Nonadherence in asthmatic patients: is there a solution to the problem?

Digital technology for monitoring adherence to inhaled therapies in people with cystic fibrosis

BACKGROUND

Improved understanding and treatment of cystic fibrosis (CF) has led to longer life expectancy, which is accompanied by an increasingly complex regimen of treatments. Suboptimal adherence to the treatment plan, in the context of respiratory disease, has been found to be associated with poorer health outcomes. With digital technology being more accessible, it can be used to monitor adherence to inhaled therapies via chipped nebulisers, mobile phone apps and web-based platforms. This technology can allow monitoring of adherence as well as clinical outcomes, and allow feedback to both the person with CF and their healthcare team.

OBJECTIVES

To assess the effects of using digital technology to monitor adherence to inhaled therapies and health status in adults and children with CF.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books.  Date of last search: 28 October 2021. We also searched Embase and three clinical trial registries and checked references of included studies. Date of last search: 9 November 2021.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) looking at the effects of a digital technology for monitoring adherence of children and adults with CF to inhaled therapies.

DATA COLLECTION AND ANALYSIS

Two review authors screened the search results for studies eligible for inclusion in the review and extracted their data. We used Risk of Bias 2 for assessing study quality. We assessed the overall certainty of the evidence using GRADE.

MAIN RESULTS

We included two studies in our review, with 628 participants aged five to 41 years. There was one study each for two different comparisons.  Nebuliser target inhalation mode versus standard inhalation mode The included parallel study was carried out over 10 weeks after a run-in period of four to six weeks. The study compared the effects of a digitally enhanced inhalation mode (target inhalation mode) for nebulised antibiotics compared to standard mode in children attending a regional CF clinic in the United Kingdom. The study's primary outcome was the time taken to complete the inhaled treatment, but investigators also reported on adherence to therapy. The results showed that there may be an improvement in adherence with the target inhalation mode when this intervention is used (mean difference (MD) 24.0%, 95% confidence interval (CI) 2.95 to 45.05; low-certainty evidence). The target inhalation mode may make little or no difference to forced expiratory volume in one second (FEV1) % predicted (MD 1.00 % predicted, 95% CI -9.37 to 11.37; low-certainty evidence). The study did not report on treatment burden, quality of life (QoL) or pulmonary exacerbations. eNebuliser with digital support versus eNebuliser without support One large multicentre RCT monitored adherence via data-tracking nebulisers. The intervention group also receiving access to an online web-based platform, CFHealthHub, which offered tailored, flexible support from the study interventionist as well as access to their adherence data, educational and problem-solving information throughout the 12-month trial period. We graded all evidence as moderate certainty. Compared to usual care, the digital intervention probably improves adherence to inhaled therapy (MD 18%, 95% CI 12.90 to 23.10); probably leads to slightly reduced treatment burden (MD 5.1, 95% CI 1.79 to 8.41); and may lead to slightly improved FEV1 % predicted (MD 3.70, 95% CI -0.23 to 7.63). There is probably little or no difference in the incidence of pulmonary exacerbations or QoL between the two groups.

AUTHORS' CONCLUSIONS

Digital monitoring plus tailored support via an online platform probably improves adherence to inhaled therapies and reduces treatment burden (but without a corresponding change in QoL) in the medium term (low- and moderate-certainty evidence). In a shorter time frame, technological enhancement of inhaling antibiotics may improve adherence to treatment (low-certainty evidence). There may be little or no effect on lung function with either intervention, and online monitoring probably makes no difference to pulmonary exacerbations.  Future research should assess the effect of digital technology on adherence in both children and adults. Consideration of adherence to the total treatment regimen is also important, as an improvement in adherence to inhaled therapies could come at the cost of adherence to other parts of the treatment regimen.

Progress in diagnosis and treatment of difficult-to-treat asthma in children

At present, medications containing inhaled corticosteroids (ICS-containing) are the keystones of asthma treatment. The majority of asthmatic children can significantly improve clinical outcomes with little worsening by standardized inhaled glucocorticoid treatment, but there is still a small proportion of children who are unable to achieve good symptom control even after the maximum standardized treatment, known as 'children with difficult-to-treat asthma (DA)'. The high heterogeneity of DA makes therapy challenging and expensive, which poses a serious risk to children's health and makes it extremely difficult for clinical physicians to accurately identify and treat children with DA. This article reviews the definition, evaluation, and treatment of this asthma in order to provide a reference for optimal clinical decision-making.

Symptom-driven inhaled corticosteroid/long-acting beta-agonist therapy for adult patients with asthma who are non-adherent to daily maintenance inhalers: a study protocol for a pragmatic randomized controlled trial

BACKGROUND

While inhaled corticosteroids (ICS) are considered the essential foundation of most asthma therapy, ICS inhaler nonadherence is a notoriously common problem and a significant cause of asthma-related morbidity. Partially acknowledging the problem of nonadherence, international organizations recently made paradigm-shifting recommendations that all patients with mild-to-moderate persistent asthma be considered for symptom-driven ICS-containing inhalers rather than relying on adherence to traditional maintenance ICS inhalers and symptom-driven short-acting beta-agonists (SABA). With this new approach, asthma patients are at least exposed to the important anti-inflammatory effects of ICS-containing inhalers when their symptom reliever inhaler is deployed due to acute symptoms.

METHODS

This study will (Part 1) complete a pragmatic randomized controlled trial to evaluate if an inhaler strategy that utilizes symptom-driven ICS inhalers is particularly beneficial in maintenance ICS inhaler non-adherent asthma patients, and (Part 2) use a dissemination and implementation (D&I) science conceptual framework to better understand patients' and providers' views of inhaler nonadherence. This study, which will have an option of taking place entirely remotely, will use a Food and Drug Administration (FDA)-approved electronic sensor (Hailie® sensor) to monitor inhaler adherence and includes semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR).

DISCUSSION

This study is assessing the problem of nonadherence using a D&I implementation science research lens while testing a new inhaler approach to potentially ameliorate the detrimental consequences of maintenance inhaler nonadherence. We hypothesize that the use of a symptom-driven ICS/LABA management strategy, as compared to traditional maintenance ICS treatment and symptom-driven SABA, will lead to improved adherence to an asthma treatment strategy, decreased asthma-related morbidity, less cumulative ICS exposure, and greater patient satisfaction with an inhaler approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05111262. Registered on November 8, 2021.

Digital Coaching Using Smart Inhaler Technology to Improve Asthma Management in Patients With Asthma in Italy: Community-Based Study

BACKGROUND

Reliance on short-acting β-2 agonists and nonadherence to maintenance medication are associated with poor clinical outcomes in asthma. Digital health solutions could support optimal medication use and therefore disease control in patients with asthma; however, their use in community settings has not been determined.

OBJECTIVE

The primary objective of this study is to investigate community implementation of the Turbu+ program designed to support asthma self-management, including adherence to budesonide and formoterol (Symbicort) Turbuhaler, a combination inhaler for both maintenance therapy or maintenance and reliever therapy. The secondary objective is to provide health care professionals with insights into how patients were using their medication in real life.

METHODS

Patients with physician-diagnosed asthma were prescribed budesonide and formoterol as maintenance therapy, at a dose of either 1 inhalation twice daily (1-BID) or 2 inhalations twice daily (2-BID), or as maintenance and reliever therapy (1-BID and reliever or 2-BID and reliever in a single inhaler), and they received training on Turbu+ in secondary care centers across Italy. An electronic device attached to the patients' inhaler for ≥90 days (data cutoff) securely uploaded medication use data to a smartphone app and provided reminders, visualized medication use, and motivational nudge messages. Average medication adherence was defined as the proportion of daily maintenance inhalations taken as prescribed (number of recorded maintenance actuations per day or maintenance inhalations prescribed per day) averaged over the monitoring period. The proportion of adherent days was defined as the proportion of days when all prescribed maintenance inhalations were taken on a given day. The Wilcoxon test was used to compare the proportion of adherent days between patients in the maintenance regimen and patients in the maintenance and reliever regimen of a given dose.

RESULTS

In 661 patients, the mean (SD) number of days monitored was 217.2 (SD 109.0) days. The average medication adherence (maintenance doses taken/doses prescribed) was 70.2% (108,040/153,820) overall and was similar across the groups (1-BID: 6332/9520, 66.5%; 1‑BID and reliever: 43,578/61,360, 71.0%; 2-BID: 10,088/14,960, 67.4%; 2-BID and reliever: 48,042/67,980, 70.7%). The proportion of adherent days (prescribed maintenance doses/doses taken in a given day) was 56.6% (31,812/56,175) overall and was higher with maintenance and reliever therapy (1-BID and reliever vs 1-BID: 18,413/30,680, 60.0% vs 2510/4760, 52.7%; P<.001; 2-BID and reliever vs 2-BID: 8995/16,995, 52.9% vs 1894/3740, 50.6%; P=.02). Rates of discontinuation from the Turbu+ program were significantly lower with maintenance and reliever therapy compared with maintenance therapy alone (P=.01).

