Medication adherence and the risk of severe asthma exacerbations: a systematic review

Telemedicine and adherence monitoring in children with asthma

PURPOSE OF REVIEW

Telemedicine, defined as synchronous video visits between a provider and a child with asthma, often takes place in the school setting. This review examines the new electronic sensors for adherence monitoring and studies that used telemedicine in the school setting to improve asthma outcomes.

RECENT FINDINGS

School-based telemedicine provides an important service to families of school-aged children who have difficulty due to time and distance in planning and keeping in-person appointments with primary or specialty providers. Significant improvements in objective measures of asthma control are inconsistently observed although caregiver and parent quality of life and child self-management behaviors are improved and satisfaction is high. Assessment and outcomes related to adherence are mentioned in studies but results are not often reported. However, it appears that adherence interventions are beneficial while maintained but the effects are not sustained upon intervention discontinuation.

SUMMARY

The school setting provides a convenient and suitable environment to conduct telemedicine visits between school-aged children and their primary care or specialty provider. Electronic adherence sensors allow review of controller and rescue medication use through a cloud-based dashboard and provides an opportunity for real-time assessment and intervention by providers to improve asthma outcomes.

Impact of comorbid asthma on severity of coronavirus disease (COVID-19)

The severity of the coronavirus disease (COVID-19) is associated with various comorbidities. However, no studies have yet demonstrated the potential risk of respiratory failure and mortality in COVID-19 patients with pre-existing asthma. We selected 7272 adult COVID-19 patients from the Korean Health Insurance Review and Assessment COVID-19 database for this nationwide retrospective cohort study. Among these, 686 patients with asthma were assessed by their severities and evaluated by the clinical outcome of COVID-19 compared to patients without asthma. Of 7272 adult COVID-19 patients, 686 with asthma and 6586 without asthma were compared. Asthma was not a significant risk factor for respiratory failure or mortality among all COVID-19 patients (odds ratio [OR] = 0.99, P = 0.997 and OR = 1.06, P = 0.759) after adjusting for age, sex, and the Charlson comorbidity score. However, a history of acute exacerbation (OR = 2.63, P = 0.043) was significant risk factors for death among COVID-19 patients with asthma. Asthma is not a risk factor for poor prognosis of COVID-19. However, asthma patients who had any experience of acute exacerbation in the previous year before COVID-19 showed higher COVID-19-related mortality, especially in case of old age and male sex.

Sustained release of tulobuterol from graphene oxide laden hydrogel to manage asthma

Bronchial asthma is a chronic disease which is currently treated using various inhalants. However, the medication adherence with the inhalants is poor due to complex procedure to use them along with frequent dosing. In this paper, we have developed tulobuterol loaded Pluronic® F127-reduced graphene oxide transdermal hydrogel to sustain the release of tulobuterol to manage asthma for days. The synthesis of Pluronic^® F127-reduced graphene oxide was confirmed by Fourier transform infrared spectroscopy, X-ray diffraction, and Raman spectroscopy. The transmission electron microscope showed wrinkled flat nano sheets. The hydrogel showed sufficient mechanical properties for topical application and was safe in the skin irritation study (rabbit model). The ex vivo release data demonstrated the ability of reduced graphene oxide to sustain the release of tulobuterol for 72 h, due to strong π-π interaction between drug and graphene oxide. The pharmacokinetic profile in Sprague-Dawley rat model confirmed the potential of tulobuterol-Pluronic^® F127-reduced graphene oxide hydrogel to sustain the release of tulobuterol for effective management of asthma.

Updated Australian guidelines for mild asthma: what's changed and why?

The Australian asthma guidelines have recently been updated and include additional treatment options for adults and adolescents with mild asthma Mild asthma is not necessarily a benign condition and patients are still at risk of severe flare-ups, particularly if they overuse short-acting beta2 agonists such as a salbutamol inhaler For adults and adolescents with mild asthma, the updated guidelines include as-needed inhaled low-dose budesonide–formoterol as an alternative to daily low-dose inhaled corticosteroid plus as-needed short-acting beta2 agonist The budesonide–formoterol combination should be taken as needed to provide symptom relief and reduce the risk of severe exacerbations

Assessment of Poor Inhaler Technique in Older Patients with Asthma or COPD: A Predictive Tool for Clinical Risk and Inhaler Performance

BACKGROUND/OBJECTIVES

Older patients with asthma or chronic obstructive pulmonary disease (COPD) are particularly susceptible to inhaler technique errors and poor clinical outcomes. Several factors may influence their risk, but most studies are inconsistent and contradictory. We developed a tool for the major predictors of individual risk in these patients.

