A randomised clinical trial of feedback on inhaler adherence and technique in patients with severe uncontrolled asthma

Adherence to corticosteroids and clinical outcomes in mepolizumab therapy for severe asthma

INTRODUCTION

Inhaled corticosteroids (ICS) achieve disease control in the majority of asthmatic patients, although adherence to prescribed ICS is often poor. Patients with severe eosinophilic asthma may require treatment with oral corticosteroids (OCS) and/or biologic agents such as mepolizumab. It is unknown if ICS adherence changes on, or alters clinical response to, biologic therapy.

METHODS

We examined ICS adherence and clinical outcomes in OCS-dependent severe eosinophilic asthma patients who completed 1 year of mepolizumab therapy. The ICS medicines possession ratio (MPR) was calculated (the number of doses of ICS issued on prescription/expected number) for the year before and the year after biologic initiation. Good adherence was defined as MPR >0.75, intermediate 0.74-0.51 and poor <0.5. We examined outcomes after 12 months of biologic therapy, including OCS reduction and annualised exacerbation rate (AER), stratified by adherence to ICS on mepolizumab.

RESULTS

Out of 109 patients commencing mepolizumab, 91 who had completed 12 months of treatment were included in the final analysis. While receiving mepolizumab, 68% had good ICS adherence, with 16 (18%) having poor ICS adherence. ICS use within the cohort remained similar before (MPR 0.81±0.32) and during mepolizumab treatment (0.82±0.32; p=0.78). Patients with good adherence had greater reductions in OCS dose (median (interquartile range) OCS reduction 100 (74-100)% versus 60 (27-100)%; p=0.031) and exacerbations (AER change -2.1±3.1 versus 0.3±2.5; p=0.011) than those with poor adherence. Good ICS adherence predicted the likelihood of stopping maintenance OCS (adjusted OR 3.19, 95% CI 1.02-9.94; p=0.045).

CONCLUSION

ICS nonadherence is common in severe eosinophilic asthma patients receiving mepolizumab, and is associated with a lesser reduction in OCS requirements and AER.

What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions

INTRODUCTION

Respiratory inhalers, when used correctly, provide critical treatments for managing pulmonary conditions. However, many patients misuse inhalers, negatively affecting disease control, quality of life, healthcare utilization, and costs. Numerous factors are associated with misuse and are nested within four levels of influence: individual, interpersonal, organizational/institutional, and policy.

AREAS COVERED

This review analyzed published literature and identified the most salient factors at each socio-ecological framework level. English language articles from any year were identified from PubMed, Google Scholar, and Embase databases. Misuse exists across clinical settings, patient populations, and device types. Several potential solutions are highlighted. Published interventions to improve inhaler technique have utilized handouts, in-person, virtual, and biofeedback approaches both inside and outside of healthcare settings with varied effectiveness. However, some interventions have superior effectiveness for improving technique and reducing acute care utilization.

EXPERT OPINION

To robustly address inhaler misuse, future solutions should focus on multi-level approaches to account for the myriad of factors contributing to inhaler misuse. Solutions should also streamline inhaler equipment, identify innovative technology-based solutions, support collaborations across healthcare and non-healthcare settings, and ensure reimbursement to healthcare professionals for inhaler education. Rigorous research studies must be funded and supported to identify and disseminate solutions.

Low adherence to inhaled corticosteroids/long-acting β2-agonists and biologic treatment in severe asthmatics

Eligibility criteria for a biologic treatment for severe asthma include poor disease control despite a full medication plan according to Global Initiative for Asthma steps 4–5 [1]. Adherence to inhaled therapy should be verified as part of that prescription requirement [2]. In fact, it has been demonstrated that poor adherence is a major cause of uncontrolled asthma, regardless of its severity [3]. Furthermore, biologics do not exert a disease-modifying effect [4]; in contrast to allergen immunotherapy, which is able to permanently modulate the way the immune system reacts to allergens beyond the immunotherapy treatment course [5], biologic therapy withdrawal usually leads to asthma relapse [4]. Thus, a low adherence rate to inhaled treatment in patients undergoing biologic therapy raises some issues related to sustainability.

Less than half of severe asthmatic patients show a >80% adherence rate to inhaled treatment just before and during biologic therapy. This has implications in biologic treatment sustainability and disease prevalence estimation.http://bit.ly/3cRTJB0

Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives

Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.

Controller Inhalers: Overview of Devices, Instructions for Use, Errors, and Interventions to Improve Technique

Inadequate inhaler technique in persistent asthma is frequently reported. However, there is little consensus on inhaler checklists, and critical elements of technique are not uniformly described. In addition, inhaler error rates and risk factors for poor technique are variable across studies. This Clinical Commentary Review summarizes the literature on inhaler design, use, and interventions to improve technique. Our aim is to help clinicians identify patients with poor inhaler technique, recognize the most important errors, and correct technique using evidence-based interventions.