CONCLUSIONS

Overall, the high medication adherence observed during the study might be attributed to the electronic monitoring and feedback mechanism provided by the Turbu+ program.

[Therapeutic adherence among asthma patients: Variations according to age groups. How can it be improved? The potential contributions of new technologies]

While asthma patients' treatment adherence (TA) generally leaves to be desired, few data exist on TA evolution from age group to another. During the meeting of a working group of pneumo-pediatricians and adult pulmonologists, we reviewed the literature on adherence according to age group, examined explanations for poor adherence, and explored ways of improving adherence via new technologies. Asthma is a chronic disease for which TA is particularly low, especially during adolescence, but also among adults. Inhaled medications are the least effectively taken. Several explanations have been put forward: cost and complexity of treatments, difficulties using inhalation devices, poor understanding of their benefits, erroneous beliefs and underestimation of the severity of a fluctuating disease, fear of side effects, neglect, and denial (especially among teenagers). Poor TA is associated with risks of needless treatment escalation, aggravated asthma with frequent exacerbations, increased school absenteeism, degraded quality of life, and excessive mortality. Better compliance is based on satisfactory relationships between caregivers and asthmatics, improved caregiver training, and more efficient transmission to patients of relevant information. The recent evolution of innovative digital technologies opens the way for enhanced communication, via networks and dedicated applications, and thanks to connected inhalation devices, forgetfulness can be limited. Clinical research will also help to ameliorate TA. Lastly, it bears mentioning that analysis of the existing literature is hampered by differences in terms of working definitions and means of TA measurement.

Novel Fluticasone Propionate and Salmeterol Fixed-Dose Combination Nano-Encapsulated Particles Using Polyamide Based on L-Lysine

One of the key challenges in developing a dry powder inhaler (DPI) of an inhalable potent fixed-dose combination (FDC) is the ability of the formulation to generate an effective and reproducible aerosol able to reach the lower parts of the lungs. Herein, a one-step approach is presented to expedite the synthesis of nanoaggregates made from a biocompatible and biodegradable polyamide based on L-lysine amino acid employing market-leading active pharmaceutical ingredients (fluticasone propionate (FP) and salmeterol xinafoate (SAL)) for the management of asthma. The nanoaggregates were synthesized using interfacial polycondensation that produced nanocapsules with an average particle size of 226.7 ± 35.3 nm and zeta potential of -30.6 ± 4.2 mV. Differential scanning calorimetric analysis and x-ray diffraction, as well as scanning electron microscopy of the produced FDC, revealed the ability of the produced nanocapsules to encapsulate the two actives and display the best aerodynamic performance. The FDC nanocapsules displayed 88.5% and 98.5% of the emitted dose for FP and SAL, respectively. The fine particle fraction of the nominated dose was superior to the marketed product (Seretide Diskus®, Brentford, United Kingdom). The in-vitro release study showed an extended drug release profile. Our findings suggest that nanoaggregates using polyamides based on L-lysine and interfacial polycondensation can serve as a good platform for pulmonary drug delivery of FDC systems.

FeNO in Asthma

Asthma is a common disease affecting 350 million people worldwide, which is characterized by airways inflammation and hyperreactivity. Historically diagnosis and treatment have been mainly based on symptoms, which have the potential to result in misdiagnosis and inappropriate treatment. Nitric oxide (NO) is exhaled in human breath and is a marker of airways inflammation. Levels of NO are increased in the exhaled breath of patients with type 2 asthma and fractional exhaled nitric oxide (FeNO) provides an objective biomarker of airway inflammation. FeNO testing is an accessible, noninvasive, and easy-to-use test. Cut-off values have been established by the American Thoracic Society (ATS), the Global Initiative for Asthma (GINA), and the National Institute for Health and Care Excellence (NICE) but vary between guidance. FeNO levels have been shown to be predictive of blood and sputum eosinophil levels but should not be used in isolation and current guidance emphasizes the importance of incorporating clinical symptoms and testing when utilizing FeNO results. The inclusion of FeNO testing can increase diagnostic accuracy of asthma, while high levels in asthmatic patients can help predict response to inhaled corticosteroids (ICS) and suppression of levels with ICS to monitor adherence. FeNO levels are also a predictor of asthma risk with increased exacerbation rates and accelerated decline in lung function associated with high levels as well as having an emerging role in predicting response to some biologic therapies in severe asthma. FeNO testing is cost-effective and has been shown, when combined with clinical assessment, to improve asthma management.

The Impact of Adherence and Health Literacy on Difficult-to-Control Asthma

Medication nonadherence and health literacy are key factors that influence the management of difficult-to-control asthma. Adherence, or the extent to which a patient follows a treatment plan, extends beyond asthma medication use and includes an appropriate inhaler technique. Assessment of adherence is critical before making a diagnosis of severe asthma and stepping up asthma therapy but is challenging in the clinical context. Health literacy, or the degree to which individuals can obtain, process, and understand health information and services needed to make health care decisions, is additionally important for asthma management and has been shown to impact medication adherence. Initiatives aiming to improve difficult-to-control asthma should address medication adherence and health literacy. Universal health literacy precautions are recommended while communicating with patients, in addition to the creation of low health literacy asthma action plans. To improve adherence, a comprehensive assessment of adherence should be conducted. Additional evidence-based interventions aiming to improve adherence focus on appropriate inhaler use, improved access to medications, the use of digital platforms, school-based asthma interventions, and the implementation of culturally tailored interventions. Data are limited regarding the use of these initiatives in patients with severe or difficult-to-control asthma.

Patient and Physician Perspectives on Asthma and Its Therapy in Romania: Results of a Multicenter Survey

Background and Objectives: Patient’s behaviours, attitudes and beliefs related to asthma and its treatment were shown to influence the adherence to therapy and the level of asthma control. This survey aimed to assess the level of asthma control and patient-reported behaviours, attitudes and expectations related to their disease in Romanian patients. Materials and Methods: This cross-sectional quantitative survey was performed in February-March 2019 and enrolled 70 specialist physicians experienced in asthma management and 433 asthma patients under their care. Results: Of the 433 patients enrolled, 19.4% had mild asthma, 60.5% moderate asthma and 20.1% severe asthma. For the previous 12 months, asthma symptoms, exacerbations and emergency room visits were common in the sample analysed, with significantly higher figures in severe asthma patients (p < 0.001). The most important treatment goal for asthma patients was participation in all activities of daily living, while for physicians this was preventing asthma exacerbations. The valuation of the treatment goals was different between patients with severe asthma and those with mild and moderate forms. Based on the patients’ responses, 3 attitude clusters were identified: empowered savvy (36.5% of the patients), pessimistic non-compliers (43.2%), and anxious strugglers (20.3%). “Empowered savvy” had the lowest frequency of severe asthma, the highest adherence to maintenance therapy and the highest level of confidence in the effectiveness of asthma medication. The opposite of this attitude cluster is the “anxious strugglers”, containing more patients with severe asthma, a higher score for worries about asthma therapy and better self-reported knowledge of their treatment, contrasting with a proportion of 25% taking maintenance therapy only when having breathing difficulties. Conclusion: Asthma control in Romania remains poor, with frequent exacerbations and hospitalizations. The differences in treatment goals found between patients and physicians and between different asthma severity groups suggest the need for more patient-centred approaches.

[Severe adult asthma and treatment adherence: Results of the FASE-CPHG study]

INTRODUCTION

Data on severe asthma in France are scarce. The aim of this study was to evaluate adherence to asthma treatments and its determinants in a population of severe asthmatics.

METHODS

From May 2016 to June 2017, the French Collège des Pneumologues des Hôpitaux Généraux organized a large-scale prospective, cross-sectional, multicenter study on this topic; 1502 patients with severe asthma were included.

RESULTS

The average number of substantive treatments was 2.5±1.1. Assessed by self-questionnaire in 1289 patients, overall adherence was 64.8%, in good agreement with the findings of the pneumologist in charge (p<0.0001). Control of asthma according to the GINA criteria was more successful in compliant patients (p<0.01). In univariate analysis, the most compliant participants were frequent exacerbator patients (p=0.02), those with nasal polyposis (p=0.01) and those receiving an anticholinergic agent (p<0.01), anti-IgE biotherapy (p<0.0001) or oral corticosteroids (p<0.01). The least compliant participants were younger (p<0.0001), active smokers (p<0.001), with shorter average disease duration (24.2±15.7 vs 29.1±18.7 years, p<0.0001) and a lower number of substantive asthma treatments (2.2±1 vs 2.6±1, p<0.0001). In multivariate analysis, age, length of disease and anti-IgE treatment were the only factors affecting therapeutic compliance.

CONCLUSION

In this large-scale study of severe asthmatic patients, 64.8% were compliant according to the MMAS-4© self-administered questionnaire and appeared to be better monitored according to the criteria defined in our study. Overall, adherence was more satisfactory among older patients and those whose disease had been evolving over a long period of time or were receiving anti-IgE biotherapy.