DESIGN, SETTING AND PARTICIPANTS

In this multicentre, cross-sectional study, several demographic, socioeconomic and clinical characteristics were collected as potential predictors. Clinical features and inhaler technique performance were the main outcomes. Linear and logistic regression models were set up to identify significant variables. Subgroup analysis was performed according to age, cognitive performance and different types of inhalers.

RESULTS

We included 130 participants, mean age of 74.4 (± 6.4) years. Mean years of device use were 5.8 (± 7.3). Inhaler errors affected 71.6% (95% CI 64-78.5) and critical mistakes 31.1% (95% CI 24-38.8). There were respiratory comorbidities in 82.3% of participants, and 56.2% had moderate to severe disease. A predictive score of misuse probability was developed for clinical practice, including points attributable to cognitive score, adherence and having received previous education on a placebo device. Other significant variables of individual risk were having respiratory allergies or comorbidities, smoking status, depression and educational level. Worse performance was detected in cognitively impaired patients older than 75 years who were using dry powder inhalers (DPI). Lung function was associated with smoking load, incorrect dose activation and absent end pause after inhalation.

CONCLUSIONS

Individual risk assessment in older individuals should focus on inhaler technique performance (mainly on dose activation and end pause) and adherence, smoking, respiratory comorbidities and cognitive impairment. Placebo device training provided by doctors seems to best suit these patients.

Overuse of reliever inhalers and associated healthcare utilization of asthma patients

Global Initiative for Asthma 2019 guidelines recommend to avoid strengthening patients’ reliance on relievers since they increase exacerbation risk. Our aim was to examine the association between reliever inhalers overuse and all-cause healthcare utilization (HCU). A retrospective study among Clalit Health Services (CHS) adult enrollees (n = 977) for 2012–2017. Reliever inhalers overuse was defined as consistent prescription refills of ≥ 3 canisters annually. Adherence to controllers was calculated using the proportion of days covered. HCU included: hospitalizations, diagnostic and surgical procedures, medications, emergency room (ER) visits, and clinic visits. 27% of the study population (n = 264) consistently refilled ≥ 3 relievers prescriptions annually, and had higher adherence to controllers (0.38 vs. 0.24, p < 0.001). Their total 6-year HCU costs were not higher than that of others ($5,550 vs. $5,562, p = 0.107). Most HCU components [including hospitalization (p = 0.405) and ER visits (p = 0.884)] were comparable; however, medication costs were higher ($1734 vs. $1504, p < 0.001). A multivariable ordered-logit model revealed that frequent and regular use of relievers was not associated with higher HCU costs (OR = 0.82, 95% CI 0.62–1.09, p = 0.175). Higher adherence to maintenance and reliever therapy (OR = 2.18, 95% CI 1.44–3.28, p < 0.001), other controllers (OR = 3.30, 95% CI 2.11–5.16, p < 0.001), and nebulized SABAs and SAMAs (OR = 1.08, 95% CI 1.02–1.14, p = 0.007) was associated with higher costs. Overuse of reliever inhalers was prevalent and associated with higher adherence to controllers, yet not associated with higher all-cause HCU. This highlights the need to examine the sources of elevated usage in order to develop intervention strategies to optimize pharmaceutical therapy of asthma patients.