Adherence to omalizumab: A multicenter "real-world" study

Background

Adherence to medications is crucial in patients with severe asthma in light of the negative clinical impact and costs of non-adherence. Adherence to omalizumab has not been well studied in real-world settings. The aim of this study was to assess adherence to omalizumab and evaluate treatment effectiveness in relation to adherence.

Methods

This was a retrospective, observational, and multicenter real-world study. Omalizumab dose, timing of administration, and duration of treatment (<2 years; 2–4 years; > 4 years) were analyzed. Adherence was evaluated by examining rates of expected and missing doses. Good adherence (<10% of doses missed) and poor adherence (>10% doses missed) were determined. For effectiveness in relation to adherence of omalizumab we considered asthma exacerbations, hospitalizations, asthma control test (ACT), and Forced Expiratory Volume in 1 s (FEV₁).

Results

A total of 196 patients were evaluated, and 161 were suitable for data analyses. Good adherence was shown in 90.7% of patients and poor adherence in 9.3%. Considering adherence in relation to treatment duration: <2 years, 87.8% of patients were adherent (expected doses, 1186; missed doses, 53); 2–4 years, 85.9% were adherent (expected doses, 2985; missed doses, 127); >4 years, 100% were adherent (expected doses, 6120; missed doses, none). Indices of efficacy between pre- and post-treatment showed significant improvement (p < 0.001). The effectiveness indices between pre- and post-treatment, among adherent and non-adherent patients, ACT, and asthma exacerbations both showed significant differences (p = 0.043 and p = 0.049, respectively). Binomial logistic regression analysis showed that increasing age, better ACT score, and 14-day timing were significantly associated with increased adherence to therapy.

Conclusions

High adherence to omalizumab was demonstrated in a real-world setting, which was associated with better outcomes and control of asthma.

The application of proteomics in the diagnosis and treatment of bronchial asthma

Bronchial asthma is a common chronic inflammatory disease of the airways. Although its pathogenic mechanism remains unknown, it is influenced by both genetic and environmental factors. The emergence and application of proteomic technologies can help to facilitate analysis of the changes in transcription factors, inflammatory mediators, chemokines, cytokines, and cell apoptosis-and proliferation-related proteins in the pathological processes of asthma. Proteomic technologies can unearth prospects and theoretical bases for improved understanding of the biological mechanism of asthma and effective identification of diagnostic and therapeutic targets.

A quantitative evaluation of adherence and inhalation technique among respiratory patients: An observational study using an electronic inhaler assessment device

BACKGROUND

Problems related to poor adherence and inhaler technique (IT) are historically reported in the literature. Most common methods used for adherence and IT assessment are reported to be either inaccurate or subjective. Few electronic monitoring devices (EMDs) that provide an objective measure of both adherence and IT while patients use inhalers at home now exist. Therefore, this study aimed to examine adherence level and IT among respiratory patients in community care using such an EMD for the first time in England.

METHODS

A prospective, multicentre, observational cohort study was conducted. Patients with chronic obstructive pulmonary disease (COPD) or asthma were recruited from independent community pharmacies within West and South London. Patients were provided with a dry-powder inhaler (DPI) mounted with an EMD to use for 1 month. Adherence was also assessed using pharmacy dispensing data, inhaler dose counter and self-reporting.

RESULTS

Data were available for 48 patients. Only eight patients used their inhaler in the correct manner at the correct interval as identified by the chosen EMD. The median actual adherence rate, as measured by the EMD, was 42.7%. This was significantly different from the median dose counter adherence (100%), medication refill adherence (MRA) (100%), proportions of days covered (PDC) (97.8%) and self-reported adherence (P < .001, each). Within a 1-month period, there were 2188 files showing attempted use of the DPI, of which 840 had IT errors. The median technique error rate (TER) was 30.1%. Most common errors recorded were as follows: multiple inhalations, drug priming without inhalation and failure to prime the device correctly.

CONCLUSION

The current study demonstrates that measures such as dose counter, prescription refill and self-reporting showed a high level of adherence among the observed patients. However, the objective data provided by the EMD showed a significantly lower actual adherence rate, reflecting how adherence remains variable and problematic among patients in the community.

