Asthma medication - persistence with adrenergics, steroids and combination products over a 5-year period

Medication adherence with fixed-dose versus free-equivalent combination therapies: Systematic review and meta-analysis

Objective: We conducted a large-scale meta-analysis and subgroup analysis to compare the effect of fixed-dose combination (FDC) therapy with that of free-equivalent combination (FEC) therapy on medication adherence. Methods: Studies published in Web of Science, PubMed, Cochrane Library, ScienceDirect, and Embase up to May 2022 were identified according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary assessed outcomes were the medication possession ratio (MPR) and proportion of days covered (PDC). We investigated the probability of being adherent to the prescribed treatment (MPR or PDC ≥80%) or the average estimate of these two parameters. Studies reporting such results were included in this meta-analysis. The summary measures were reported as the risk ratio (RR) and the weighted mean difference (MD) with 95% of confidence interval (CI) using the random-effects model of DerSimonian and Laird. The quality of the cohort studies was assessed using the Newcastle-Ottawa scale. Results: Of the 1,814 screened studies, 61 met the predefined inclusion criteria. The meta-analysis of the results showed that compared to FEC, FDC significantly improved the medication compliance of patients by 1.29 times (95% CI:1.23-1.35, p < 0.00001). I² of 99% represent high heterogeneity across studies. The mean difference in medication adherence between FDC and FEC was 0.10 (95% CI: 0.06-0.14, p < 0.00001) with an I² estimate of 100%. Subgroup analyses were performed for studies that reported adherence outcomes according to disease type, period of evaluation and compliance indicators. A sensitivity analysis was conducted to exclude the results of low-quality studies, as well as studies in which there was ambiguity in the method of calculating the estimator. Conclusion: Analysis of the assessed parameters for the intention-to-treat and subgroup populations suggests that FDC can improve adherence to treatment and its advantages over FEC may increase over time. Further research is needed to better understand how medical conditions affect the impact of reduced pill burden on adherence, particularly in diseases other than cardiovascular disease and type 2 diabetes mellitus.

Extent of non-adherence and non-persistence in asthma patients: analysis of a large claims data set

OBJECTIVE

The objective of this study was to assess non-adherence (NA) and non-persistence (NP) to long-acting asthma medications in Germany by differentiating between measurement of NA in periods of therapy continuation and measurement of NP in therapy-naïve patients.

METHODS

We analyzed treatment adherence to long-acting asthma medication using German claims data for periods of treatment continuation based on the medication possession ratio (MPR) and the proportion of days covered. Persistence was assessed in treatment-naïve patients. Outcomes were observed from the date of the first to the last prescription within a 12-month period. Both NA and NP analyses considered prescription supply, using either defined daily dosages, or prescribed daily dosages derived from a medical chart review.

RESULTS

We identified 52,508 asthma patients (mean age: 40.1, 58.4% female) who received at least two long-acting asthma prescriptions within 12 months; 50,660 treatment-naïve patients were included in the NP analysis (mean age: 39.7, 58.8% female). The mean 12-month MPR was 38.5% (89.4% NA according to MPR ≤ 80%) and the average proportion of days covered was 40.4% (85.9% NA). Agent-specific MPR and NA rates varied between 31.8% (91.8% NA) and 56.2% (71.6% NA). The average weighted-MPR increased to 53.1% when using the prescribed daily dosage. Based on a > 90-day gap definition, 86.7% of patients were considered non-persistent after 12 months (>180: 72.3%). When using prescribed daily dosages, NP rates ranged from 66.7 to 78.5%.

CONCLUSION

High levels of treatment NA and NP indicate a substantial need to improve adherence and persistence to long-acting asthma medication in Germany.

A data-driven typology of asthma medication adherence using cluster analysis

Asthma preventer medication non-adherence is strongly associated with poor asthma control. One-dimensional measures of adherence may ignore clinically important patterns of medication-taking behavior. We sought to construct a data-driven multi-dimensional typology of medication non-adherence in children with asthma. We analyzed data from an intervention study of electronic inhaler monitoring devices, comprising 211 patients yielding 35,161 person-days of data. Five adherence measures were extracted: the percentage of doses taken, the percentage of days on which zero doses were taken, the percentage of days on which both doses were taken, the number of treatment intermissions per 100 study days, and the duration of treatment intermissions per 100 study days. We applied principal component analysis on the measures and subsequently applied k-means to determine cluster membership. Decision trees identified the measure that could predict cluster assignment with the highest accuracy, increasing interpretability and increasing clinical utility. We demonstrate the use of adherence measures towards a three-group categorization of medication non-adherence, which succinctly describes the diversity of patient medication taking patterns in asthma. The percentage of prescribed doses taken during the study contributed to the prediction of cluster assignment most accurately (84% in out-of-sample data).