Mobile Health and Inhaler-Based Monitoring Devices for Asthma Management

Mobile health and web applications (apps), wearables, and other personal monitoring devices have tremendous potential to improve the management of asthma. More than 500 asthma-related apps, whether standalone or paired with sensors on inhalers, are currently available for health education, symptom recording, tracking of inhaler use, displaying environmental alerts, and providing medication reminders. Benefits of these tools include the ability to longitudinally collect symptom, trigger, and inhaler usage data, allowing the detection of significant changes over time to help patients and their caregivers determine whether symptoms are worsening. In addition, data from external information sources, including weather, allergen, and air quality reports, can be integrated with user-specific data to enhance predictions on when patients may experience symptoms and/or need to avoid triggers. Barriers to adoption of asthma-related apps and inhaler-based devices include uncertain efficacy and effectiveness, potential high cost, sustained user engagement, and concerns about privacy. Moreover, ensuring the acceptability and utility of asthma management apps for individuals of all races/ethnicities, socioeconomic groups, ages, genders, and literacy levels is necessary. Based on studies thus far, mobile health apps and inhaler-based devices have great potential to serve as useful tools in the patient-doctor relationship and revolutionize asthma care.

Retrospective analysis of the effect of inhaler education on improvements in inhaler usage

INTRODUCTION

Various types of inhalation devices have been released, and it is necessary to acquire the skills for using each of them. The factors that have been previously associated with poor inhalator usage include gender, duration of disease, age, and the type of device. However, it is unclear whether these factors also apply to the Japanese population. The number of education sessions needed to acquire inhaler usage skills is also not established.

PATIENTS AND METHODS

We performed a retrospective review of the medical records of selected patients and their subjective assessments of their inhaler usage skills between January 2016 and March 2018. The primary outcome was the effect of inhaler education for each inhaler device. The secondary outcomes were the factors affecting the effectiveness of inhaler education, the effects of inhalation education stratified by age, and the number of inhaler education sessions needed to improve inhaler usage skills.

RESULTS

Data from 399 patients were analyzed. Age and the type of delivery device affected the mastery of inhaler usage skills. Approximately half of the patients had acquired inhaler usage skills during baseline evaluation. Approximately 90% of patients acquired inhalation usage skills after two education sessions, regardless of the type of inhalation device. Among the older patients, 35.0% had acquired inhaler usage skills during the baseline evaluation, and 86.8% acquired them after two education sessions.

CONCLUSIONS

Inhaler usage skills significantly improved, regardless of the device, after inhalation education, and this was also observed in elderly patients after two education sessions.

Self-titration of inhaled corticosteroid and β2-agonist in response to symptoms in mild asthma: a pre-specified analysis from the PRACTICAL randomised controlled trial

INTRODUCTION

In mild asthma, as-needed budesonide-formoterol is superior or noninferior to maintenance budesonide plus as-needed short-acting β₂-agonist in reducing severe exacerbations. In this pre-specified analysis, we investigated patterns of inhaled corticosteroid (ICS) and β₂-agonist use in PRACTICAL, a randomised controlled trial.

METHODS

Participants were randomised 1:1 to as-needed budesonide-formoterol (200/6 μg Turbuhaler, one actuation) or maintenance budesonide (200 μg Turbuhaler, one actuation twice a day) with as-needed terbutaline (250 μg, two actuations) for 52 weeks. 110 participants had electronic monitors attached to their study inhalers which captured the time and date of every actuation. Key outcome measures were patterns of ICS and β₂-agonist use. One actuation of budesonide-formoterol was considered to be an equivalent bronchodilator dose as two actuations of terbutaline.

RESULTS

Participants randomised to as-needed budesonide-formoterol had more days with no ICS use compared with maintenance budesonide (median total days of no use 156 versus 22 days, respectively), lower median daily budesonide dose (164 versus 328 μg, respectively) and a greater median number of days of ≥4 budesonide actuations (4 versus 1 days, respectively). Participants randomised to as-needed budesonide-formoterol took higher equivalent doses of β₂-agonist both overall (median number of actuations 0.8 versus 0.3 per day, respectively) and in response to worsening asthma (total number of "overuse days" of >8 or >16 actuations of budesonide-formoterol or terbutaline 33 versus 10 days, respectively).

CONCLUSIONS

The timing of ICS dose when self-titrated to β₂-agonist use is more important than total ICS dose in reducing severe exacerbation risk in mild asthma, when associated with greater overall use of as-needed β₂-agonist.

Pharmacotherapeutic management of asthma in pregnancy and the effect of sex hormones

INTRODUCTION

Asthma is a common medical condition that can frequently affect pregnancy, and thus optimal management of asthma in pregnancy is important for both mother and baby. This article reviews recent developments of asthma pharmacotherapy and provides emerging data on the safety of asthma controller medications and biological therapies in pregnancy. The authors highlight the clinical outcomes of asthma during pregnancy, and summarize emerging new data related to the influence of sex hormones and fetal sex on asthma severity.