The Utility of Electronic Inhaler Monitoring in COPD Management: Promises and Challenges

COPD is a common respiratory disorder that poses a major health-care burden with societal and financial ramifications. Although effective inhaled therapies are available, nonadherence is common among patients with COPD and potentially contributes to the burden of this disease. Electronic inhaler monitoring (EIM) is a novel modality that enables real-time assessment of adherence to inhaled therapy and informs the assessment of treatment effectiveness. EIM can be combined with physician feedback, automated audiovisual reminders, and text messaging to bolster adherence. Clinical studies have suggested that EIM can diagnose nonadherence, improve adherence, and predict exacerbations. Using an EIM-guided protocol has the potential to avoid treatment escalation in the nonadherent. Coupling EIM to behavioral intervention is an area of ongoing research with mixed results, with some studies showing benefit and others showing minimal or no significant change in clinical outcomes. Further investigation is necessary to understand the incremental benefits of EIM features, delineate optimal program implementation, and target patient populations that would benefit the most from monitoring.

Remotely Monitored Therapy and Nitric Oxide Suppression Identifies Nonadherence in Severe Asthma

RATIONALE

Poor adherence is common in difficult-to-control asthma. Distinguishing patients with difficult-to-control asthma who respond to inhaled corticosteroids (ICS) from refractory asthma is an important clinical challenge.

OBJECTIVES

Suppression of fractional exhaled nitric oxide (Fe_NO) with directly observed ICS therapy over 7 days can identify nonadherence to ICS treatment in difficult-to-control asthma. We examined the feasibility and utility of Fe_NO suppression testing in routine clinical care within UK severe asthma centers using remote monitoring technologies.

METHODS

A web-based interface with integrated remote monitoring technology was developed to deliver Fe_NO suppression testing. We examined the utility of Fe_NO suppression testing to demonstrate ICS responsiveness and clinical benefit on electronically monitored treatment with standard high-dose ICS and long-acting β₂-agonist treatment.

MEASUREMENTS AND MAIN RESULTS

Clinical response was assessed using the Asthma Control Questionnaire-5, spirometry, and biomarker measurements (Fe_NO and peripheral blood eosinophil count). Of 250 subjects, 201 completed the test with 130 positive suppression tests. Compared with a negative suppression test, a positive test identified a Fe_NO-low population when adherent with ICS/long-acting β₂-agonist (median, 26 ppb [interquartile range, 16-36 ppb] vs. 43 ppb [interquartile range, 38-73 ppb]) with significantly greater FEV₁% (mean, 88.2 ± 16.4 vs. 74.1 ± 20.9; P < 0.01). Asthma Control Questionnaire-5 improved significantly in both groups (positive test: mean difference, -1.2; 95% confidence interval, -0.9 to -1.5; negative test: mean difference, -0.9; 95% confidence interval, -0.4 to -1.3).

CONCLUSIONS

Remote Fe_NO suppression testing is an effective means of identifying nonadherence to ICS in subjects with difficult-to-control asthma and the substantial population of subjects who derive important clinical benefits from optimized ICS/long-acting β₂-agonist treatment.

Severe Asthma and Biological Therapy: When, Which, and for Whom

Asthma is a heterogeneous chronic inflammatory disease of the airways that affects approximately 300 million people worldwide. About 5-10% of all asthmatics suffer from severe or uncontrolled asthma, associated with increased mortality and hospitalization, reduced quality of life, and increased health care costs. In recent years, new treatments have become available, and different asthma phenotypes characterized by specific biomarkers have been identified. Biological drugs are currently indicated for patients with severe asthma that is not controlled with recommended treatments. They are mostly directed against inflammatory molecules of the type 2 inflammatory pathway and are effective at reducing exacerbations, maintaining control over asthma symptoms, and reducing systemic steroid use, which is associated with well-known adverse events. Although biological drugs for severe asthma have had a major impact on the management of the disease, there is still a need for head-to-head comparison studies of biologics and to identify new biomarkers for asthma diagnosis, prognosis, and response to treatment. Identifying novel biomarkers could facilitate the development of therapeutic strategies that are precisely tailored to each patient's requirements.

Trajectory Analyses of Adherence Patterns in a Real-Life Moderate to Severe Asthma Population

BACKGROUND

Global Initiative for Asthma step 5 therapies (GINA-5), other than inhaled corticosteroids and long-acting β-agonists in fixed dose combinations (ICS/LABA FDC), often entail more expensive (eg, monoclonal biologics) or less safe (eg, maintenance oral corticosteroids [OCS]) treatments. It is therefore important to assess poor inhaler adherence as a possible cause of suboptimal response to ICS/LABA FDC before additional GINA-5.

OBJECTIVE

To determine rates of, and time to, additional GINA-5 after first-year ICS/LABA FDC use, and their association with inhaler adherence.