Ethical considerations in pediatric chronic illness: The relationship between psychological factors, treatment adherence, and health outcomes

Children, adolescents, and young adults with chronic illnesses are often faced with complicated and burdensome treatments that not only require a great deal of time and energy to manage, but will also likely impact relationships with parents, siblings, and peers. Adolescents and young adults with chronic illness are often impacted by several unique and challenging factors that can ultimately impact health behaviors and treatment outcomes. Working with a psychologist can help to ameliorate these unique challenges, which will positively impact health behaviors and health outcomes. The present paper provides an overview of psychological interventions that were designed to target the unique challenges that are often associated with maladaptive health behaviors and ultimately poor health outcomes. As demonstrated in this commentary, when working with adolescents and young adults who have unique developmental challenges, it is important to deliver multi-faceted intervention approaches that utilize a number of different strategies and frameworks. These eclectic intervention approaches provide a unique opportunity to improve health behaviors during critical developmental periods, including the transition from childhood to adolescence to young adulthood.

Measuring adherence to therapy in airways disease

Non-adherence to medication is one of the most significant issues in all airways disease and can have a major impact on disease control as well as on unscheduled healthcare utilisation. It is vital that clinicians can accurately determine a patient's level of adherence in order to ensure they are gaining the maximal benefit from their therapy and also to avoid any potential for unnecessary increases in therapy. It is essential that measurements of adherence are interpreted alongside biomarkers of mechanistic pathways to identify if improvements in medication adherence can influence disease control. In this review, the most common methods of measuring adherence are discussed. These include patient self-report, prescription record checks, canister weighing, dose counting, monitoring drug levels and electronic monitoring. We describe the uses and benefits of each method as well as potential shortcomings. The practical use of adherence measures with measurable markers of disease control is also discussed.

Educational aims

To understand the various methods available to measure adherence in airways disease.To learn how to apply these adherence measures in conjunction with clinical biomarkers in routine clinical care.

Serum Inhaled Corticosteroid Detection for Monitoring Adherence in Severe Asthma

BACKGROUND

Daily inhaled corticosteroids (ICSs) are fundamental to asthma management, but adherence is low.

OBJECTIVES

To investigate (1) whether LC-MS/MS could be used to detect ICSs in serum and (2) whether serum levels related to markers of disease severity.

METHODS

We collected blood samples over an 8-hour period from patients with severe asthma prescribed at least 1000 μg daily of beclomethasone dipropionate equivalent. Following baseline sampling, patients were observed taking their usual morning dose. Subsequent blood samples were obtained 1, 2, 4, and 8 hours postinhalation and analyzed by LC-MS/MS. Correlations between serum ICS levels and severity markers were investigated.

RESULTS

A total of 60 patients were recruited (41 females; 39 prescribed maintenance prednisolone; mean age, 49 ± 12 years; FEV₁, 63 ± 20 %predicted). Eight hours postinhalation, all patients using budesonide (n = 10) and beclomethasone dipropionate (15), and all but 1 using fluticasone propionate (28), had detectable serum drug levels. Fluticasone furorate was detected in 2 patients (of 4), ciclesonide in none (of 7). Low adherence by repeat prescription records (<80%) was identified in 43%. Blood ICS levels correlated negatively with exacerbation rate, and (for fluticasone propionate only) positively with FEV₁ %predicted.

CONCLUSIONS

Commonly used ICSs can be reliably detected in the blood at least 8 hours after dosing, and could therefore be used as a measure of adherence in severe asthma. Higher exacerbation rates and poorer lung function (for fluticasone propionate) were associated with lower blood levels.

Effectiveness of Text Message Reminders on Adherence to Inhaled Therapy in Patients With Asthma: Prospective Multicenter Randomized Clinical Trial

Background

Poor adherence to inhaled medication in asthma patients is of great concern. It is one of the main reasons for inadequate asthma control.

Objective

The goal of the research was to determine if motivational messages using short message service (SMS, or text) improved adherence to inhaled medication in patients with asthma.

Methods

A prospective multicenter randomized parallel-group clinical trial was conducted in 10 asthma clinics in Spain. Adherence was assessed with electronic monitors (Smartinhaler, Adherium Ltd) connected to inhalers. Patients in the SMS group received psychologist-developed motivational messages every 3 days for 6 months.

Results

There were 53 patients in the SMS group and 88 patients in the control group. After 6 months, mean electronic adherence was 70% (SD 17%) in the intervention group and 69% (SD 17%) in the control group (P=.82). Significant differences between the study groups in morning and evening adherence to inhaled therapy, asthma control, exhaled nitric oxide levels, or improvement of lung functions were not observed.

Conclusions

Motivational messages were not useful to improve adherence to inhaled asthma medication compared with usual care.

Fractional exhaled nitric oxide and asthma treatment adherence

PURPOSE OF REVIEW

Despite increased clinician awareness, nonadherence to inhaled corticosteroid treatment presents a major challenge to successful asthma management and risks inappropriate treatment escalation, particularly in severe disease. In patients with Type-2 mediated biology, fractional exhaled nitric oxide (FeNO) has a role in assessment and monitoring of adherence to inhaled corticosteroids.

RECENT FINDINGS

Asthmatic patients with elevated FeNO are at an increased risk of exacerbation. High FeNO is often secondary to suboptimal adherence to inhaled corticosteroid treatment, whether intentional or nonintentional. FENO-suppression can 'unmask' underlying adherence issues and is a useful test in the presence of Type-2 biology in the 'difficult-to-control' asthma population. Identification of nonadherence can improve asthma control and prevent inappropriate commencement of costly biologic therapies.

SUMMARY

Assessment of adherence and FeNO response to monitored inhaled corticosteroid in Type-2 biomarker high asthmatic individuals may prevent unnecessary escalation to biologic therapy. Establishing an 'optimised' FeNO may alert clinicians to the possibility of underlying nonadherence at future clinical assessments.

ICS-formoterol reliever versus ICS and short-acting β2-agonist reliever in asthma: a systematic review and meta-analysis

Background

The Global Initiative for Asthma recommends as-needed inhaled corticosteroid (ICS)-formoterol as an alternative to maintenance ICS plus short-acting β₂-agonist (SABA) reliever at step 2 of its stepwise treatment algorithm. Our aim was to assess the efficacy and safety of these two treatment regimens, with a focus on prevention of severe exacerbation.

Methods

We performed a systematic review and meta-analysis of all randomised controlled trials (RCTs) comparing as-needed ICS-formoterol with maintenance ICS plus SABA. MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Clinicaltrials.gov were searched from database inception to 12 December 2019. The primary outcome was time to first severe exacerbation. RCTs were excluded if they used as-needed budesonide-formoterol as part of a maintenance and reliever regimen, or did not report on severe exacerbations. The review is registered with PROSPERO (identifier number CRD42020154680).

Results

Four RCTs (n=8065 participants) were included in the analysis. As-needed ICS-formoterol was associated with a prolonged time to first severe exacerbation (hazard ratio 0.85, 95% CI 0.73–1.00; p=0.048) and reduced daily ICS dose (mean difference −177.3 μg, 95% CI −182.2–−172.4 μg). Asthma symptom control was worse in the as-needed group (Asthma Control Questionnaire-5 mean difference 0.12, 95% CI 0.09–0.14), although this did not meet the minimal clinically important difference of 0.50 units. There was no significant difference in serious adverse events (OR 1.07, 95% CI 0.84–1.36).

Conclusion

As-needed ICS-formoterol offers a therapeutic alternative to maintenance low-dose ICS plus SABA in asthma and may be the preferred option when prevention of severe exacerbation is the primary aim of treatment.

As-needed low-dose ICS-formoterol prolongs time to first severe asthma exacerbation compared to maintenance ICS/SABA reliever and represents an alternative for patients, particularly when severe exacerbation prevention is the primary treatment aimhttps://bit.ly/3mpHVKc

[Description of the use of inhaled rescue medication in an asthmatic population treated in the Primary Care clinics. UMI-ASMA Study]

OBJECTIVE

To describe the quantitative use of inhaled rescue medication in an asthmatic population treated in the Primary Care clinics, and secondly to determine its possible relationship as regards other variables associated with control.

MATERIAL AND METHODS

An observational, descriptive study was conducted on a randomised sample of all the asthmatic patients with more than one year of onset, and coming from 17 Primary Care catchment areas. 1 year observation period. The data collected included sociodemographic variables and characteristics of the asthma, such as the use of short-acting beta-agonists (SABA) and level of control as regards its frequency of use, the use of inhaled control medication (ICM), number of hospital exacerbations, smoking habits, and availability of an action plan. The data were obtained from the clinical history and the computerised prescription modules.

