Does drug compliance change in asthmatic patients during pregnancy?

Country-based report: the safety of omalizumab treatment in pregnant patients with asthma

BACKGROUND/AIM

We aimed to report outcomes of pregnant patients with asthma under omalizumab treatment and their infants in our country.

MATERIALS AND METHODS

Patients with asthma who received omalizumab for at least 6 months and at least one dose during their pregnancy were retrospectively evaluated using a questionnaire regarding their disease and therapy and the health of their infants.

RESULTS

Twenty pregnant patients and their 23 infant’s data were analyzed. The mean delivery age was 31.8 ± 7.4 years. They received omalizumab for 28.9 ± 21.8 months. Eight (36.4%) patients showed exacerbation of the disease during pregnancy. Forced expiratory volume in 1 s (FEV1) and asthma control test (ACT) scores at the starting time of omalizumab administration, first month of the pregnancy, and after delivery were 71 ± 18%, 83.4 ± 10.5%, and 80.5 ± 13% (FEV1), and 11.9 ± 4.9, 20.2 ± 2.6, and 20.4 ± 2.2 (ACT), respectively. One patient gave birth to twin infants, two patients to two infants each in different years, and 17 to one infant each. Three (13%) infants had low birth weight and five (21.7%) were born prematurely. No congenital anomalies were detected. Seven (30.4%) infants presented atopic diseases during their life.

CONCLUSION

Omalizumab treatment during pregnancy seems to be safe for both patients and their infants.

Factors Associated with Nonadherence to Inhaled Corticosteroids for Asthma During Pregnancy

BACKGROUND

Nonadherence is common among pregnant women prescribed inhaled corticosteroids (ICS) for asthma and may have serious consequences for mother and baby. Factors associated with ICS nonadherence have not been determined in this population.

OBJECTIVES

To determine factors associated with {1} nonadherence to ICS in early-mid pregnancy (cross-sectional) and {2} persistent nonadherence to ICS during pregnancy (longitudinal).

METHODS

Data used come from 3 prospective studies (2004-2019) involving women with asthma recruited by 23 weeks' gestation (N = 1614). Demographics, asthma history, and current symptoms were assessed, and spirometry was performed at baseline and throughout pregnancy. Women self-reported current medication use and number of ICS doses missed in the past week. Nonadherence was defined as ≥20% of prescribed dosages missed in the past week (baseline) and on at least 2 occasions during follow-up (persistent). Factors associated with ICS nonadherence were examined using backward stepwise logistic regression.

RESULTS

Of 610 (38%) women prescribed ICS at baseline, 236 (39%) were classified as nonadherent. Of 612 (38%) women prescribed ICS during at least 2 follow-up visits, 149 (24%) were classified as persistent nonadherent. Factors associated with nonadherence at baseline were current or ex-smoking, non-Caucasian/non-Indigenous ethnicity, adult diagnosis of asthma, and lower lung function. Factors associated with persistent nonadherence to ICS were lower maternal age, higher parity, and no prescribed ICS at baseline.

CONCLUSION

Young multiparous non-Caucasian/non-Indigenous mothers are at increased risk of being nonadherent to ICS during pregnancy. Strategies to improve ICS nonadherence should address maternal smoking and target women who (re-)initiate ICS use in pregnancy.

Inhaled corticosteroid use during pregnancy among women with asthma: A systematic review and meta-analysis

BACKGROUND

Studies demonstrate the prescription rate for inhaled corticosteroids (ICS) decreases in early pregnancy, possibly increasing exacerbation risk. This could be related to non-adherence to prescribed asthma medication or medication cessation by the patient or doctor. ICS use during pregnancy has not previously been summarized in a systematic review.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the use of ICS during pregnancy among asthmatic women, specifically: (1) the prevalence of use, (2) changes of use during pregnancy compared with pre-pregnancy and (3) medication adherence among ICS users.

METHODS

We systematically searched literature in Embase, MEDLINE, CINAL and Cochrane, using terms related to asthma, pregnancy and medication use. All English articles reporting ICS among pregnant women with asthma were included. Prevalence, changes in ICS use during pregnancy and ICS adherence were pooled using STATA (version 15.0, StataCorp USA).