METHODS

Patients initiating ICS/LABA FDC between 2013 and 2017 were identified from Australian national dispensing data. Group-based trajectory modeling was used to estimate medication adherence patterns. Multivariable Cox proportional hazards models were used to examine the association between adherence trajectories and GINA-5 addition during 2-year follow-up.

RESULTS

In total, 3062 new ICS/LABA FDC users were identified, of whom 120 (3.9%) received additional GINA-5 (OCS: 89; long-acting muscarinic antagonists: 39; biologics: <3). Mean time to commencing additional GINA-5 was 705.2 (standard deviation, 1.7) days. Adherence trajectories were nonpersistent use (20%), seasonal use (8%), poor adherence (58%), and good adherence (13%). Although poor adherence was associated with longer time to additional GINA-5 (adjusted hazard ratio: 0.58; 95% confidence interval: 0.35-0.95), over 80% of additional GINA-5 was commenced in poorly adherent patients. Use of ≥2 OCS/antibiotic courses also predicted additional GINA-5.

CONCLUSIONS

Almost 1 in 20 people with asthma commenced additional GINA-5 after ICS/LABA initiation, most of whom (>80%) were poorly adherent to inhaled preventers. There is a substantial unmet need for inhaler adherence to be addressed before prescribing additional GINA-5.

Does a tailored intervention to promote adherence in patients with chronic lung disease affect exacerbations? A randomized controlled trial

BACKGROUND

Poor medication-adherence is common in chronic lung patients, resulting in reduced health-outcomes and increased healthcare-costs. This study aimed to investigate the impact of an acoustic reminder and support calls on adherence to inhaled therapy in asthma and COPD patients and to determine their effect on exacerbations.

METHODS

This single-blinded randomized controlled trial investigated asthma and COPD patients during 6 months in an ambulatory setting. The intervention consisted of daily alarm clock and support phone calls, whenever use of rescue medication doubled or inhaled medication was not taken as prescribed. Primary outcome was time to next exacerbation. Frequency of exacerbations, adherence to inhaled medication and quality of life scores were secondary outcomes. Cox and Poisson regression were used to determine intervention effect on time to exacerbation and frequency of exacerbations, respectively.

RESULTS

Seventy-five participants were assigned to the intervention group and 74 to usual follow-up care. During a median follow-up of 6.2 months, 22 and 28% in the intervention and control groups respectively, experienced at least one exacerbation. Intervention had no effect on time to first exacerbation (HR 0.65, 95% CI 0.21 to 2.07, P = .24), but showed a trend toward a 39% decreased frequency of exacerbations (RR = 0.61, 95% CI 0.35 to 1.03, P = .070) for the adjusted models, respectively. The intervention group had significantly more days with 80-100% taking adherence regarding puff inhalers (82 ± 14% vs. 60 ± 30%, P < .001) and dry powder capsules (90 ± .10% vs. 80 ± 21%, P = .01). Timing adherence in participants using puff inhalers was higher in the intervention group (69 ± 25% vs. 51 ± 33%, P < .001). No significant differences in QoL were found between the two groups.

CONCLUSION

Participants assigned to the intervention group had significantly better taking and timing adherence of inhaled medication resulting in a trend towards a decreased frequency of exacerbations. However, no effect on time to next exacerbation was observed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02386722, Registered 14 February 2014.

Inadequate assessment of adherence to maintenance medication leads to loss of power and increased costs in trials of severe asthma therapy: results from a systematic literature review and modelling study

Adherence to inhaled maintenance therapy in severe asthma is rarely adequately assessed, and its influence on trial outcomes is unknown. We systematically determined how adherence to maintenance therapy is assessed in clinical trials of "add-on" therapy for severe asthma. We model the improvement in trial power that could be achieved by accurately assessing adherence.A systematic search of six major databases identified randomised trials of add-on therapy for severe asthma. The relationship between measuring adherence and study outcomes was assessed. An estimate of potential improvements in statistical power and sample size was derived using digitally recorded adherence trial data.87 randomised controlled trials enrolling 22 173 participants were included. Adherence assessment was not reported in 67 trials (n=13 931, 63%). Studies that reported adherence used a range of self-report and subjective methods. None of the studies employed an objective assessment of adherence. Studies that reported adherence had a significantly reduced pooled variance in forced expiratory volume in 1 s (FEV₁) compared to those that did not assess adherence: s²=0.144 L² versus s²=0.168 L², p<0.0001. Power to detect clinically relevant changes in FEV₁ was significantly higher in trials that reported adherence assessment (mean power achieved 59% versus 49%). Modelling suggests that up to 50% of variance in FEV₁ outcomes is attributable to undetected variations in adherence. Controlling for such variations could potentially halve the required sample size.Few trials of add-on therapy monitor adherence to maintenance inhaled therapy, resulting in a greater variance in trial outcomes and inadequate power for determining efficacy.