Long-Term Inhaled Corticosteroid Adherence in Asthma Patients with Short-Term Adherence

BACKGROUND

Although the use of inhaled corticosteroids (ICS) in asthma is known to be overall erratic, the long-term use of ICS by patients selected during an episode of regular use is poorly documented.

OBJECTIVE

In a cohort of patients with asthma regularly acquiring ICS therapy over several months, we verified whether these patients remained treated in the following 12 months. The correlates of regular ICS use over this period were investigated.

METHODS

A historical cohort of patients with asthma was identified from the Echantillon généraliste de bénéficiaires national French health care reimbursement data (2007-2012). Patients (6-40 years) were selected during a regular ICS use episode, with 3 or more ICS refills within 120 days. Continuous multiple-interval measures of medication availability (CMA) were computed for the 12 months after the third dispensation, and the factors associated with a CMA value of 80% or more (adherent patients) were identified.

RESULTS

Among 5096 patients (42.1% children/teenagers, 48.8% females), only 24.0% had a CMA value of 80% or more (mean CMA = 54.4%) over the 12 months following the ICS selection period. Achieving a CMA value of 80% or more was primarily associated with being a child/teenager (P = .002), having more severe or less controlled asthma (P = .007), more previous dispensing of short-acting beta agonists (P < .0001), and receiving devices with 200 unit doses (P < .0001). Adherent patients had more frequent general practitioner visits (P < .0001), more distinct prescribers of respiratory therapy (P = .0002), and more frequent switches of ICS (P < .0001).

CONCLUSIONS

Most patients with asthma selected during an episode of regular ICS use did not maintain therapy over the following months. Adherence should be repeatedly monitored, and the reasons for discontinuation should be investigated, at prescriber and patient 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.

A comparison of medication adherence/persistence for asthma and chronic obstructive pulmonary disease in the United Kingdom

AIM

To describe and compare adherence and persistence with maintenance therapies in patients with asthma or chronic obstructive pulmonary disease (COPD) in the United Kingdom (UK).

METHODS

A retrospective prescribing database cohort was obtained from 44 general practitioner surgeries in National Health Service Forth Valley Scotland. Patients with physician-diagnosed asthma or COPD who received maintenance therapy between January 2008 and December 2009 were included. Five classes of therapy were assessed: inhaled corticosteroids, long-acting beta-agonists, combination therapy inhalers, theophyllines and long-acting muscarinic antagonists. Adherence was calculated using the medication possession ratio (MPR) and persistence was determined using Kaplan-Meier survival analysis for the time to discontinuation (TTD) over 1 year. Two step-wise logistic regressions were performed to assess the contribution of diagnosis to adherence/persistence.

RESULTS

A total of 13,322 patients were included in the analysis: 10,521 patients with asthma and 2801 patients with COPD. 25.2% of medication episodes for asthma and 45.6% of medication episodes for COPD were classified as having an adequate medication supply (MPR of 80-120%). The overall median TTD was 92 days (IQR, interquartile range: 50-186 days) for patients with asthma and 116 days (IQR: 58-259 days, comparison p < 0.001) for patients with COPD. Patients with COPD were found to be more likely to achieve an MPR of at least 80% (OR: 1.27, 95% CI: 1.15-1.40), but had a similar likelihood of persistence at 1 year to patients with asthma.

CONCLUSION

Adherence and persistence with respiratory therapies in the UK is relatively low. There is suggestion that patients with COPD may display more adherent behaviours than patients with asthma.

Adherence to inhaled corticosteroids by asthmatic patients: measurement and modelling