RESULTS

A total of 442 asthmatic patients were included (59.5% female), with a mean age of 45.4 years. The total number of SABA containers prescribed in one year per patient was between 0 and 25 containers, with a mean of 4.26 (SD=4.1). Only 46.6% showed a regular use of an ICM. The number of SABA containers prescribed to patients with an intermittent use of an ICM was significantly higher than those patients that used it regularly (P=.001). There was an association between the number of exacerbations and the number of SABA containers prescribed (Spearman correlation coefficient=0.474, P<.001), as such that the higher the number of containers prescribed there was also a higher number of hospitalised asthmatic exacerbations.

CONCLUSIONS

A considerable number of asthmatics in the sample had elevated prescriptions for SABA inhalers and within the defined quantitative ranges of at least a partially or poor-controlled asthma. There is a positive relationship between the overuse of SABA and the intermittent use of the ICM, the same as with hospital exacerbations, smoking, and the lack of a written action plan..

Assessment of regular drug use and inhaler technique skills in asthmatic children

OBJECTIVE

This study aimed to assess the regular use of long-term asthma-control medication and to determine inhaler techniques in asthmatic children.

METHODS

The study was conducted on asthmatic children aged 6-18 years. Information on rescue and controller medications was given and the proper inhalation technique was demonstrated. One month later, patients and parents were asked to answer a questionnaire on drug use and to demonstrate their inhaler techniques.

RESULTS

One hundred children and/or their parents were interviewed for the study. All of the patients identified long-term asthma-control medications while quick-relief asthma medications were identified by 93% of the patients. Of the patients, 34% described the dose of their quick-relief medication correctly. All steps in the inhalation technique were correctly carried out by 60.6% of patients using a metered-dose inhaler (MDI), 80% of patients using a Turbuhaler, and 58% of patients using a capsule-based dry-powder inhaler (DPI). Of the participants, 73% reported regular use of long-term asthma-control medications. While the mean age of the patients regularly using long-term asthma medications was 9.05±2.5 years, that of patients not compliant with the regular treatment was 10.29±3.26 years (p=0.04). The most common reason for irregular drug use was forgetting to take the drug.

CONCLUSION

Adherence to long-term asthma-control medications tends to be better in younger patients. Since the most common cause of irregular drug use is forgetting to take the drug, repeated training is necessary to ensure asthma control and the successful treatment of asthmatic children.

Application of Once-Monthly Self-Reported ACT Questionnaire in Management of Adherence to Inhalers in Outpatients with Asthma

PURPOSE

Poor medication adherence can negatively affect health outcomes of patients with asthma from medication and significantly increase the healthcare costs. Management of adherence to inhalers remains a challenging topic in the long-term management of patients with asthma. We aim to evaluate the role of asthma control test (ACT) in the management of adherence to inhalers in outpatients with asthma.

PATIENTS AND METHODS

Six hundred twenty-seven outpatients with asthma admitted to the clinic of respiratory medicine in a tertiary hospital in northwestern China during 2016 to 2019 were randomly divided into observation group (n= 315) and control (n= 312) and received standard inhalant therapy for 6 months and lung function test before and after treatment. The patients in the observation group took ACT questionnaires at the end of each month, while the patients in control only took an ACT at the end of the last month. The 'Test of Adherence to Inhalers' (TAI) questionnaire was used to evaluate the patients' adherence to inhalant therapy.

RESULTS

All patients completed the study. The ACT scores in the observation group showed a gradual increase month by month. The TAI results indicated that adherence to inhalers of patients in the observation group was significantly better than that in control and the patients' non-adherence pattern in the observation group, with significantly lower erratic non-adherence, was also different from that in control. After 6 months of treatment, the lung function indexes and their relative improvement and the ACT scores in the observation group were significantly better or higher than those in control.

CONCLUSION

The once-monthly self-reported ACT can effectively improve the adherence to inhalers of outpatients with asthma mainly by addressing erratic non-adherence and improve the treatment effects, and thus deserves widespread use in the treatment adherence management in patients with asthma.

The Effectiveness of Written Asthma Action Plan at the National Guard Health Affairs' Asthma Clinic

Introduction

Bronchial asthma has grown in epidemic proportions, and it is one of the most chronic diseases that affect many societies in the world. As managing asthma is complex, new management approaches have been developed, such as the written asthma action plan. This study aims to assign a baseline for the patients’ knowledge about asthma and its management and to assess their need for an asthma action plan. Then, to identify the effect of the written asthma action plan on the following parameters: exacerbations rate, and the frequency of using rescue mediations. Also, to compare the quality of life, functional limitations, and the level of patients’ self-confidence in treating their asthma before and after using the written asthma action plan.

Method

This study is a cross-sectional and interventional mixed-method study design. It was conducted at the National Guard Health Affairs (NGHA) asthma clinics between October 2017 to November 2017. Asthmatic patients who were above five years old and had no other lung comorbidities were evaluated before and after following the written asthma action plan by using three previously validated and published surveys that consist of five sections: demography, knowledge, quality of life, exacerbation rate, and overall evaluation.

Results

This study enrolled 58% (209) males and 42% (154) females. Regarding asthma medication knowledge and attack management, 62.3% of the patients do not adhere to their maintenance medications when they do not have asthma symptoms. Also, only 24.9% were very confident about knowing how to use their inhalers. For the impact of asthma on patients’ quality of life and the functional limitations, we found that 42.1% of patients were absent from school or work more than once a week because of asthma. While 61.0% of patients did not attend social events twice or less per week because of their asthma. The third section of the survey was about asthma exacerbation related events during the past year, we found that 39.0% of patients had one or more asthma attacks, 41.6% visited the emergency room (ER) once or more during the past year, and 28.1% of patients have been hospitalized because of their asthma. Finally, the section about patients’ evaluation of their asthma and their confidence about managing their condition, we found that around 20% of patients had poor or no control over their condition.

In the second phase of the study, which includes 60 subjects, we found that following the action plan helps in increasing the patients’ knowledge about their condition, and improves their quality of life and functional limitations as they learned how to cope with their symptoms. In addition, it has increased the confidence level of patients about controlling their asthma and decreasing the asthma exacerbation related events rates. Overall, the patients’ evaluation of their asthma has been increased significantly (p-value= 0.023).

Conclusion

Most of the asthmatic patients had insufficient knowledge and/or poor adherence to their treatment which impacted their quality of life. The written asthma action plan was effective in increasing the patients’ knowledge about their condition, improving their quality of life and functional limitations, and increasing their confidence level about controlling their asthma.

Measurement of Key Constructs in a Holistic Framework for Assessing Self-Management Effectiveness of Pediatric Asthma

The 2007 U.S. National Institutes of Health EPR-3 guidelines emphasize the importance creating a provider-patient partnership to enable patients/families to monitor and take control of their asthma, so that treatment can be adjusted as needed. However, major shortfalls continue to be reported in provider adherence to EPR-3 guidelines. For providers to be more engaged in asthma management, they need a comprehensive set of resources for measuring self-management effectiveness of asthma, which currently do not exist. In a previously published article in the Journal of Asthma and Allergy, the authors conducted a literature review, to develop a holistic framework for understanding self-management effectiveness of pediatric asthma. The essence of this framework, is that broad socioecological factors can influence self-agency (patient/family activation), to impact self-management effectiveness, in children with asthma. A component of socio-ecological factors of special relevance to providers, would be the quality of provider-patient/family communication on asthma management. Therefore, the framework encompasses three key constructs: (1) Provider-patient/family communication; (2) Patient/family activation; and (3) Self-management effectiveness. This paper conducts an integrative review of the literature, to identify existing, validated measures of the three key constructs, with a view to operationalizing the framework, and discussing its implications for asthma research and practice.

Predictors of Hospital Reuse Among Publicly Insured Children Hospitalized for Status Asthmaticus

BACKGROUND

Asthma is a common cause of pediatric hospitalization. Nonadherence to asthma medications is associated with worse outcomes; however, there is a paucity of data regarding posthospitalization prescription filling and hospital reuse. Our objective was to identify patients at risk for hospital reuse after being hospitalized for asthma.

METHODS

This is a retrospective study of patients with asthma who were discharged from a children's hospital in which we use Medicaid claims data to evaluate prescription fills within 30 days and 12 months. Chart reviews were used for demographics, chronic asthma severity, admission severity, and hospital reuse. t and χ² tests were performed for continuous and categorical variables. A generalized linear mixed model was fitted to predict the odds of hospital reuse, which was defined as requiring an emergency department visit or rehospitalization. Survival analysis using log-rank testing was used for modeling the time to hospital reuse.

RESULTS

Fifty-four percent of patients discharged with asthma had hospital reuse within 1 year of discharge. There was no association between hospital reuse and prescription filling for systemic steroids (odds ratio [OR] 1.30; confidence interval [CI]: 0.85-2.00; P = .21) or controller medications (OR 1.5; CI: 0.92-2.52; P = .10). There was a higher number of controller and systemic steroid prescription fills over 12 months for patients with hospital reuse. The factors associated with greater odds of hospital reuse were severity of chronic asthma diagnosis (P = .03) as well as African American race (OR 1.92; CI: 1.17-3.13; P = .01).

