Effect of asthma compliance enhancement training on asthma control in patients on combination therapy with salmeterol/fluticasone propionate: a randomised controlled trial

Asthma and metabolic syndrome: a comprehensive systematic review and meta-analysis of observational studies

Introduction: This study aimed to perform a meta-analysis on the prevalence of metabolic syndrome (MetS) among patients with asthma and to measure the association asthma has with MetS.

Methods: The Web of Science, Medline, Scopus, Embase and Google Scholar were searched using the "Asthma", "Metabolic Syndrome", "Dysmetabolic Syndrome", "Cardiovascular Syndrome", "Insulin Resistance Syndrome", "Prevalence", "Odds Ratio", "Cross-Sectional Studies", and "Case-Control Studies" keywords. All observational studies reporting the prevalence of MetS among people with and without asthma were included in the study. In the presence of heterogeneity, random-effects models were used to pool the prevalence and odds ratios (OR), as measures of association in cross-sectional and case-control/ cohort studies, respectively.

Results: The prevalence of MetS among patients with asthma (8 studies) and the OR comparing the prevalence of MetS among patients with and without asthma (5 studies) were pooled separately. The pooled prevalence of MetS among patients with asthma was found to be 25% (95% confidence interval (CI): 13%–38%). In contrast, the overall pooled OR for MetS in patients with asthma, compared to healthy controls, was 1.34 (95% CI: 0.91–1.76), which was not statistically significant.

Conclusion: The prevalence of MetS was relatively high in patients with asthma. Furthermore, the odds of MetS was higher in patients with asthma, compared to healthy controls, although this difference was not statistically significant. More original studies among different populations are needed in order to more accurately examine the association between asthma and MetS, as well as the relationship asthma has with the individual components of MetS.

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma ('difficult asthma') should undergo systematic assessment, in order to differentiate between true severe asthma, and 'difficult-to-treat' patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.

Interventions to improve adherence to inhaled steroids for asthma

BACKGROUND

Despite its proven efficacy in improving symptoms and reducing exacerbations, many patients with asthma are not fully adherent to their steroid inhaler. Suboptimal adherence leads to poorer clinical outcomes and increased health service utilisation, and has been identified as a contributing factor to a third of asthma deaths in the UK. Reasons for non-adherence vary, and a variety of interventions have been proposed to help people improve treatment adherence.

OBJECTIVES

To assess the efficacy and safety of interventions intended to improve adherence to inhaled corticosteroids among people with asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 18 November 2016.

SELECTION CRITERIA

We included parallel and cluster randomised controlled trials of any duration conducted in any setting. We included studies reported as full-text articles, those published as abstracts only and unpublished data. We included trials of adults and children with asthma and a current prescription for an inhaled corticosteroid (ICS) (as monotherapy or in combination with a long-acting beta2-agonist (LABA)). Eligible trials compared an intervention primarily aimed at improving adherence to ICS versus usual care or an alternative intervention.

DATA COLLECTION AND ANALYSIS

Two review authors screened the searches, extracted study characteristics and outcome data from included studies and assessed risk of bias. Primary outcomes were adherence to ICS, exacerbations requiring at least oral corticosteroids and asthma control. We graded results and presented evidence in 'Summary of findings' tables for each comparison.We analysed dichotomous data as odds ratios, and continuous data as mean differences or standardised mean differences, all using a random-effects model. We described skewed data narratively. We made no a priori assumptions about how trials would be categorised but conducted meta-analyses only if treatments, participants and the underlying clinical question were similar enough for pooling to make sense.