AREAS COVERED

This review of asthma pharmacotherapy during pregnancy examines the recent guidelines and reports the most pertinent publications on safety data and asthma management.

EXPERT OPINION

Asthma management during pregnancy follows the same principles as that of non-pregnant asthma. The available data for most asthma medications are reassuring, however there is a lack of adequate safety data available because pregnant women are generally excluded from clinical trials. More clarity is needed in guidelines regarding the management of asthma in pregnancy, and high-quality randomized control trials are required to strengthen the evidence base and inform future guidelines. In particular, safety studies examining biological therapies in pregnant women with severe asthma are needed.

Primary non-adherence to inhaled medications measured with e-prescription data from Poland

BACKGROUND

Treatment adherence greatly influences the clinical outcomes in various fields of medicine, including management of asthma and COPD. With the recent implementation of a nationwide e-Health solutions in Poland, new and unique opportunities for studying primary non-adherence in asthma and COPD emerged. The aim was to study primary non-adherence to inhaled medications available in Poland indicated in asthma and/or COPD and analyse the impact of patients' demographics and inhalers' characteristics (dry powder inhalers (DPIs) vs metered dose inhalers (MDIs) and presence of a dosage counter) on primary non-adherence.

METHODS

A retrospective analysis of all e-prescriptions issued in Poland in 2018 (n = 119,880) from the national e-prescription pilot framework.

RESULTS

Primary non-adherence for inhalable medications reached 15.3%. It significantly differed among age groups-the lowest (10.8%) was in 75 + years-old patients, highest (18%) in 65-74 years-old patients. No gender differences in primary non-adherence were found. The highest non-adherence was observed for ICS + LABA combinations (18.86%). A significant difference was found between MDI and DPI inhalers and between inhalers with/without a dosage counter.

CONCLUSIONS

Out of e-prescriptions for inhaled medications issued in 2018 in Poland, 15.3% were not redeemed. The degree of primary non-adherence was influenced by age, but not gender. Significant differences between MDIs and DPIs and between inhalers with/without a dosage counter were observed.

Effect of a single day of increased as-needed budesonide-formoterol use on short-term risk of severe exacerbations in patients with mild asthma: a post-hoc analysis of the SYGMA 1 study

BACKGROUND

In mild asthma, as-needed budesonide-formoterol reduces long-term exacerbation risk compared with as-needed short-acting β₂-agonist (SABA), with a similar or increased reduction versus maintenance with budesonide plus as-needed SABA, despite a lower budesonide dose. In this post-hoc analysis of the SYmbicort Given as needed in Mild Asthma (SYGMA) 1 study, we investigated the short-term risk of severe exacerbations after a single day with various levels of reliever use.

METHODS

SYGMA 1 was a 52-week, double-blind, randomised, controlled, phase 3 trial, in which patients aged 12 years or older with mild asthma were randomly assigned (1:1:1) to placebo twice daily plus as-needed terbutaline 0·5 mg, placebo twice daily plus as-needed budesonide-formoterol 200-6 μg, or budesonide 200 μg twice daily plus as-needed terbutaline (ie, budesonide maintenance group). In this post-hoc analysis, we assessed the frequency of reliever use and the risk of a severe exacerbation in the 21 days after first use of more than two, four, six, or eight reliever inhalations in 24 h. SYGMA 1 is registered with ClinicalTrials.gov, NCT02149199, and is now complete.