CONCLUSIONS

For Medicaid-insured patients discharged with asthma, worse chronic asthma severity and African American race were associated with greater odds of hospital reuse. Decreased prescription filling was not associated with greater odds of hospital reuse.

Multicenter Adherence Study of Asthma Medication for Children in Korea

Purpose

Adherence is a major component of successful medical treatment. However, non-adherence remains a barrier to effective delivery of healthcare worldwide.

Methods

Twenty healthcare facilities (secondary or tertiary hospitals) belonging to the Korean Academy of Pediatric Allergy and Respiratory Diseases (KAPARD) participated. Questionnaires were given to patients currently receiving treatment in the form of inhalant useor oral intake or transdermal patch for mild to moderate asthma.

Results

A total of 1,838 patients responded to the questionnaire. Mean age was 5.98 ± 3.79 years (range: 0-18 years). With help from their caregivers, the percentage of patients that answered “taking as prescribed” was 38.04% for inhalant users, 50.09% for oral medication users and 67.42% for transdermal users. Transdermal patch users had significantly greater adherence compared to the other 2 groups (P < 0.001). The 34.15% of inhalant users, 70.33% of oral medication users and 93.00% of transdermal patch users felt that their medication delivery system was “Easy” or “Very easy” to use (P < 0.001). “Method of administration” was deemed to be the most difficult part of the treatment regimen to follow, and 76.7% of patients preferred once-daily administration (i.e., “Frequency of administration”).

Conclusions

Asthma medication adherence in young children was found to be better in the transdermal patch group. This may be due to requiring fewer doses and easy to follow instructions. From an adherence point of view, the transdermal patch seems more useful for long-term asthma control in children compared to oral or inhaled medicine.

Cross-sectional survey study to examine underuse of twice daily inhaled maintenance therapy among patients with asthma

Objective: Anecdotal evidence suggests that some patients with asthma intentionally use their twice-daily (BID) inhaled controller therapy once daily (QD), thus not achieving optimal dosing levels. This study identified the prevalence of and factors associated with intentional QD use of BID-indicated controllers among adult patients with asthma. Methods: This was a cross-sectional survey study of adults using inhaled controllers intended for BID dosing for treatment of asthma and/or COPD. Survey responses were linked to administrative claims data for the prior 12 months (baseline). Results of patients indicating both an asthma diagnosis and current intentional QD or BID use of controllers are presented. Results: Of 1401 patients with asthma, 30.9% reported intentional QD use of their controller and 69.1% reported BID use. Intentional QD use was mostly a function of patients' lack of perceived need for BID treatment (44.1%) or physician orders to take their controller QD (34.0%). Patients reporting intentional QD use tended to be healthier (higher health status scores, and lower Charlson comorbidity scores, ambulatory and ER visits, and healthcare costs) with better asthma control (lower asthma-related ER and ambulatory visits and rescue medication use, and higher Asthma Control Test scores) compared with patients reporting BID use. Conclusions: Perceptions regarding health and the necessity of controller use to control or treat asthma were the main drivers of medication-taking behavior. Patients with less severe asthma were more likely to report once daily use of their inhaled controller, but still maintained asthma control.

The Prospects of an Active Vaccine Against Asthma Targeting IL-5

Allergen-specific T helper type 2 (Th2) responses followed by eosinophilic inflammation of the lung are important causes of allergic asthma. Interleukin-5 (IL-5) is a master regulator of eosinophil differentiation as well as activation. Blocking IL-5 using monoclonal antibodies (mAbs) against IL-5 is a powerful way to improve asthmatic symptoms in patients with an eosinophilic component of the disease. We have previously shown that vaccination against IL-5 can abrogate eosinophilic inflammation of the lung in allergic mice. More recently, we have demonstrated that eosinophil-mediated skin disease in horses with insect bite hypersensitivity can be strongly reduced by vaccination against IL-5. Here we would like to propose the development of a similar vaccine for the treatment of asthma in humans.

Treatment perceptions in patients with asthma: Synthesis of factors influencing adherence

BACKGROUND

Non-adherence to asthma treatment is a contributing factor for poorly controlled asthma.

AIM

The aim of this systematic review is to explore patients' perceptions of their inhaled asthma treatment, and how these relate to adherence, using both qualitative and quantitative data.

METHODS

Pre-determined search terms and inclusion criteria were used to search electronic databases (The Cochrane Library, MEDLINE, EMBASE and PsycINFO). Two researchers screened titles and abstracts using the Rayyan web app and data were extracted in relation to psychological components (beliefs about, and attitudes towards, medicines) and adherence.

RESULTS

Of 1638 papers, 36 met the inclusion criteria. Key themes were: Perceived need for treatment - all 12 studies using the BMQ to measure patients' perceived need for treatment found that patients' beliefs about their necessity for treatment were associated with adherence-; Concerns about treatment - immediate and long-term side effects (58%), worries about safety (19%), and potential addiction to asthma medication (31%)-; and Perceived social stigma - 22% of studies reported that embarrassment contributed to poor adherence.

CONCLUSIONS

Acknowledging and addressing patient treatment beliefs and perceptual barriers to adherence is integral to designing adherence interventions for asthma patients. Further research is needed to better our understanding of the relationship between treatment perceptions and adherence.

Comparing Ran-Out Status of Inhaled Short-Acting Beta-Agonists in Emergency Department Patients with Acute Asthma: 1996-1998 versus 2015-2017

BACKGROUND

Medication nonadherence, including running out of inhaled asthma medications, is an important problem.

OBJECTIVE

The objective of this study was to examine the changes in the proportion of adults with acute asthma who ran out of their short-acting beta-agonist (SABA) inhalers before presenting to the emergency department (ED) between 1996--1998 and 2015-2017.

METHODS

We analyzed data from prospective multicenter observational cohort studies of ED adult patients (aged 18-54 years) with acute asthma. Within the same 3 EDs, we performed a structured interview during 2 time periods: 1996-1998 and 2015-2017. We fitted multivariable models to compare ran-out status between the 2 periods, adjusting for the baseline patient demographics, socioeconomic status, chronic asthma factors, and health care utilization factors. We further adjusted for the presence of a written action plan-an intervenable factor.

RESULTS

The analytic cohort comprised 353 patients (150 from the 1996-1998 studies and 203 from the 2015-2017 study). Over the approximately 20-year period, the proportion of patients who ran out of SABA inhalers increased (18% in 1996-1998 vs 26% in 2015-2017). In the multivariable model, compared with patients in 1996-1998, those in 2015-2017 had a significantly higher risk of running out of their SABA inhalers (adjusted odds ratio [OR] 2.01; 95% confidence interval [CI] 1.06-3.81; P = .03). With further adjustment for the presence of a written action plan, this difference attenuated (adjusted OR 1.66; 95% CI 0.75-3.68; P = .21).

CONCLUSIONS

Between 1996 and 2017, the proportion of ED patients with asthma who ran out of SABA inhalers significantly increased. The increase was explained, at least partially, by a lack of a written action plan.

Living with asthma and chronic obstructive airways disease: Using technology to support self-management - An overview

Long-term respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) are common, and cause high levels of morbidity and mortality. Supporting self-management is advocated for both asthma and increasingly so for COPD, and there is growing interest in the potential role of a range of new technologies, such as smartphone apps, the web or telehealth to facilitate and promote self-management in these conditions. Treatment goals for both asthma and COPD include aiming to control symptoms, maintain activities, achieve the best possible quality of life and minimize risks of exacerbation. To do this, health professionals should be (a) helping patients to recognize deteriorating symptoms and act appropriately; (b) promoting adherence to maintenance therapy; (c) promoting a regular review where triggers can be established, and strategies for managing such triggers discussed; and (d) promoting healthy lifestyles and positive self-management of symptoms. In particular, low uptake of asthma action plans is a modifiable contributor to morbidity and possibly also to mortality in those with asthma and should be addressed as a priority. Using technology to support self-management is an evolving strategy that shows promise. This review provides an overview of self-management support and discusses how newer technologies may help patients and health professionals to meet key treatment goals.

Impact of an Electronic Monitoring Intervention to Improve Adherence to Inhaled Medication in Patients with Asthma and Chronic Obstructive Pulmonary Disease: Study Protocol for a Randomized Controlled Trial

Background

Despite progress in pharmacological and non-pharmacological treatment in recent years, the burden of disease among patients with asthma and chronic obstructive pulmonary disease (COPD) is high and patients are frequently hospitalized due to exacerbations. Reasons for uncontrolled diseases are manifold, but are often associated with poor inhalation technique and non-adherence to the prescribed treatment plan. This causes substantial mortality, morbidity, and costs to the healthcare system. In this respect, the study of causes for non-adherence and the development of measures to increase and maintain treatment adherence in chronic diseases is of major clinical importance.

Objective

The primary objective of this study is to investigate the impact of using specific, validated electronic devices on adherence to inhaled medication in patients with chronic obstructive lung diseases such as asthma and COPD. Furthermore, it aims to assess the impact of a reminder and close supervision of the course of disease and quality of life.