Electronic inhaler monitoring and healthcare utilization in chronic obstructive pulmonary disease

INTRODUCTION

The effect of electronic inhaler monitoring (EIM) on healthcare utilization in chronic obstructive pulmonary disease (COPD) has not been studied. We hypothesized that the use of EIM in conjunction with a disease management program reduces healthcare utilization in patients with COPD.

METHODS

This is a retrospective pre- and post-analysis of a quality improvement project. Patients with COPD and high healthcare utilization (≥one hospitalization or emergency room visit during the year prior to enrolment) were provided with electronic monitoring devices for monitoring controller and rescue inhaler utilization for one year. Patients were contacted when alerts were triggered, indicating suboptimal adherence to controller inhaler or increased use of rescue inhalers, potentially signalling an impending exacerbation. Healthcare utilization was assessed pre- and post-monitoring, with each subject serving as his/her own control.

RESULTS

Patients with COPD and high healthcare utilization (n = 39) were recruited. Mean EIM duration was 280.5 (±120.6) days. The mean age was 68.6 (±9.9) years, FEV1 (mean forced expiratory volume in one second) was 1.1 (±0.4) L, and mean Charlson Comorbidity index was 5.6 (±2.7). Average adherence was 44.4% (28.4%). Compared with the year prior to enrolment, EIM was associated with a reduction in COPD-related healthcare utilization per year (2.2 (±2.3) versus 3.4 (±3.2), p = 0.01). Although there was a reduction in all-cause healthcare utilization, this was not statistically significant (3.4 (±2.6) versus 4.7 (±4.1), p = 0.06).

DISCUSSION

EIM in conjunction with a disease management program may play a role in reducing healthcare utilization in COPD patients with a history of high healthcare utilization.

Inhalation technique and asthma outcomes with different corticosteroid-containing inhaler devices

Objective: Inhaler devices must be used correctly to ensure the effectiveness of the asthma treatment. This study evaluated inhalation technique across different types of corticosteroid-containing inhaler devices as well as health outcomes in patients with asthma. Methods: In a cross-sectional study, we evaluated inhaler technique by observing patients' handling of the inhaler devices and using checklists for four inhaler types, namely Diskus (n = 52), pressure metered dose inhalers (pMDIs; n = 41), Turbuhaler (n = 36) and Twisthaler (n = 16). We also collected data on patients' characteristics, asthma therapy, exacerbations, medication adherence (8-item Morisky Medication Adherence Scale), asthma control (Asthma Control Test) and quality of life (Saint George Respiratory Questionnaire). Results: In total, we included 145 patients. The mean (SD) age of the patients was 54.5 (18.9) years and 57% were female. The majority of the patients (70%) made at least one error in their inhalation technique. Patients using Turbuhaler performed the highest number of elements correctly, followed by pMDIs, Twisthaler and Diskus. Patients with Diskus or Twisthaler had better adherence compared with patients using pMDIs or Turbuhaler. Patients using Twisthaler had better asthma outcomes than patients using the other device types. Conclusions: Most patients with asthma made mistakes when handling their inhaler devices, especially those using Diskus. However, in addition to the device type being used, patients' characteristics, asthma therapy and medication adherence also played an important role in achieving good health outcomes.

Specific Factors That Influence Adherence to Beta Blocker Treatment in Primary Prevention of Variceal Bleeding in Cirrhotic Romanian Patients. a Proof of Concept Qualitative Study

Adherence to medical treatment in chronic patients challenging, especially in primary prevention where the benefit is not directly perceived by the patient. Through the directed interview of this qualitative study we assessed some specific factors that intervene in beta-blockers adherence in cirrhotic patients with oesophageal varices in primary prevention in Romanian. We identified that the most important modifiable extrinsic factor that influences adherence is the confidence in medicine. The intensely negative perception of the disease seemed to be another major driver of adherence.

Adherence to treatment in allergic rhinitis using mobile technology. The MASK Study

BACKGROUND

Mobile technology may help to better understand the adherence to treatment. MASK-rhinitis (Mobile Airways Sentinel NetworK for allergic rhinitis) is a patient-centred ICT system. A mobile phone app (the Allergy Diary) central to MASK is available in 22 countries.

OBJECTIVES

To assess the adherence to treatment in allergic rhinitis patients using the Allergy Diary App.

METHODS

An observational cross-sectional study was carried out on all users who filled in the Allergy Diary from 1 January 2016 to 1 August 2017. Secondary adherence was assessed by using the modified Medication Possession Ratio (MPR) and the Proportion of days covered (PDC) approach.