FINDINGS

Of 5721 patients enrolled in SYGMA 1, 3849 were randomly assigned to as-needed terbutaline (n=1280), as-needed budesonide-formoterol (n=1279), or budesonide maintenance (n=1290), of whom 3836 had evaluable data (n=1277 as-needed terbutaline, n=1277 as needed budesonide-formoterol, and n=1282 budesonide maintenance). Median reliever use was 0·32 (IQR 0·08-0·91) inhalations per day for the as-needed terbutaline group, 0·29 (0·07-0·72) for the as-needed budesonide-formoterol group, and 0·16 (0·04-0·52) for the budesonide maintenance group. Compared with as-needed terbutaline, after adjustment for age, sex, randomly assigned treatment, pre-study treatment group, baseline % predicted post-bronchodilator FEV₁, and severe exacerbation in the 12 months before enrolment in the study, the hazard ratio (HR) for severe exacerbation in the 21 days after a single day with more than two as-needed inhalations was 0·27 (95% CI 0·12-0·58; p=0·0008) with as-needed budesonide-formoterol and 0·39 (0·19-0·79; p=0·0091) with budesonide maintenance; after a single day of more than four as-needed inhalations the HR was 0·24 (0·10-0·62; p=0·0030) with as-needed budesonide-formoterol and 0·30 (0·13-0·72; p=0·0065) with budesonide maintenance; and after a single day of more than six as-needed inhalations the HR was 0·14 (0·02-1·06; p=0·057) with as-needed budesonide-formoterol and 0·43 (0·14-1·26; p=0·12) with budesonide maintenance. HRs were not calculated for more than eight as-needed inhalations due to the small number of events.

INTERPRETATION

In mild asthma, as-needed budesonide-formoterol reduces the short-term risk of severe exacerbations after a single day of higher use (more than two as-needed inhalations), even when overall use is infrequent. Use of an anti-inflammatory reliever might reduce the risk of short-term severe exacerbations by the timely provision of increased doses of as-needed inhaled corticosteroids and formoterol when symptoms occur. These findings should be further assessed in prospective randomised clinical trials.

FUNDING

AstraZeneca.

Change of address as a measure of housing insecurity predicting rural emergency department revisits after asthma exacerbation

OBJECTIVE

Housing insecurity is an important socioeconomic factor that may impact emergency department (ED) use for children with asthma, but housing insecurity screening has primarily relied on patient surveys or linkage to external data sources. Using patient addresses recorded in the electronic medical record (EMR), we sought to correlate recent changes in address (as a proxy for housing insecurity) with ED revisit risk.

METHODS

We retrospectively identified patients age 2-17 years seen in our rural ED for asthma exacerbation during 2016-2018. We used EMR data from the 12 months before the earliest ED visit to compare patients with and without a recent change of address (over previous 12 months) on 30- and 90-day all-cause and asthma-specific ED revisits.

RESULTS

The study included 632 children, of whom 85 (13%) had a recent address change before the index ED visit. Moving was not associated with asthma-specific 30-day or 90-day revisits. Ninety-day all-cause revisits were more common among patients who had recently moved (36% vs. 25%; p = 0.019), although this difference was not statistically significant after multivariable adjustment for Medicaid insurance coverage and number of recent health system encounters (odds ratio: 1.49; 95% confidence interval: 0.91, 2.46; p = 0.114).

CONCLUSIONS

A history of recent address change in the EMR was not independently associated with repeat ED visits for asthma exacerbation. Many children presenting to the ED did not have recent encounters with our health system where address could be ascertained. This EMR-based proxy for housing insecurity may be more applicable to patients under continuous follow-up.

Pattern of treatment of behavioural and psychological symptoms of dementia and pain: evidence on pharmacoutilization from a large real-world sample and from a centre for cognitive disturbances and dementia

Purpose

Data concerning the number of diagnoses and of the drugs prescribed to patients affected by dementia are still scarce. Here we test whether or not (1) prescription of symptomatic drugs against Alzheimer’s disease (AD) may approximate the number of patients affected by dementia in Italy and (2) adherence to this treatment affects the pattern of prescription of drugs (i.e. antipsychotics and antidepressants) for behavioural and psychological symptoms of dementia (BPSD) and the previously reported limited prescription of analgesics.

Methods

This retrospective observational study concerns 84,235 subjects older than 60 years and registered in the provincial prescription database of the health district of Cosenza accounting for a population of 298,000 inhabitants. The prescribing pattern of antipsychotics, antidepressants, and analgesics has been investigated in patients receiving concurrent prescriptions of acetylcholinesterase inhibitors (AChEI) and/or memantine. Data from a single centre for cognitive disturbances and dementia (CDCD) in the same health district were used to explore at which stage dementia was diagnosed. The study was approved by Calabria Region Ethical Committee no. 31/2017 and registered on October 31, 2017.

