Regimen and device compliance: key factors in determining therapeutic outcomes

Precision Medicine and Childhood Asthma: A Guide for the Unwary

Many thousands of articles relating to asthma appear in medical and scientific journals each year, yet there is still no consensus as to how the condition should be defined. Some argue that the condition does not exist as an entity and that the term should be discarded. The key feature that distinguishes it from other respiratory diseases is that airway smooth muscles, which normally vary little in length, have lost their stable configuration and shorten excessively in response to a wide range of stimuli. The lungs' and airways' limited repertoire of responses results in patients with very different pathologies experiencing very similar symptoms and signs. In the absence of objective verification of airway smooth muscle (ASM) lability, over and underdiagnosis are all too common. Allergic inflammation can exacerbate symptoms but given that worldwide most asthmatics are not atopic, these are two discrete conditions. Comorbidities are common and are often responsible for symptoms attributed to asthma. Common amongst these are a chronic bacterial dysbiosis and dysfunctional breathing. For progress to be made in areas of therapy, diagnosis, monitoring and prevention, it is essential that a diagnosis of asthma is confirmed by objective tests and that all co-morbidities are accurately detailed.

Asthma: A Loss of Post-natal Homeostatic Control of Airways Smooth Muscle With Regression Toward a Pre-natal State

The defining feature of asthma is loss of normal post-natal homeostatic control of airways smooth muscle (ASM). This is the key feature that distinguishes asthma from all other forms of respiratory disease. Failure to focus on impaired ASM homeostasis largely explains our failure to find a cure and contributes to the widespread excessive morbidity associated with the condition despite the presence of effective therapies. The mechanisms responsible for destabilizing the normal tight control of ASM and hence airways caliber in post-natal life are unknown but it is clear that atopic inflammation is neither necessary nor sufficient. Loss of homeostasis results in excessive ASM contraction which, in those with poor control, is manifest by variations in airflow resistance over short periods of time. During viral exacerbations, the ability to respond to bronchodilators is partially or almost completely lost, resulting in ASM being "locked down" in a contracted state. Corticosteroids appear to restore normal or near normal homeostasis in those with poor control and restore bronchodilator responsiveness during exacerbations. The mechanism of action of corticosteroids is unknown and the assumption that their action is solely due to "anti-inflammatory" effects needs to be challenged. ASM, in evolutionary terms, dates to the earliest land dwelling creatures that required muscle to empty primitive lungs. ASM appears very early in embryonic development and active peristalsis is essential for the formation of the lungs. However, in post-natal life its only role appears to be to maintain airways in a configuration that minimizes resistance to airflow and dead space. In health, significant constriction is actively prevented, presumably through classic negative feedback loops. Disruption of this robust homeostatic control can develop at any age and results in asthma. In order to develop a cure, we need to move from our current focus on immunology and inflammatory pathways to work that will lead to an understanding of the mechanisms that contribute to ASM stability in health and how this is disrupted to cause asthma. This requires a radical change in the focus of most of "asthma research."

The Digital Asthma Patient: The History and Future of Inhaler Based Health Monitoring Devices

The wave of digital health is continuously growing and promises to transform healthcare and optimize the patients' experience. Asthma is in the center of these digital developments, as it is a chronic disease that requires the continuous attention of both health care professionals and patients themselves. The accurate and timely assessment of the state of asthma is the fundamental basis of digital health approaches and is also the most significant factor toward the preventive and efficient management of the disease. Furthermore, the necessity of inhaled medication offers a basic platform upon which modern technologies can be integrated, namely the inhaler device itself. Inhaler-based monitoring devices were introduced in the beginning of the 1980s and have been evolving but mainly for the assessment of medication adherence. As technology progresses and novel sensing components are becoming available, the enhancement of inhalers with a wider range of monitoring capabilities holds the promise to further support and optimize asthma self-management. The current article aims to take a step for the mapping of this territory and start the discussion among healthcare professionals and engineers for the identification and the development of technologies that can offer personalized asthma self-management with clinical significance. In this direction, a technical review of inhaler based monitoring devices is presented, together with an overview of their use in clinical research. The aggregated results are then summarized and discussed for the identification of key drivers that can lead the future of inhalers.

Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery

INTRODUCTION

The inhaled route has many advantages, but requires the patient to use, and to master the use of, an inhaler device. Poor inhaler technique and non-adherence to therapy lead to a highly variable lung dose in clinical practice, with subsequent loss of clinical efficacy and wastage of economic resources.

AREAS COVERED

This paper discusses problems of poor inhaler technique, non-adherence to inhaler therapy, other issues relating to the precision of dose delivery, the consequences of these problems and how they can be addressed.