MAIN RESULTS

We included 39 parallel randomised controlled trials (RCTs) involving adults and children with asthma, 28 of which (n = 16,303) contributed data to at least one meta-analysis. Follow-up ranged from two months to two years (median six months), and trials were conducted mainly in high-income countries. Most studies reported some measure of adherence to ICS and a variety of other outcomes such as quality of life and asthma control. Studies generally were at low or unclear risk of selection bias and at high risk of biases associated with blinding. We considered around half the studies to be at high risk for attrition bias and selective outcome reporting.We classified studies into four comparisons: adherence education versus control (20 studies); electronic trackers or reminders versus control (11 studies); simplified drug regimens versus usual drug regimens (four studies); and school-based directly observed therapy (three studies). Two studies are described separately.All pooled results for adherence education, electronic trackers or reminders and simplified regimens showed better adherence than controls. Analyses limited to studies using objective measures revealed that adherence education showed a benefit of 20 percentage points over control (95% confidence interval (CI) 7.52 to 32.74; five studies; low-quality evidence); electronic trackers or reminders led to better adherence of 19 percentage points (95% CI 14.47 to 25.26; six studies; moderate-quality evidence); and simplified regimens led to better adherence of 4 percentage points (95% CI 1.88 to 6.16; three studies; moderate-quality evidence). Our confidence in the evidence was reduced by risk of bias and inconsistency.Improvements in adherence were not consistently translated into observable benefit for clinical outcomes in our pooled analyses. None of the intervention types showed clear benefit for our primary clinical outcomes - exacerbations requiring an oral corticosteroid (OCS) (evidence of very low to low quality) and asthma control (evidence of low to moderate quality); nor for our secondary outcomes - unscheduled visits (evidence of very low to moderate quality) and quality of life (evidence of low to moderate quality). However, some individual studies reported observed benefits for OCS and use of healthcare services. Most school or work absence data were skewed and were difficult to interpret (evidence of low quality, when graded), and most studies did not specifically measure or report adverse events.Studies investigating the possible benefit of administering ICS at school did not measure adherence, exacerbations requiring OCS, asthma control or adverse events. One study showed fewer unscheduled visits, and another found no differences; data could not be combined.

AUTHORS' CONCLUSIONS

Pooled results suggest that a variety of interventions can improve adherence. The clinical relevance of this improvement, highlighted by uncertain and inconsistent impact on clinical outcomes such as quality of life and asthma control, is less clear. We have low to moderate confidence in these findings owing to concerns about risk of bias and inconsistency. Future studies would benefit from predefining an evidence-based 'cut-off' for acceptable adherence and using objective adherence measures and validated tools and questionnaires. When possible, covert monitoring and some form of blinding or active control may help disentangle effects of the intervention from effects of inclusion in an adherence trial.

Enrolment in an Asthma Management Program during Pregnancy and Adherence with Inhaled Corticosteroids: The 'Management of Asthma during Pregnancy' Program

BACKGROUND

Poor adherence with inhaled corticosteroids (ICS) is a major problem in asthma and according to previous studies not least during pregnancy.

OBJECTIVE

Our aim was to assess if enrolment in an asthma management program, and by that close monitoring, can improve self-reported and documented adherence with ICS in pregnant women with asthma.

METHODS

Pregnant women with doctor-diagnosed asthma, currently being prescribed ICS, referred during a 12-month period to the outpatient respiratory clinic, were consecutively included in the study. They had follow-up visits every 4 weeks during pregnancy. Asthma control was assessed according to GINA guidelines. Self-reported adherence was compared to documented adherence, defined as medical possession rate (MPR), calculated on the basis of filled prescriptions (data from each individuals' medication profile at www.fmk-online.dk).

RESULTS

A total of 130 women fulfilled the inclusion criteria, but at the initial visit, 16 women reported no current use of ICS, and the analyses are therefore based on 114 patients. Self-reported adherence to ICS was significantly higher during pregnancy than before pregnancy (73 and 52%, respectively, reporting good adherence; p < 0.001). The actual adherence, i.e. MPR, was also higher during pregnancy than before (46 vs. 28%, p < 0.0001). In keeping with this, an overall improvement was also observed in asthma control. Of the women with a low pre-pregnancy MPR, 71% had moderate or good adherence (MPR) during pregnancy. Self-reported adherence was significantly correlated with MPR during pregnancy (p = 0.004) but not before pregnancy (p = 0.46). At the 3-month postpartum visit, adherence was close to the pre-pregnancy level.