Results

The data show that 859 patients are treated with AChEI and/or memantine; 420 patients (48.89%) receive at least 80% of the recommended medications. CDCD data indicate a delay in dementia diagnosis, which often was made when the patients were moderately to severely demented (Mini Mental State Examination, MMSE ≤ 20). Adherence did not influence prescription of most of the drugs explored, but use of non-steroidal anti-inflammatory drugs was higher in non-adherent patients. Antipsychotics and antidepressants are frequently used (20.61–20.71% and 42.37–51.43%, respectively), and this, at least in part, might stem from the observed under-treatment of chronic pain (opioids are prescribed in the 4.76% and 12.46% of adherent and non-adherent patients and gabapentin and pregabalin are used in the 4.29% and 4.07% of adherent and non-adherent patients respectively), resulting in more frequent BPSD. 16.43% of patients receive antipsychotics for longer than 6–12 weeks.

Conclusion

This 2-year period study, including a wide cohort of community demented patients, shows that dementia is diagnosed late and that prevalence of BPSD prescriptions is high and not impacted by adherence to anti-dementia drugs. The rate of prescription of potentially harmful antipsychotics and antidepressants appears to be high though whether the concomitantly observed limited prescription of analgesics might be a contributing factor needs to be further investigated. Our data support the development of strategies to improve the management of BPSD.

Asthma in children and adolescents: the ControL'Asma project

The control of asthma is the objective of asthma management. However, it is difficult to obtain in clinical practice. The Italian Society of Allergy and Clinical Immunology promoted the nationwide project "ControL'Asma" to investigate the real situation in a group of children and adolescents with asthma. The preliminary outcomes demonstrated that many asthmatic subjects do not achieve adequate asthma control. Moreover, asthma in Italian children and adolescents was usually more frequent in males, had an early onset and allergic phenotype with very frequent rhinitis comorbidity, uncontrolled and partly controlled asthma affected about the half of subjects. However, this project suggested that the assessment of asthma symptom perception by VAS could be a reliable tool in the asthma management.

Psychological and Medical Characteristics Associated with Non-Adherence to Prescribed Daily Inhaled Corticosteroid

Medication non-adherence is associated with sub-optimal asthma control. Identification of medical and psychological characteristics associated with non-adherence is important to enable a targeted and personalized approach when working with patients and for the development of interventions to improve patient outcomes by improving medication adherence. We enrolled adults who had diagnosed asthma and who were prescribed daily inhaled corticosteroid medication. We used published and validated instruments to measure medical characteristics including asthma features, practical asthma knowledge and perceived involvement in care and psychological characteristics including anxiety, depression, optimism, and personality traits, to assess the relationship with medication non-adherence. A total of 126 participants provided data, with 64 (50.8%) of the participants identified as non-adherent. Multivariate analyses showed that younger age, high neuroticism scores and a previous asthma hospital admission were associated with non-adherence. Interestingly, depression was associated with a lower risk of non-adherence. This study showed that a personalized medicine approach would include interventions targeting those who are younger, who have been in hospital for asthma and who rate high on the neuroticism personality trait. Given the availability of effective medications for asthma, better understanding of the characteristics associated with non-adherence is important to enhance optimal self-management.

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).

A Proposed Approach to Chronic Airway Disease (CAD) Using Therapeutic Goals and Treatable Traits: A Look to the Future

Chronic airflow obstruction affects a wide range of airway diseases, the most frequent of which are asthma, COPD, and bronchiectasis; they are clearly identifiable in their extremes, but quite frequently overlap in some of their pathophysiological and clinical characteristics. This has generated the description of new mixed or overlapping disease phenotypes with no clear biological grounds. In this special article, a group of experts provides their perspective and proposes approaching the treatment of chronic airway disease (CAD) through the identification of a series of therapeutic goals (TG) linked to treatable traits (TT) - understood as clinical, physiological, or biological characteristics that are quantifiable using biomarkers. This therapeutic approach needs validating in a clinical trial with the strategy of identification of TG and treatment according to TT for each patient independently of their prior diagnosis.