RESULTS

A total of 12 143 users were registered. A total of 6 949 users reported at least one VAS data recording. Among them, 1 887 users reported ≥7 VAS data. About 1 195 subjects were included in the analysis of adherence. One hundred and thirty-six (11.28%) users were adherent (MPR ≥70% and PDC ≤1.25), 51 (4.23%) were partly adherent (MPR ≥70% and PDC = 1.50) and 176 (14.60%) were switchers. On the other hand, 832 (69.05%) users were non-adherent to medications (MPR <70%). Of those, the largest group was non-adherent to medications and the time interval was increased in 442 (36.68%) users.

CONCLUSION AND CLINICAL RELEVANCE

Adherence to treatment is low. The relative efficacy of continuous vs on-demand treatment for allergic rhinitis symptoms is still a matter of debate. This study shows an approach for measuring retrospective adherence based on a mobile app. This also represents a novel approach for analysing medication-taking behaviour in a real-world setting.

Two Sides of the Same Coin?-Treatment of Chronic Asthma in Children and Adults

Globally, asthma is one of the most common chronic conditions that affect individuals of all ages. When poorly controlled, it negatively impacts patient's ability to enjoy life and work. At the population level, effective use of recommended strategies in children and adults can reduce symptom burden, improve quality of life and significantly reduce the risk of exacerbation, decline of lung function and asthma-related death. Inhaled corticosteroid as the initial maintenance therapy, ideally started within 2 years of symptom onset, is highly effective in both children and adults and across various degrees of asthma severity. If asthma is not controlled, the choice of subsequent add-on therapies differs between children and adults. Evidence supporting pharmacological approach to asthma management, especially for those with more severe disease, is more robust in adults compared to children. This is, in part, due to various challenges in the diagnosis of asthma, in the recruitment into clinical trials and in the lack of objective outcomes in children, especially those in the preschool age group. Nevertheless, where evidence is emerging for younger children, it seems to mirror the observations in adults. Clinicians need to develop strategies to implement guideline-based recommendations while taking into consideration individual variations in asthma clinical phenotypes, pathophysiology and treatment responses at different ages.

An evaluation of roflumilast and PDE4 inhibitors with a focus on the treatment of asthma

INTRODUCTION

Asthma is a common chronic airway inflammatory disease characterized by diverse inflammatory events leading to airway hyperresponsiveness and reversible airflow obstruction. Corticosteroids have been the mainstay for asthma treatment due to their broad anti-inflammatory actions; however, other medications such as phosphodiesterase 4 inhibitors also demonstrate anti-inflammatory activity in the airways.

AREAS COVERED

This review describes tissue expression of phosphodiesterase 4 in the airways, the different phosphodiesterase 4 isoenzymes identified, and the anti-inflammatory activities of phosphodiesterase 4 inhibition in asthma and related findings in chronic obstructive pulmonary disease (COPD). The authors further review clinical trials demonstrating that drugs such as roflumilast have an excellent safety profile and efficacy in patients with asthma and COPD.

EXPERT OPINION

Phosphodiesterase 4 inhibitors suppress the activity of immune cells, an effect similar to corticosteroids although by acting through different anti-inflammatory pathways and uniquely blocking neutrophilic inflammation. Roflumilast and other phosphodiesterase 4 inhibitors have been shown to provide additive protection in asthma when added to corticosteroid and anti-leukotriene treatment. Developmental drugs with dual phosphodiesterase 3 and 4 inhibition are thought to be able to provide bronchodilation and anti-inflammatory activities and will consequently be pushed forward in their clinical development for the treatment of asthma and COPD.

A review of the use and effectiveness of digital health technologies in patients with asthma

OBJECTIVE

A new generation of digital health technologies (DHT) offers the opportunity to improve adherence and asthma control. Recent literature was reviewed to summarize the use of technological aids and evaluate their impact on health outcomes in patients with asthma.

DATA SOURCES

PubMed and Embase were searched to identify articles published over the past 5 years (2013 to 2017).

STUDY SELECTIONS

All records were judged for eligibility by 2 independent reviewers; 28 articles met the inclusion criteria.

RESULTS

Interactive websites were the most frequently evaluated type of DHT (50% of all studies), followed by mobile apps in adult patient cohorts. Relatively few studies assessed electronic monitoring devices, phone calls, or text messaging. Among the 16 studies that focused on children, most interventions that used interactive websites (n = 8) showed at least some benefit, although results varied based on the specific outcome. Twelve studies focused on adults, with interventions using interactive websites (n = 6) reporting results that were generally less consistent compared with the pediatric studies. The 6 studies that assessed mobile apps with adult patients reported consistent benefits across a range of outcomes, including medication adherence and asthma control.