Methods

In this ongoing prospective, single-blind, randomized controlled study, adherence to inhaled medication is analyzed over a 6-month period in at least 154 in- and outpatients with asthma or COPD who have experienced at least 1 exacerbation during the last year. Adherence is measured using electronic data capture devices, which save the date and time of each inhalative device actuation and transfer these data daily via a wireless connection to a Web-based database. Patients are randomly assigned to either the intervention or the control group. The clinical intervention consists of an automated and personal reminder. The intervention group receives an audio reminder and support calls in case medication has not been taken as prescribed or if rescue medication is used more frequently than pre-specified in the study protocol. During the study, participants are assessed every 2 months in the form of clinical visits.

Results

Recruitment started in January 2014. To date, a total of 169 patients have been recruited. Follow-up assessments are still ongoing. The study will be concluded in the first quarter of 2017. Data analysis will take place during 2017.

Conclusions

Few studies have investigated medication adherence in patients with chronic obstructive lung diseases. With this prospective study design and the use of state-of-the-art devices for measuring adherence, we expect scientifically relevant and clinically meaningful results that will have a substantial and positive impact on the provision of healthcare in chronically ill patients suffering from asthma or COPD.

Trial Registration

ClinicalTrials.gov: NCT02386722; https://clinicaltrials.gov/ct2/show/NCT02386722 (Archived by WebCite at http://www.webcitation.org/6oJq1fel0)

Seasonal patterns of Asthma medication fills among diverse populations of the United States

OBJECTIVE

Nonadherence to controller and overuse of reliever asthma medications are associated with exacerbations. We aimed to determine patterns of seasonal asthma medication use and to identify time period(s) during which interventions to improve medication adherence could reduce asthma morbidity.

METHODS

We conducted a retrospective cohort study of asthmatics 4-50 years of age and enrolled in three diverse health insurance plans. Seasonal patterns of medications were reported by monthly prescription fill rates per 1000 individuals with asthma from 1998 to 2013, and stratified by healthcare plan, sex, and age.

RESULTS

There was a distinct and consistent seasonal fill pattern for all asthma medications. The lowest fill rate was observed in the month of July. Fills increased in the autumn and remained high throughout the winter and spring. Compared with the month of May with high medication fills, July represented a relative decrease of fills ranging from 13% (rate ratio, RR: 0.87, 95% confidence interval, 95%CI: 0.72-1.04) for the combination of inhaled corticosteroids (ICS) + long acting beta agonists (LABA) to 45% (RR: 0.55, 95%CI: 0.49-0.61) for oral corticosteroids. Such a seasonal pattern was observed each year across the 16-year study period, among healthcare plans, sexes, and ages. LABA containing control medication (ICS+LABA and LABA) fill rates were more prevalent in older asthmatics, while leukotriene receptor antagonists were more prevalent in the younger population.

CONCLUSIONS

A seasonal pattern of asthma medication fill rates likely represents a reactive response to a loss of disease control and increased symptoms. Adherence to and consistent use of asthma medications among individuals who use medications in reaction to seasonal exacerbations might be a key component in reducing the risk of asthma exacerbations.

Changes in inhaler inhalation acoustic features during induced bronchoconstriction: a pilot study

Asthma is a chronic respiratory disease affecting millions of people worldwide, and is consequently a major issue for global health. Exacerbations are acute events involving the worsening of asthma's primary respiratory symptoms and are a major cause of morbidity in asthma patients, largely due to the unpredictability of their onset. This study aimed to investigate the relationship between changes in acoustic features of inhaler inhalations and changes in forced expiratory volume in one second (FEV1) that occur during a simulated exacerbation, a bronchial challenge test (BCT). This is a clinical test that simulates an asthma exacerbation through the administration of a bronchoconstrictor agent. Eight patients indicated for a BCT were recruited for this study. Non-contact and tracheal microphones were employed to record Diskus™ inhaler inhalations throughout the course of a BCT. A spirometer was employed to measure inhaler peak inspiratory flow rate (PIFR). In patients responsive to the BCT (n=4), significant correlations between changes in FEV1 and acoustic features on both microphones existed, with fractal increment of Katz fractal dimension yielding the strongest correlation (R=0.58), and between FEV1 and PIFR (R=0.62). These findings suggest that inhaler inhalation acoustic features may assist in the early detection of exacerbations. Future research will determine whether this is the case in a larger cohort of patients with non-simulated exacerbations.

Multidisciplinary Consensus on the Nonadherence to Clinical Management of Inhaled Therapy in Spanish asthma patients

PURPOSE

Rates of nonadherence to asthma treatment in Spain are between 24% and 76%, which results in poor disease control and increased health care costs. The main objective of this multidisciplinary consensus was to investigate the opinions of health professionals and patients regarding adherence to inhaled therapy in Spain. The results will help to identify the causes of nonadherence and to establish strategies to detect and correct the problem.

METHODS

This research was conducted by using a modified Delphi method organized into 2 rounds and involving a panel of 64 physicians, 16 nurses, and 10 community pharmacists. In addition, 70 patients with asthma completed a simplified 1-round survey, based on the Delphi questionnaire. The items proposed to reach a consensus included topics such as impact and causes of nonadherence, as well as strategies to improve adherence to treatment.

FINDINGS

Expert panelists reached a consensus on ~80% of the items proposed. They agreed that the lack of control in asthma has an important economic impact. The causes of nonadherence with more agreement were the patients' beliefs about treatment and the complexity of the inhalation devices. Panelists agreed that the most important strategies to improve adherence were modification of patients' beliefs, training of professionals in the management of adherence, and personalization of interventions. Most patients only agreed with items that referred to strategies to improve adherence.

IMPLICATIONS

Although the problems, impact, causes, and interventions regarding nonadherence to asthma treatment are known, adequate monitoring of adherence to treatment is not performed. A multidisciplinary and personalized approach is necessary to control and improve adherence.

A framework for measuring self-management effectiveness and health care use among pediatric asthma patients and families

Asthma is associated with substantial health care expenditures, including an estimated US$56 billion per year in direct costs. A recurring theme in the asthma management literature is that costly asthma symptoms, including hospitalizations and multiple emergency department (ED)/outpatient visits, can often be prevented through patient/family adherence to the national (National Institutes of Health Expert Panel Report-3) guidelines for effective self-management of asthma, specifically 1) medication adherence and 2) environmental trigger avoidance, as outlined in the patient's personalized Asthma-Action Plan. It is important to note however that while effective self-management of asthma is known to reduce ED visits and hospitalizations, the relationship between asthma self-management effectiveness and outpatient visit frequency remains ambiguous, reflecting a gap in the literature. For instance, do patients/families who self-manage effectively visit outpatient clinics more frequently for asthma care (compared to those who do not self-manage effectively), after accounting for differences in asthma severity, demographic characteristics, and risk factors? Do patients/families who visit outpatient clinics more frequently for asthma care, in turn have fewer ED and inpatient encounters for asthma? On the other hand, do patients/families who do not revisit outpatient clinics regularly have higher ED visits and hospitalizations? It is important to address these gaps, in order to reduce the costs and public health burden of asthma. This paper provides a foundation for addressing these gaps, by conducting an integrative review of the asthma management literature, to develop a conceptual framework for measuring self-management effectiveness and health care use among pediatric asthma patients/families. In doing so, the paper lays the groundwork for future research seeking to explicate the relationship between asthma self-management effectiveness and health care use, which in turn has potential to engage asthma providers in promoting ideal self-management and optimal health care use for pediatric asthma, in accordance with national evidence-based guidelines for asthma management.

See I told you I was taking it! - Attitudes of adolescents with asthma towards a device monitoring their inhaler use: Implications for future design

Adherence to treatment in asthma is often poor, particularly in adolescents and children where the condition is most prevalent. Electronic monitoring devices have shown potential for improving inhaler use, yet little research has considered the attitudes of patients towards these devices. We gave seven adolescents with asthma an electronic monitoring device to use for one month and collected their views on important issues including monitoring and data sharing. Our results showed that participants felt positively about using the data to demonstrate responsibility for their condition to both their parents and medical professionals, but expressed concern for the attention the device's appearance could draw to them and their asthma. This paper considers the positive and negative perceptions of this novel device and provides new insight into the attitudes of adolescents towards inhaler monitoring, as well as future directions for design and development of monitoring devices for asthma and other chronic medical conditions.