Anti-Contractile and Anti-Inflammatory Effects of Diacerein on Isolated Mouse Airways Smooth Muscle and Mouse Asthma Model

Characterized by abnormal smooth muscle contractility and airway inflammation, asthma is one of the most common airway diseases worldwide. Diacerein is a well-known anti-inflammatory drug, widely used in osteoarthritis. In current study, the innovative usage of diacerein in anti-contractile and anti-inflammatory treatment of asthma was studied. In vitro experiments including tension measurement and patch-clamp technique and in vivo experiments including establishment of mice model and measurement of respiratory resistance were applied to explore the role of diacerein in asthma. It turned out that agonist-precontracted mouse airway smooth muscle could be relaxed by diacerein via intracellular and extracellular calcium mobilization which was mediated by switched voltage-dependent L-type Ca²⁺ channels, non-selective cation channels, large-conductance Ca²⁺-activated K⁺ channel, and Na⁺/Ca²⁺ exchangers. Furthermore, diacerein could relieve bronchospasm and control airway inflammation in asthmatic mice via reduction of several inflammatory factors. Our studies elucidated the potential therapeutic property of diacerein in asthma treatment and the possible underlying mechanism. It also confirmed that new uses for already-approved drugs could be an important form of innovation.

Validation of the inhaler adherence questionnaire

Background

Although electronic monitoring is the “gold standard” for adherence monitoring, the range of inhaler devices on the market exceeds the availability of appropriate monitoring devices. Simple tools, applicable across a range of inhalers, are needed to assess patients’ adherence to prescribed inhaled medication. This study reports on the validation of an Inhaler Adherence Questionnaire (IAQ).

Methods

Seventy-four adults who self-reported doctor diagnosed asthma and who were prescribed daily inhaled corticosteroids (ICS) for asthma contributed data for these analyses. These participants were part of a larger study, investigating factors associated with non-adherence to prescribed daily inhaled corticosteroid medication. Participants were informed the research was investigating asthma management without explicit mention that medication adherence was being monitored. Inhaled corticosteroid medication adherence was measured in two ways. Firstly, participants completed the 6-item IAQ at enrolment. Secondly, ICS via pressurised Metered Dose Inhaler (pMDI) use was monitored electronically using the DoserCT which recorded daily use over 6 weeks. During the 6 weeks of prospective medication monitoring via the DoserCT we did not have contact with participants so that the adherence measure would reflect usual self-management behaviour.

Results

Two of the six questions in the IAQ had poor face validity and their exclusion from the questionnaire resulted in improved internal consistency. Mean days adherent were 37.1, 29.2 and 33.2% for subjects with IAQ scores of 0, 1 and 2 respectively. Higher IAQ scores of 3 and 4 were associated with greater mean days adherent of 73.7 and 67.4% respectively. A cut-point of 2 or less had a sensitivity of 73% and a specificity of 80% for detecting non-adherence. The area under the ROC curve was 0.764 (p < 0.001).

Conclusions

The modified 4-item IAQ is simple, quick to complete and useful for measuring adherence with prescribed daily inhaled medication. This validation of the IAQ provides evidence for its utility in research and it will be important to validate this simple, inexpensive tool for use in clinical practice.

Asthma attacks in children are always preceded by poor asthma control: myth or maxim?

Some, but not all, asthma exacerbations in children are preceded by poor asthma control https://bit.ly/3muIy6h.

A Retrospective Audit of Pharmacologic and Non-Pharmacologic Management of Childhood Acute Asthma Exacerbation at Usmanu Danfodiyo University Teaching Hospital, Sokoto: Adherence to Global Treatment Guidelines

Background

Adequate management of childhood acute asthma exacerbation requires optimal non-pharmacotherapy and pharmacotherapy. Global asthma guidelines provide critical information and serves as a quick reference decision-support material for clinicians.

Objectives

We aimed at evaluating hospital management of childhood acute asthma exacerbation to ascertain its conformity to the global treatment guidelines, and to identify factors that predict short or prolonged observation in the hospital.

Method

This was a retrospective audit of the management of acute asthma exacerbation in children seen between 01 January 2017 and 31 December 2018 at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. Relevant data on demography, asthma triggers and severity, functional and clinical diagnoses, types of controller medications used before and after presentation, non-pharmacotherapy and pharmacotherapy instituted during presentation, duration of observation in the hospital, and treatment outcomes were extracted from the case file of each eligible patient.

