on the effectiveness of MHI for improving NCS adherence in AR.

METHODS

We systematically searched MEDLINE, Embase and the Cochrane Central register of Controlled Trials (CENTRAL) for randomised controlled trials filtered for publication dates between 2010 and 2021. We evaluated the effects of MHI aiming to improve NCS adherence on self-management outcomes in AR and comorbid conditions. Two reviewers independently screened potential studies, extracted study characteristics and outcomes from eligible papers and assessed risk of bias using the Cochrane Risk of Bias tool 2.0. High heterogeneity precluded meta-analysis. Data were descriptively and narratively synthesised.

RESULTS

Our searches identified 776 individual studies of which 4 met the inclusion criteria. These studies were heterogeneous with respect to participant, intervention and outcome characteristics. We considered all outcome-specific overall risk of bias assessments to be of high risk of bias except for two studies examining NCS adherence which received 'some concern' grades. The three studies which reported on NCS adherence found that MHI were associated with improvement in NCS adherence. Significant MHI-associated improvement in symptoms or disease-specific quality of life was found in one study each, whilst no study reported significant differences in nasal patency.

CONCLUSIONS

Whilst MHI showed potential to improve NCS adherence, their effect on clinical outcomes varied. Furthermore, robust studies with longer intervention durations are needed to adequately assess effects of MHI and their individual features on NCS adherence and clinical outcomes.

Safety Concerns of Nasal Corticosteroids Usage in Patients With Allergic Rhinitis

Background

Intranasal corticosteroids (INCSs) are the first-line treatment for patients with moderate to severe conditions of allergic rhinitis (AR) as per current guidelines. However, patients' knowledge and practice towards the safety of such medications remains ambiguous. Therefore, this study was undertaken to identify the awareness of and knowledge about the safety of nasal corticosteroid usage in patients with allergic rhinitis as well as their adherence to taking the medication.

Materials and methods

We conducted a cross-sectional study from June to September 2020 at Imam Mohammad Ibn Saud Islamic University Medical Center, Riyadh, Kingdom of Saudi Arabia. Data were collected through questionnaire-based surveys, and a total of 375 patients were enrolled in the study. The eligibility criteria included all adult patients diagnosed with allergic rhinitis.

Results

Most of the patients had used intranasal corticosteroids. However, only two-fifths of patients stated these medications were effective and only 27% thought they were safe to use. More than half of the patients expressed concerns about using intranasal corticosteroids; however, there was no difference among the patients when asked if their concerns made them discontinue their medication. The majority of patients (73.3%) did not receive appropriate advice on how to use intranasal corticosteroids, but most were compliant with the therapy regardless of their uncertainty about the medication’s safety (71.5%). Most patients reported a benefit of using intranasal corticosteroids (71.5%). Half of the patients (53.9%) reported being aware of a special technique for how to use a nasal spray, but the nonsmokers were more knowledgeable about the techniques than the smokers (p = 0.007).

Conclusion

The patients' knowledge about, adherence to, and perceptions of intranasal corticosteroid use were found to be suboptimal. Patients’ age, gender, socioeconomic status, education level, and smoking status were recognized as potential barriers to a positive perception of and adherence to the treatment plan. Corrective measures are needed to ensure better health outcomes.

Quality of life of chronic kidney patients on hemodialysis and related factors

OBJECTIVE

to verify the association between the health-related quality of life of chronic renal patients on hemodialysis with sociodemographic, clinical, depression and medication adherence characteristics.

METHOD

a cross-sectional study with 183 chronic renal patients undergoing hemodialysis in the state of Rio Grande do Sul, Brazil. A sociodemographic and clinical questionnaire, Kidney Disease and Quality of Life Short-Form, Beck Depression Inventory and Morisky Medication Adherence Scale - eight items were used. Among the variables, comorbidities, complications of kidney disease and intercurrences during and after hemodialysis were evaluated. The analysis was performed with descriptive and analytical statistics.

RESULTS

55.2% of the patients were 60 years old or older, 35.0% were hypertensive, with regular quality of life, average of 62.61. Scores below average in the dimensions of quality of life were mainly associated with repetitive infections and edema as complications of the disease, pain during hemodialysis and weakness afterwards. Low drug adherence resulted in a worse quality of life, impacting ten of the 20 dimensions evaluated and depression in all, except for patient satisfaction.

CONCLUSION

reduced quality of life in this population is associated with depressive symptoms, complications such as repetitive infections, pain and anemia, weakness after the dialysis session and low medication adherence. Actions aimed at changing these factors can promote well-being.

Adherence to treatment in allergic respiratory diseases

Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice. Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence. Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.