CONCLUSION

Most interventions reported at least some benefit, although results varied based on the specific outcome. Overall, technology that included more interactive features, such as website-based daily diary entries and apps that provided real-time feedback, was associated with increased asthma control, as was the case for multidimensional interventions that combined the use of several complementary types of DHT.

Adherence to medication in children and adolescents with asthma: methods for monitoring and intervention

INTRODUCTION

Poor adherence in children with asthma is a major cause of asthma attacks and poor control, leads to large health-care costs, and has been identified as a factor in asthma deaths. However, it is difficult to detect and frequently overlooked leading to inappropriate escalation of asthma treatment. There is a need for cost effective ways to monitor adherence in order to intervene to change this modifiable behavior. Areas covered: Several measurement tools have been developed to assess adherence in adults and children with asthma. The current methods for measuring adherence, both subjective and objective, have several flaws and even the current gold standard, electronic monitoring devices (EMDs), has limitations. This review will outline and critique the adherence monitoring tools and highlight ways in which they have been used for the purpose of intervention. Expert commentary: Although advances have been made in adherence monitoring, we still have some way to go in creating the ideal monitoring tool. There are no validated tailored self-monitoring questionnaires for children with asthma and most objective measures, such as prescription refill rate and weighing canisters, overestimate adherence. Current EMDs, although useful, need improved accuracy to ensure that both actuation and inhalation are measured, and the devices need to be affordable for use in routine health-care practice.

Cost-Effectiveness of Biological Asthma Treatments: A Systematic Review and Recommendations for Future Economic Evaluations

BACKGROUND

Recently developed asthma biological therapies have been shown to provide relief for severe asthma patients not controlled by inhaled treatment. Given the relatively high costs of biological therapies, cost-effectiveness analyses (CEAs) may be required as a prerequisite for coverage and reimbursement.

OBJECTIVE

We aimed to systematically review published literature on the economic impact of biological asthma therapies and to identify key drivers that impact cost-effectiveness in order to provide recommendations for future economic evaluations.

METHODS

We conducted a systematic literature search in PubMed and Google Scholar. We included studies that assessed the cost-effectiveness of asthma biologics and were published in English between 2000 and 2018. The Quality of Health Economic Studies (QHES) instrument was used to evaluate quality.

RESULTS

Twenty asthma biological CEAs were identified. Nineteen studies analyzed the cost-effectiveness of omalizumab, and one study analyzed mepolizumab. Ten studies concluded that omalizumab was cost-effective in base-case scenarios, four studies concluded omalizumab was not cost-effective, and the remaining studies concluded omalizumab or mepolizumab was cost-effective only when targeted to specific severe subgroups or given considerable price discounts. Key drivers of cost-effectiveness included day-to-day health-related quality of life (HRQoL), asthma-related mortality, acquisition price of the biological therapy, and time horizon.

CONCLUSIONS

Most studies recommended carefully targeting biological therapy to specific populations such as responders or discounting acquisition price in order to further improve value. The quality of the studies was generally satisfactory, but improved evidence is needed linking HRQoL to utilities as well as understanding interventions' impact on asthma-related mortality. Key recommendations from this review may allow for greater comparability across future cost-effectiveness studies.

Selecting the right biologic for your patients with severe asthma

OBJECTIVE

Severe asthma affects 5% to 10% of the adult asthma population and is associated with increased morbidity, mortality, and consumption of health care resources. Recently, several biologic medications have been approved for use in severe asthma. These medications target the type 2 inflammatory pathway, which is characterized by activation of cytokines, including interleukin (IL)-4, IL-5, and IL-13, which results in eosinophilia, high FeNO, and atopic features. The objective of this review was to provide clinicians with key points to assist in selecting the best biologic medication for each patient.

DATA SOURCES

A comprehensive literature search was performed, and data were reviewed from basic science articles of inflammatory mediators in type 2 airway inflammation, and clinical trials of biologic medications in patients with severe asthma.

STUDY SELECTIONS

These studies analyzed outcomes of biologic medications in type 2-high severe asthma including clinical biomarkers, exacerbation rates, lung function, and quality of life measures.

RESULTS

Biologic mediations in type 2-high severe asthma improve outcomes, including clinical biomarkers, exacerbation rates, lung function, and quality-of-life measures.

CONCLUSION

When choosing a biologic medication for patients with severe asthma, asthma endotype, clinical biomarkers, and patient-centered factors should be taken into account.