Background Poor adherence to inhaled corticosteroids (ICS) is known as the main cause for therapeutic failure in asthma treatment and associated morbidity. To improve adherence, targetted and effective interventions need to be developed ideally based on using longitudinal follow-up of a large study cohort to establish patterns and influences on adherence. Objective To develop an annual measure of asthma patients’ adherence to ICS using primary care prescribing data over consecutive annual intervals, and to statistically model ICS adherence controlling for a range of patient factors. Setting A retrospective cohort study between 1997 and 2010 using United Kingdom general practice prescribing data on asthma patients aged between 12 and 65 years, without a diagnosis of chronic obstructive pulmonary disease. Method Patient’s ICS prescriptions are used to calculate the ‘number of days prescribed during calendar year’ divided by ‘number of days in the interval’ to form an annual prescription possession ratio (PPR) for each patient. Several definitions of PPR are considered and compared when calculating numerator and denominator. Adherence, measured by the preferred PPR, is then modelled to estimate the effect of asthma exacerbation, severity, control and other patient factors on adherence. Main outcome measure PPR, being a proxy measure for adherence. Results Annual PPR by all strategies gave a similar frequency profile. ICS were either over- or under-prescribed for over half of the follow-up time. Adherence was lower in younger patients, those newer to the study timeframe, those with less severe asthma, those with good control, with lower previous adherence, and who had not previously experienced an exacerbation. Conclusion The chosen PPR simulated clinical use of ICS most closely; including overlapping days, excess days passed to the next interval, considering gaps in the denominator, with censoring at 100 %. The PPR is a useful measure for signalling or measuring adherence changes over time. The modelling results identified many characteristics which would indicate which asthma patients and at what points in their treatment cycle they would be at increased risk of low adherence.

Adequate levels of adherence with controller medication is associated with increased use of rescue medication in asthmatic children

Background

The role of asthma controller medication adherence and the level of asthma control in children is poorly defined.

Aims

To assess the association between asthma controller medication adherence and asthma control in children using routinely acquired prescribing data.

Methods

A retrospective observational study of children aged 0–18 years prescribed inhaled corticosteroids only (ICS), leukotriene receptors antagonists (LTRA), or long-acting β2 agonists (LABA) and ICS prescribed as separate or combined inhalers, between 01/09/2001 and 31/08/2006, registered with primary care practices contributing to the Practice Team Information database. The medication possession ratio (MPR) was calculated and associations with asthma control explored. Poor asthma control was defined as the issue of prescriptions for ≥1 course of oral corticosteroids (OCS) and/or ≥6 short-acting β2 agonists (SABA) canisters annually.

Results

A total of 3172 children prescribed asthma controller medication were identified. Of these, 15–39% (depending on controller medication) demonstrated adequate MPR. Adequate MPR was associated with male gender, good socio-economic status, and oral LTRA therapy. Adequate MPR was more likely to be associated with increased use of rescue medication. However logistic regression only identified a significant relationship for ICS only (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.35–2.48; p<0.001), LTRA (OR, 2.11; 95% CI, 1.27–3.48; p = 0.004) and LABA/ICS (OR, 2.85; 95% CI, 1.62–5.02; p<0.001).

Conclusion

Poor adherence was observed for all asthma controller medications, although was significantly better for oral LRTA. In this study adequate adherence was not associated with the use of less rescue medication, suggesting that adherence is a complex issue.

Medication persistence with long-term, specific grass pollen immunotherapy measured by prescription renewal rates

OBJECTIVE

We assessed medication persistence using prescription renewal rates for grass pollen specific immunotherapy (SIT) in a representative population of patients in Germany to evaluate whether the perception of superior persistence for the subcutaneous route compared to the sublingual route could be confirmed in clinical practice.

METHODS

Individual prescriptions for allergen immunotherapy were extracted from a national prescription database (INSIGHT Health) and followed over 3 years on a per-patient basis. However, patients' medical history and treatment schedules were not available for analysis. Products were identified by the national drug code (PZN number) and grouped to either subcutaneous immunotherapy (SCIT) with natural extract injections, SCIT with modified allergens (allergoids) or sublingual immunotherapy (SLIT) with natural pollen extract solutions. Persistence was defined as at least one prescription of the individual drug in the respective years.

RESULTS

A total of 1409 patients started SIT in 2005 (112, 695, and 602 for natural extract SLIT, natural extract SCIT, and allergoid SCIT, respectively). In 2006, 71%, 55%, and 59% of those patients had at least one renewal prescription of natural extract SLIT, natural extract SCIT, and allergoid SCIT, respectively, as well as 51%, 34%, and 39% in 2007. In both years, persistence with natural extract SLIT was significantly higher than with natural extract SCIT (p = 0.0015 for 2006, p = 0.0003 for 2007) and allergoid SCIT (p = 0.0152 for 2006, p = 0.0111 for 2007). There were no significant differences between the two SCIT groups.

CONCLUSION

Medication persistence with grass pollen SIT in a representative sample of patients in Germany was similar to published medication persistence in asthma and COPD patients. The sublingual application route shows significantly better persistency than the subcutaneous route with native allergens or allergoids.