RESULTS

A total of 4237 references were retrieved in the initial search. Screening and review led to the inclusion of 52 articles for one or more aims (Aim 1: N = 45; Aim 2, N = 13; and Aim 3, N = 5). The pooled prevalence of ICS use during pregnancy was 41% (95%CI 36%-45%); 49% (95%CI 44%-55%) in Europe, 39% (95%CI 32%-47%) in Australia and 34% (95%CI 27%-41%) in North America. In eight prescription databases, ICS prescription rates lowered in the first trimester of pregnancy, compared with pre-pregnancy, increased in the second trimester and decreased in the third trimester. Five studies reported ICS adherence among pregnant women, using four measures of self-reported non-adherence. In two comparable studies, pooled ICS non-adherence was 40% (95%CI 36%-44%).

CONCLUSIONS

The prevalence of ICS use among pregnant women with asthma is 41% and varies widely between countries and continents, and prescription rates for ICS change throughout pregnancy. More studies are needed to investigate ICS adherence during pregnancy in women with asthma.

The course of asthma during pregnancy in a recent, multicase-control study on respiratory health

Background

Over the years it has been widely stated that approximately one-third of asthmatic women experience worsening of the disease during pregnancy. However, the literature has not been reviewed systematically and the meta-analytic reviews include old studies. This study aimed to examine whether the prevalence of worsening asthma during pregnancy is still consistent with prior estimate or it has been reduced.

Methods

A detailed Clinical Questionnaire on respiratory symptoms, medical history, medication, use of services, occupation, social status, home environment and lifestyle was administered to random samples of the Italian population in the frame of the Gene Environment Interactions in Respiratory Diseases (GEIRD) study. Only clinical data belong to 2.606 subjects that completed the clinical stage of the GEIRD study, were used for the present study.

Results

Out of 1.351 women, 284 self-reported asthma and 92 of them had at least one pregnancy. When we considered the asthma course during pregnancy, we found that 16 women worsened, 31 remained unchanged, 25 improved. Seven women had not the same course in the different pregnancies and 13 did not know. The starting age of ICS use almost overlaps with that of asthma onset in women with worsening asthma during pregnancy (19 years ± 1.4), unlike the other women who started to use ICS much later (30.3 years ± 12). In addition, the worsening of asthma was more frequent in women with an older age of onset of asthma (18 years ± 9 vs 13 years ± 10). Among women who completed the ACT during the clinical interview, the 50% of women who experienced worsening asthma during pregnancy (6/12) had an ACT score below 20.

Conclusion

Asthma was observed to worsen during pregnancy in a percentage much lower to that generally reported in all the previous studies. There is still room in clinical practice to further reduce worsening of asthma during pregnancy by improving asthma control, with a more structured approach to asthma education and management prepregnancy.

Managing asthma in pregnancy

Asthma is a common comorbidity during pregnancy and its prevalence is increasing in the community. Exacerbations are a major clinical problem during pregnancy with up to 45% of women needing to seek medical help, resulting in poor outcomes for mothers and their babies, including low birth weight and preterm delivery. The goals of effective asthma management in pregnancy are to maintain the best possible asthma control and prevent exacerbations. This is achieved by aiming to prevent day- and night-time symptoms, and maintain lung function and normal activity. In addition, maintaining fetal oxygenation is an important consideration in pregnancy. Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis. Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has demonstrated success in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, the exhaled nitric oxide fraction (F eNO). The use of an algorithm that adjusted inhaled corticosteroids (ICS) according to F eNO and added long-acting β-agonists when symptoms remained uncontrolled resulted in fewer exacerbations, more women on ICS but at lower mean doses, and improved infant respiratory health at 12 months of age. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

KEY POINTS

Asthma is the most common chronic disease to affect pregnant women.Exacerbations occur in up to 45% of pregnant women with asthma.Asthma should be managed during pregnancy as for other adults.Treatment adjustment using a marker of airway inflammation reduces the exacerbation rate in pregnancy.

EDUCATIONAL AIMS

To identify the goals of and steps associated with effective asthma management in pregnancy.To understand the maternal and perinatal risks associated with asthma during pregnancy.To describe a management strategy that has been shown to reduce exacerbations in pregnant women with asthma.