Matching Inhaler Devices with Patients: The Role of the Primary Care Physician

Poor inhaler technique and nonadherence impair the efficacy of medications for asthma and chronic obstructive pulmonary disease (COPD). A range of factors, including age, dexterity, inspiratory capacity, cognitive ability, health literacy, and ethnicity, can impact a patient's ability and intention to use their device. Treatment success can also be influenced by patient preferences and perceptions. Therefore, it is important that healthcare professionals effectively match inhaler devices to individual patients' needs and abilities and empower patients by including them in treatment decisions. Physicians must, therefore, fully understand the characteristics of each device, as well as their patients' demographic characteristics and comorbidities. Following device selection, patient training and education, including a physical demonstration of the device, are key to eliminate any critical errors that may impact on health outcomes. Inhaler technique should be frequently rechecked. This review will examine the important role of primary care providers in the selection of appropriate inhaler devices and provision of training for patients with COPD and asthma to optimize correct inhaler use and adherence. An overview of the key features of available devices and of the factors to consider when selecting devices will be provided in the context of current asthma and COPD guidelines.

Exacerbation of asthma due to inadvertent use of a dummy inhaler

Asthma is a common airways disease. Fortunately most patients respond well to inhaled therapy. Regular use of a combination inhaler delivering corticosteroid and a long-acting beta-2 agonist, is the mainstay of treatment and allows asthmatics to live a relatively normal life. However, management of asthma depends not only on the choice of drug/inhaler but also on patient compliance and optimal inhaler technique. This report describes a patient who continued to deteriorate despite adhering to prescribed treatment and demonstrating a good inhaler technique. Unfortunately the combination inhaler she was taking inadvertently was a designated placebo device for a branded product. This error was identified and corrected only after she was admitted with an asthma attack.

A novel statistical method for assessing effective adherence to medication and calculating optimal drug dosages

OBJECTIVE

We derive a novel model-based metric for effective adherence to medication, and validate it using data from the INhaler Compliance Assessment device (INCATM). This technique employs dose timing data to estimate the threshold drug concentration needed to maintain optimal health.

METHODS

The parameters of the model are optimised against patient outcome data using maximum likelihood methods. The model is fitted and validated by secondary analysis of two independent datasets from two remote-monitoring studies of adherence, conducted through clinical research centres of 5 Irish hospitals. Training data came from a cohort of asthma patients (~ 47,000 samples from 218 patients). Validation data is from a cohort of 204 patients with COPD recorded between 2014 and 2016.

RESULTS

The time above threshold measure is strongly predictive of adverse events (exacerbations) in COPD patients (Odds Ratio of exacerbation = 0.52 per SD increase in adherence, 95% Confidence Interval [0.34-0.79]). This compares well with the best known previous method, the Area Under the dose-time Curve (AUC) (Odds Ratio = 0.69, 95% Confidence Interval [0.48-0.99]). In addition, the fitted value of the dose threshold (0.56 of prescribed dosage) suggests that prescribed doses may be unnecessarily high given good adherence.

CONCLUSIONS

The resulting metric accounts for missed doses, dose-timing errors, and errors in inhaler technique, and provides enhanced predictive validity in comparison to previously used measures. In addition, the method allows us to estimate the correct dosage required to achieve the effect of the medication using the patients' own adherence data and outcomes. The adherence score does depend not on sex or other demographic factors suggesting that effective adherence is driven by individual behavioural factors.

Advances in Audio-Based Systems to Monitor Patient Adherence and Inhaler Drug Delivery

Hundreds of millions of people worldwide have asthma and COPD. Current medications to control these chronic respiratory diseases can be administered using inhaler devices, such as the pressurized metered dose inhaler and the dry powder inhaler. Provided that they are used as prescribed, inhalers can improve patient clinical outcomes and quality of life. Poor patient inhaler adherence (both time of use and user technique) is, however, a major clinical concern and is associated with poor disease control, increased hospital admissions, and increased mortality rates, particularly in low- and middle-income countries. There are currently limited methods available to health-care professionals to objectively and remotely monitor patient inhaler adherence. This review describes recent sensor-based technologies that use audio-based approaches that show promising opportunities for monitoring inhaler adherence in clinical practice. This review discusses how one form of sensor-based technology, audio-based monitoring systems, can provide clinically pertinent information regarding patient inhaler use over the course of treatment. Audio-based monitoring can provide health-care professionals with quantitative measurements of the drug delivery of inhalers, signifying a clear clinical advantage over other methods of assessment. Furthermore, objective audio-based adherence measures can improve the predictability of patient outcomes to treatment compared with current standard methods of adherence assessment used in clinical practice. Objective feedback on patient inhaler adherence can be used to personalize treatment to the patient, which may enhance precision medicine in the treatment of chronic respiratory diseases.