CONCLUSION

Enrolment in an asthma management program during pregnancy seems to improve adherence with controller medication, but self-reported adherence is not a valid measure for actual adherence in patients with asthma.

Asthma and metabolic syndrome: Current knowledge and future perspectives

Asthma and obesity are epidemiologically linked; however, similar relationships are also observed with other markers of the metabolic syndrome, such as insulin resistance and dyslipidemia, which cannot be accounted for by increased body mass alone. Obesity appears to be a predisposing factor for the asthma onset, both in adults and in children. In addition, obesity could make asthma more difficult to control and to treat. Although obesity may predispose to increased Th2 inflammation or tendency to atopy, other mechanisms need to be considered, such as those mediated by hyperglycaemia, hyperinsulinemia and dyslipidemia in the context of metabolic syndrome. The mechanisms underlying the association between asthma and metabolic syndrome are yet to be determined. In the past, these two conditions were believed to occur in the same individual without any pathogenetic link. However, the improvement in asthma symptoms following weight reduction indicates a causal relationship. The interplay between these two diseases is probably due to a bidirectional interaction. The purpose of this review is to describe the current knowledge about the possible link between metabolic syndrome and asthma, and explore potential application for future studies and strategic approaches.

Adherence to inhaled therapies, health outcomes and costs in patients with asthma and COPD

Suboptimal adherence to pharmacological treatment of asthma and chronic obstructive pulmonary disease (COPD) has adverse effects on disease control and treatment costs. The reasons behind non-adherence revolve around patient knowledge/education, inhaler device convenience and satisfaction, age, adverse effects and medication costs. Age is of particular concern given the increasing prevalence of asthma in the young and increased rates of non-adherence in adolescents compared with children and adults. The correlation between adherence to inhaled pharmacological therapies for asthma and COPD and clinical efficacy is positive, with improved symptom control and lung function shown in most studies of adults, adolescents and children. Satisfaction with inhaler devices is also positively correlated with improved adherence and clinical outcomes, and reduced costs. Reductions in healthcare utilisation are consistently observed with good adherence; however, costs associated with general healthcare and lost productivity tend to be offset only in more adherent patients with severe disease, versus those with milder forms of asthma or COPD. Non-adherence is associated with higher healthcare utilisation and costs, and reductions in health-related quality of life, and remains problematic on an individual, societal and economic level. Further development of measures to improve adherence is needed to fully address these issues.

Patient-centered care and its effect on outcomes in the treatment of asthma

Patient-centered care may be pivotal in improving health outcomes for patients with asthma. In addition to increased attention in both research and clinical forums, recent legislation also highlights the importance of patient-centered outcomes research in the Patient Protection and Affordable Care Act. However, whether patient-centered care has been shown to improve outcomes for this population is unclear. To answer this question, we performed a systematic review of the literature that aimed to define current patient-focused management issues, characterize important patient-defined outcomes in asthma control, and identify current and emerging treatments related to patient outcomes and perspectives. We used a parallel search strategy via Medline(®), Cochrane Central Register of Controlled Trials, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO(®), complemented with a reference review of key articles that resulted in a total of 133 articles; 58 were interventions that evaluated the effect on patient-centered outcomes, and 75 were descriptive studies. The majority of intervention studies demonstrated improved patient outcomes (44; "positive" results); none showed true harm (0; "negative"); and the remainder were equivocal (14; "neutral"). Key themes emerged relating to patients' desires for asthma knowledge, preferences for tailored management plans, and simplification of treatment regimens. We also found discordance between physicians and patients regarding patients' needs, beliefs, and expectations about asthma. Although some studies show promise regarding the benefits of patient-focused care, these methods require additional study on feasibility and strategies for implementation in real world settings. Further, it is imperative that future studies must be, themselves, patient-centered (eg, pragmatic comparative effectiveness studies) and applicable to a variety of patient populations and settings. Despite the need for further research, enough evidence exists that supports incorporating a patient-centered approach to asthma management, in order to achieve improved outcomes and patient health.