EXPERT OPINION

The precision of dosing by the pulmonary route can be improved by appropriate choice of inhaler device and by education. It is vital to educate patients about their disease, about the importance of taking prescribed medications and about correct inhaler use. One-on-one sessions with healthcare professionals probably represent the most effective educational method. For some drugs and patient groups, inhalers containing small microprocessors may also be used to control inhalation technique, and hence, to obtain a more reproducible lung dose. As the range of drugs delivered by inhalation increases, the need for correct inhaler technique, adherence to therapy and precise dosing becomes more and more important.

Guidelines for aerosol devices in infants, children and adults: which to choose, why and how to achieve effective aerosol therapy

Multiple types of aerosol devices are commonly used for the administration of medical aerosol therapy to patients with pulmonary diseases. All of these devices have been shown to be effective in trials where they are used correctly. However, failure to operate any of these devices properly has been associated with poor clinical response and limited patient adherence to therapy. Therefore, the selection of the best aerosol device for the individual patient is very important for optimizing the results of medical aerosol therapy. This article presents the rationale for selecting the most appropriate aerosol device to administer inhaled drugs in specific patient populations, with emphasis on patient-, drug-, device- and environment-related factors and with a comparison between the available devices. The following recommendations for the selection of the 'best' aerosol device for each patient population are intended to help clinicians gain a clear understanding of the specific issues and challenges so that they can optimize aerosol drug delivery and its therapeutic outcomes in patients.

Adherence monitoring in drug delivery

Adherence monitoring is an important issue in inhaled drug delivery. Adherence is commonly found to be low and poor adherence is associated with increased mortality and morbidity and increased use of health services. Improving adherence is essential to maintaining disease and symptom control for patients and decreasing health costs. Feedback on actual adherence has been shown to increase subsequent adherence. In addition, education programs, reminder systems and increased patient-clinician interaction can also improve adherence. However, improved adherence is not sufficient if inhalation devices are being used incorrectly; the emphasis must be on devices being used in accordance with both the prescribed regimen and the instructions for use. As a result of technological advancements, drug delivery devices that both monitor adherence and address poor inhaler technique are now available. These devices combine monitoring systems with various feedback mechanisms in order to 'coach' the patient to use the device correctly. Some devices also incorporate connectivity to communicate accurate adherence and inhaler technique data to the clinician. This editorial considers current and future adherence monitoring devices and the impact that such technology could have on improving the patient's adherence and inhaler technique.

Accurate assessment of adherence: self-report and clinician report vs electronic monitoring of nebulizers

BACKGROUND

People with cystic fibrosis have a high treatment burden. While uncertainty remains about individual patient level of adherence to medication, treatment regimens are difficult to tailor, and interventions are difficult to evaluate. Self- and clinician-reported measures are routinely used despite criticism that they overestimate adherence. This study assessed agreement between rates of adherence to prescribed nebulizer treatments when measured by self-report, clinician report, and electronic monitoring suitable for long-term use.

METHODS

Seventy-eight adults with cystic fibrosis were questioned about their adherence to prescribed nebulizer treatments over the previous 3 months. Self-report was compared with clinician report and stored adherence data downloaded from the I-Neb nebulizer system. Adherence measures were expressed as a percentage of the prescribed regimen, bias was estimated by the paired difference in mean (95% CI) patient and clinician reported and actual adherence. Agreement between adherence measures was calculated using intraclass correlation coefficients (95% CI), and disagreements for individuals were displayed using Bland-Altman plots.

RESULTS

Patient-identified prescriptions matched the medical record prescription. Median self-reported adherence was 80% (interquartile range, 60%-95%), whereas median adherence measured by nebulizer download was 36% (interquartile range, 5%-84.5%). Nine participants overmedicated and underreported adherence. Median clinician report ranged from 50% to 60%, depending on profession. Extensive discrepancies between self-report and clinician report compared with nebulizer download were identified for individuals.

CONCLUSIONS

Self- and clinician-reporting of adherence does not provide accurate measurement of adherence when compared with electronic monitoring. Using inaccurate measures has implications for treatment burden, clinician prescribing practices, cost, and accuracy of trial data.

Personalizing aerosol medicine: development of delivery systems tailored to the individual

Inhalation of drugs for therapeutic effects is not a recent innovation as illicit drugs have been ‘smoked’ for millennia. Nicotine delivery ‘devices’ in convenient packaged cartons of cigarettes are simple to use, inexpensive per dose and accessible to people of most ages and lung function, but of course their use leads to increased cancer, emphysema, heart disease and other medical and societal problems. In contrast, many inhalation pharmaceutical medical devices are expensive, nonportable, inconvenient, and/or are used improperly thus leading to poor therapeutic benefit. We review the current state of the art with respect to aerosol delivery, inhalation devices and the ability to personalize the treatment and management of lung disease. The confluence of many drivers will lead to more programmable and flexible devices in the future: the transition from the blockbuster model to customized therapy, technological advancements (e.g., smartphones) and cultural changes including social networking.

[Diagnosis and treatment guidelines for difficult-to-control asthma in children]

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.