Spotlight on fluticasone furoate/vilanterol trifenatate for the once-daily treatment of asthma: design, development and place in therapy

The use of inhaled corticosteroids (ICSs) plays a key role in the treatment of asthmatic patients, and international guidelines have designated ICSs as an early maintenance therapy in controlling asthma symptoms. When asthmatic patients remain symptomatic on ICSs, one common option is to add a long-acting beta₂ agonist (LABA) to the maintenance treatment. Fixed combination inhalers that contain both an ICS and a LABA have been popular for both chronic obstructive pulmonary disease (COPD) and asthma. Historically, these inhalers have been dosed twice daily. However, currently, there is a once-daily combination therapy with the ICS fluticasone furoate (FF) and the LABA vilanterol trifenatate (VI) with indications for use in both COPD and asthma. This dry powder inhaler (DPI) comes in two doses of FF (100 or 200 μg) both combined with VI (25 μg). This article reviews the clinical trial data for FF, VI and FF/VI combination inhalers and documents the efficacy and safety of once-daily inhaled maintenance therapy by DPI in asthmatic patients.

Comply With Us: Improving Medication Adherence

Medication noncompliance is a pervasive problem resulting in significant morbidity and mortality. There are many terms used to describe medication-taking behavior including compliance, adherence, intelligent compliance, and drug forgiveness. More recently, clinicians have focused on the need for a collaborative partnership with patients to attain medication adherence. Problems identified include the patient’s failing to initiate therapy, under using or overusing a drug, stopping a drug too soon, and mistiming or skipping doses. Adherence to medications is a complex health behavior. There are many risk factors associated with decreased compliance, and many strategies have been shown to improve drug-taking behavior and patient outcomes. By careful assessment, the pharmacist can identify the high-risk patient, recommend an individualized care plan, and provide the follow-up necessary to successfully change patient behavior. Pharmacists should focus on improving their own application of behavior modification principles and patient communication skills. Improved medication compliance results in improved humanistic, clinical, and economic outcomes.

Development and validation of a predictive model of failed stepping-down of inhaled corticosteroids in adult asthmatics

BACKGROUND

Asthma guidelines suggest stepping-down of inhaled corticosteroids (ICSs) when asthma is stable.

OBJECTIVE

To determine outcomes of stepping-down and prediction of outcome after stepping-down of ICSs in controlled adult asthma.

METHODS

We performed a retrospective study on 21-81 year-old hospital-based outpatients with asthma in Japan. Protocol for stepping-down of ICSs was performed according to the GINA guideline. Failure/success of stepping-down is judged as occurring exacerbation or not for stepping-down of ICSs. Multiple logistic regression analysis was used to develop a prediction model for failed stepping-down, and then was validated by the leave-one-out cross-validation method. Our model of prediction score was calculated using receiver-operating characteristic area under the curve (AUC) analysis. The Nelson-Aalen curve demonstrated time to failure of stepping-down of ICSs.

RESULTS

A total of 126 patients with asthma attempted the stepping-down of ICSs according to the guideline. Of patients with follow-up, 97 (77.0%) of stepping-down attempts were successful. Using multivariate logistic regression analysis, comorbidity with rhinitis/rhinosinusitis and phlegm grade were independent predictors of failed stepping-down of ICSs, with odds ratios of 3.8 (95% confidence interval, 1.04-13.3; P=0.04) and 1.3 (95% confidence interval, 1.01-11.5; P=0.04), respectively. These variables were then used to build a prediction score in terms of the prediction of failed stepping-down events. When the two variables were added to form the prediction score, the discriminative power of scores calculated by the prediction model using the AUC was 0.75 (range: 0.62-0.88) for naïve prediction and 0.72 (range: 0.60-0.86) after cross-validation. In the time-to-failure models, cumulative hazard ratio of failed stepping-down have fixed 1 year after stepping-down.

CONCLUSION

Our results suggest that comorbidity with rhinitis/rhinosinusitis and phlegm grade are imperative to predict failed stepping-down of ICSs in controlled patients with adult asthma.

The combination of fluticasone furoate and vilanterol trifenatate in the management of asthma: clinical trial evidence and experience

The treatment of persistent asthma has been aided by the recent approval of new medications. The combined inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA) powder inhaler fluticasone furoate (FF)/vilanterol trifenatate (VI) is one of these new agents, which was recently approved as a maintenance therapy for persistent asthma. This once-daily ICS/LABA inhaler has previously been approved and used in chronic obstructive pulmonary disease as a maintenance therapy. Both FF and VI individually have been shown to have efficacy in the treatment of persistent asthma; the combination of FF/VI at the dose of 100/25 μg daily improves trough peak expiratory flows and forced expiratory volume in 1 s. It also reduces the frequency of asthma exacerbations in patients with persistent asthma. The once-daily dosing is well tolerated, with limited clinically significant adverse events; the once-daily inhaled dosing regimen should also improve medication adherence. The data supporting the use of the FF/VI inhaler in persistent asthma are reviewed. The dry powder inhaler of FF/VI (100/25 μg) is an effective and well tolerated once-daily maintenance treatment for patients with persistent asthma.

High degree of supervision improves adherence to inhaled corticosteroids in children with asthma

Purpose

Adherence to treatment with inhaled corticosteroids (ICS) is a critical determinant of asthma control. The objective of this study was to assess factors that determine adherence to ICS therapy in children with asthma.

Methods

Fifty-eight children with asthma, aged 5 to 16 years, used ICS with or without a spacer for 3 months. Adherence rates as measured from questionnaires and canisters, asthma symptom scores, and inhalation technique scores were assessed every 30 days. The degree of supervision by caregivers was assessed at day 30.

Results

Adherence rates measured using canisters were lower at day 60 than at day 30 (P=0.044) and did not change thereafter (74.4%±17.4% at day 30, 66.5%±18.4% at day 60, and 67.4%±22.2% at day 90). Adherence rates at days 60 and 90 and during the total study period were significantly different when measured by using questionnaires versus canisters (P<0.001, P=0.022, and P=0.001, respectively). In the comparison of adherence rates repeatedly measured at days 30, 60, and 90 and adherence rates during the total study period among the 3 groups, adherence rates in the high-degree supervision group were significantly higher than those in the low-degree supervision group (82.0±16.0 vs. 66.1±14.5, 75.4±14.4 vs. 56.2±18.4, 75.0±18.3 vs. 55.0±19.7 [P=0.027]; 77.9±12.2 vs. 59.1±11.4 [P=0.021]) after adjustment for sex and age.

Conclusion

The level of caregiver supervision is an important factor affecting adherence to ICS therapy in children with asthma. Therefore, a high degree of supervision may be required to increase adherence to ICS therapy in children with asthma.

Impact of comorbid depression on medication adherence and asthma-related healthcare costs in Texas Medicaid patients with asthma

Objectives

To compare: (1) rates of adherence to asthma controllers (ACs) between patients with asthma alone (A) and patients with asthma and comorbid depression (A + D); (2) rates of adherence to AC between patients who adhere to antidepressants and patients who do not adhere to antidepressants; and (3) asthma-related healthcare costs between the A and A + D groups.

Methods

Texas Medicaid insurance claims from 1 January 2007 to 31 October 2011 were extracted for adults (18–63 years) diagnosed with asthma with at least two fills of the same AC (inhaled corticosteroids, long-acting beta agonists, fixed-dose combinations (FDC) and leukotriene modifiers) in the A group, and at least two antidepressant claims in the A + D group. Proportion of days covered (PDC) was used to assess adherence to antidepressants and AC, while controlling for demographics, chronic disease score (CDS) and AC therapy type (monotherapy, FDC, dual therapy). Asthma-related healthcare costs included asthma-related prescriptions, inpatient and outpatient costs. Descriptive statistics, Wilcoxon test and regression analyses were used.

Key findings

The patients (n = 3626) were 40.1 ± 14.0 years, primarily women (75.0%), Caucasians (37.3%), FDC therapy users (56.3%), with CDS = 0 (74.2%). Results showed that compared to the A group (n = 3400), patients in the A + D group (n = 226) were 1.6 times more likely to adhere (PDC ≥50%) to their AC (odds ratio (OR) = 1.596; 95% confidence interval (CI) = 1.198–2.128; P &lt; 0.001). Compared to patients who do not adhere to antidepressants (PDC &lt; 80%) (n = 140), patients who adhered to antidepressants (PDC ≥80%) (n = 86) were 2.5 times more likely to adhere (PDC ≥50%) to AC, while controlling for covariates (OR = 2.517; 95% CI = 1.304–4.855; P = 0.006). After controlling for covariates, compared to the A group, the A + D disorder group had significantly lower total asthma-related healthcare costs (P &lt; 0.001).

Conclusions

In the A + D group, the higher costs of asthma-related prescriptions was offset by the lower costs of inpatient and outpatient claims. Patients in the A + D group should be encouraged to adhere to both their ACs and antidepressants.

CYT003, a TLR9 agonist, in persistent allergic asthma - a randomized placebo-controlled Phase 2b study

BACKGROUND

New treatment options are required for patients with asthma not sufficiently controlled with inhaled therapies. In a Phase 2a trial, CYT003, a Toll-like receptor-9 agonist immunomodulator, improved asthma control during inhaled glucocorticosteroid reduction in patients with allergic asthma. This double-blind Phase 2b study assessed the efficacy and safety of CYT003 in patients with persistent moderate-to-severe allergic asthma not sufficiently controlled on standard inhaled glucocorticosteroid therapy with/without long-acting beta-agonists (LABAs).

METHODS

Overall, 365 patients received seven doses of subcutaneous CYT003 (0.3, 1, or 2 mg) or placebo as add-on therapy to conventional controller medication. Change from baseline in Asthma Control Questionnaire (ACQ) score was the primary outcome; secondary outcomes included change in forced expiratory volume, Mini Asthma Quality of Life Questionnaire, and safety.

RESULTS

All groups, including placebo, showed a clinically important improvement in ACQ score; however, there was no significant difference between the CYT003 and placebo groups at week 12 (least-squares mean difference 0.3 mg: -0.027 [95% confidence interval -0.259 to 0.204]; 1 mg: 0.097 [-0.131 to 0.325]; 2 mg: 0.081 [-0.148 to 0.315]). No significant differences were seen in secondary outcomes. CYT003 was well tolerated; the most common treatment-emergent adverse events were injection site reactions. Due to lack of efficacy, the study was prematurely terminated at the end of the treatment phase with no further follow-up.

CONCLUSIONS

Toll-like receptor-9 agonism with CYT003 showed no additional benefit in patients with insufficiently controlled moderate-to-severe allergic asthma receiving standard inhaled glucocorticosteroid therapy with or without LABAs.

Medicines Compliance and Reimbursement Level in Portugal

During a severe financial crisis, it is a priority to use scientific evidence to identify factors that enable therapeutic compliance by patients. This study aimed to evaluate a possible association between the number of patients who attended a medical appointment and had medicine prescribed and the number of these same patients who purchased the prescribed medicine and whether the level of reimbursement was a deciding factor. We perform a correlation analysis at primary care centers in Portugal, between 2010 and 2012 (n = 96). We found a moderate to high positive association, which is statistical significant, between the number of the patients with medicines dispensing and medicines reimbursement levels. The correlation coefficient varies from .5 to .63 (P < .01). The compliance increases along with the increase in the reimbursement levels.

Adherence to controller asthma medications: 6-month prevalence across a US community pharmacy chain

WHAT IS KNOWN AND OBJECTIVE

Non-adherence to controller asthma medications is an important public health problem. It is estimated to occur in 30-70% of individuals and is a significant risk factor for asthma morbidity and mortality. The aim of this study was to determine the level of adherence, as indicated by refill rates, to controller asthma medications in a community pharmacy setting.

METHODS

Secondary analyses of a community pharmacy dispensing database in 15 locations throughout Utah.

RESULTS AND DISCUSSION

The dispensing records of 2193 patients who received controller medications for asthma in a 12-month period, and had a minimum of 6-month potential coverage (180 days) from the date of their first receipt of a controller medication in that period, were examined. Using standard metrics to gauge adherence, the proportion of days covered (PDC) and the medication possession ratio (MPR), the average coverage for controller asthma medications across a 6-month period (180 days) was poor, averaging less than 50% of days' availability. Standard cut-offs (≥80% medication availability) indicated that only 14-16% of patients had 'satisfactory' adherence over their 6-month follow-on period. Females and older patients had significantly greater satisfactory adherence. Medication adherence was significantly greater with inhaled corticosteroid (ICS)-long-acting β₂ -agonist (LABA) combinations than with ICS alone.

WHAT IS NEW AND CONCLUSION

This study confirms the considerable scope of the asthma therapy non-adherence problem. Therefore, it is imperative to conduct survey-based research linked directly to pharmacy-based dispensing data to derive patient behavioural, attitudinal and environmental factors that may contribute to the issue, and then pilot and evaluate interventions for change.

An acoustic method of automatically evaluating patient inhaler technique

Chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) affect millions of people worldwide. Inhalers are devices utilized to deliver medication in small doses directly to the airways in the treatment of asthma and COPD. Despite the proven effectiveness of inhaler medication in controlling symptoms, many patients suffer from technique errors leading to decreased levels of medication efficacy. This study employs a recording device attached to a commonly used dry powder inhaler (DPI) to obtain the acoustic signals of patients taking their inhaler medication. The audio files provide information on how a patient uses their inhaler over a period of one month. Manually listening to such a large quantity of audio files would be a time consuming and monotonous process and therefore an algorithm that could automatically carry out this task would be of great benefit. An algorithm was thus designed and developed to detect inhalation, exhalation and blister events in the audio signals, analyze the quantity of each event, the order in which the events took place and finally provide a score on the overall performance. The algorithm was tested on a dataset of 185 audio files obtained from five community dwelling asthmatic patients in real world environments. Evaluation of the algorithm on this dataset revealed that it had an accuracy of 92.8% in deciding the correct technique score compared to manual detection methods.

Negative impact of asthma on patients in different age groups

Objective:

To evaluate the impact of asthma on patients in Brazil, by age group (12-17 years, 18-40 years, and ≥ 41 years).

Methods:

From a survey conducted in Latin America in 2011, we obtained data on 400 patients diagnosed with asthma and residing in one of four Brazilian state capitals (São Paulo, Rio de Janeiro, Curitiba, and Salvador). The data had been collected using a standardized questionnaire in face-to-face interviews. For the patients who were minors, the parents/guardians had completed the questionnaire. The questions addressed asthma control, number of hospitalizations, number of emergency room visits, and school/work absenteeism, as well as the impact of asthma on the quality of life, sleep, and leisure. We stratified the data by the selected age groups.

Results:

The proportions of patients who responded in the affirmative to the following questions were significantly higher in the 12- to 17-year age group than in the other two groups: "Have you had at least one episode of severe asthma that prevented you from playing/exercising in the last 12 months?" (p = 0.012); "Have you been absent from school/work in the last 12 months?" (p < 0.001); "Have you discontinued your asthma relief or control medication in the last 12 months?" (p = 0.008). In addition, 30.2% of the patients in the 12- to 17-year age group reported that normal physical exertion was very limiting (p = 0.010 vs. the other groups), whereas 14% of the patients in the ≥ 41-year age group described social activities as very limiting (p = 0.011 vs. the other groups).

Conclusions:

In this sample, asthma had a greater impact on the patients between 12 and 17 years of age, which might be attributable to poor treatment compliance.

Quantification of Aerosol Hydrofluoroalkane HFA-134a Elimination in the Exhaled Human Breath Following Inhaled Corticosteroids Administration

Inhaled corticosteroids (ICS) and β2-agonists are the primary pharmacotherapies of asthma management. However, suboptimal medication compliance is common in asthmatics and is associated with increased morbidity. We hypothesized that exhaled breath measurements of the aerosol used in the inhaled medications might prove useful as surrogate marker for asthma medication compliance. To explore this, 10 healthy controls were recruited and randomly assigned to ICS (Flovent HFA) or short acting bronchodilators (Proventil HFA). Both inhalers contain HFA-134a as aerosol propellant. Exhaled breath sampling and pulmonary function tests were performed prior to the inhaler medication dispersion, immediately after inhalation, then at 2, 4, 6, 8, 24, and 48 hours postadministration. At baseline, mean (SD) levels of HFA-134a in the breath were 252 (156) pptv. Immediately after inhalation, HFA-134a breath levels increased to 300 × 10(6) pptv and were still well above ambient levels 24 hours postadministration. The calculated ratio of forced expiratory volume in 1 second over forced vital capacity did not change over time following inhaler administration. This study demonstrates, for the first time, that breath HFA-134a levels can be used to assess inhaler medication compliance. It may also be used to evaluate how effectively the medicine is delivered.

Screening and functional pathway analysis of genes associated with pediatric allergic asthma using a DNA microarray

The present study aimed to identify differentially expressed genes (DEGs) associated with pediatric allergic asthma, and to analyze the functional pathways of the selected target genes, in order to explore the pathogenesis of the disease. The GSE18965 gene expression profile was downloaded from the Gene Expression Omnibus database and was preprocessed. This gene expression profile consisted of seven normal samples and nine samples from patients with pediatric allergic asthma. The DEGs between the normal and pediatric allergic asthma samples were screened using limma package in R, and the cut‑off value was set at false discovery rate <0.05 and log fold change >1. Following hierarchical clustering of the DEGs based on the expression profiles, the up‑ and downregulated genes underwent a functional enrichment analysis by topological approach (P<0.05), using the Database for Annotation, Visualization and Integrated Discovery. A total of 127 DEGs were identified between the normal and pediatric allergic asthma samples. The up‑ and downregulated genes were significantly enriched in the actin filament‑based process and the monosaccharide metabolic process, respectively. Seven downregulated DEGs (M6PR, TPP1, GLB1, NEU1, ACP2, LAMP1 and HGSNAT) were identified in the lysosomal pathway, with P=6.4x10(‑9). These results suggested that variation in lysosomal function, triggered by the seven downregulated genes, may lead to aberrant functioning of the T lymphocytes, resulting in asthma. Further research regarding the treatment of pediatric allergic asthma through targeting lysosomal function is required.