Results

A total of 119 children presented with features of suspected acute asthma exacerbations during the study period but only 63 (52.9%) that met the inclusion criteria for the study were included for analysis. The 63 children that were evaluated had mild (47; 74.6%) and moderate (16; 25.4%) acute asthma exacerbations. Their median (interquartile range) age was 8 (5–15) years. More males (36; 57.1%) than females (27; 42.9%) presented with features of the condition. Majority (50; 79.8%) of the patients had at least one trigger factor and of the 73 trigger factors reported, cold weather (19; 26.0%) was the commonest. Nebulized salbutamol (48; 76.5%), in addition to intravenous (23; 57.9%) and oral (17; 42.5%) corticosteroids, was used during hospital treatment. Patients were discharged mostly on short course of oral corticosteroid only (37; 58.8%). Of the 17 major recommendations in the Global Initiative for Asthma (GINA) guidelines, good (5; 29.4%), moderate (7; 41.2%), and poor (5; 29.4%) levels of adherence were observed. Specifically, moderate and poor levels of adherence were observed in the management of 61(96.8%) and 2(3.2%) patients, respectively. The odds of admission for ≤12 h were higher for female children and patients with mild cases.

Conclusion

Good and moderate adherence levels to 12 of the 17 GINA recommendations were observed in our center. Nonetheless, reinforcement of institutional guidelines for acute asthma management is suggested to further improve the quality of care of childhood acute asthma exacerbations.

Towards a personalised treatment approach for asthma attacks

Asthma attacks (exacerbations) are common, accounting for over 90 000 UK hospital admissions per annum. They kill nearly 1500 people per year in the UK, have significant associated direct and indirect costs and lead to accelerated and permanent loss of lung function. The recognition of asthma as a heterogeneous condition with multiple phenotypes has revolutionised the approach to the long-term management of the condition, with greater emphasis on personalised treatment and the introduction of the treatable traits concept. In contrast asthma attacks are poorly defined and understood and our treatment approach consists of bronchodilators and systemic corticosteroids. This review aims to explore the current limitations in the description, assessment and management of asthma attacks. We will outline the risk factors for attacks, strategies to modify this risk and describe the recognised characteristics of attacks as a first step towards the development of an approach for phenotyping and personalising the treatment of these critically important events. By doing this, we hope to gradually improve asthma attack treatment and reduce the adverse effects associated with recurrent courses of corticosteroids.

Risk factors for intensive care admission in children with severe acute asthma in the Netherlands: a prospective multicentre study

Rationale

Severe acute asthma (SAA) can be fatal, but is often preventable. We previously observed in a retrospective cohort study, a three-fold increase in SAA paediatric intensive care (PICU) admissions between 2003 and 2013 in the Netherlands, with a significant increase during those years of numbers of children without treatment of inhaled corticosteroids (ICS).

Objectives

To determine whether steroid-naïve children are at higher risk of PICU admission among those hospitalised for SAA. Furthermore, we included the secondary risk factors tobacco smoke exposure, allergic sensitisation, previous admissions and viral infections.

Methods

A prospective, nationwide multicentre study of children with SAA (2–18 years) admitted to all Dutch PICUs and four general wards between 2016 and 2018. Potential risk factors for PICU admission were assessed using logistic regression analyses.

Measurements and main results

110 PICU and 111 general ward patients were included. The proportion of steroid-naïve children did not differ significantly between PICU and ward patients. PICU children were significantly older and more exposed to tobacco smoke, with symptoms >1 week prior to admission. Viral susceptibility was not a significant risk factor for PICU admission.

Conclusions

Children with SAA admitted to a PICU were comparable to those admitted to a general ward with respect to ICS treatment prior to admission. Preventable risk factors for PICU admission were >7 days of symptoms without adjustment of therapy and exposure to tobacco smoke. Physicians who treat children with asthma must be aware of these risk factors.

Preventable risk factors for PICU admission among those with severe acute asthma are >7 days of symptoms without adjustment of therapy and environmental exposure to tobacco smoke, underlining the importance of smoking cessation of caregivershttps://bit.ly/3ezPzxT

Patient preferences for asthma management: a qualitative study

OBJECTIVE

Preference for asthma management and the use of medications is motivated by the interplay between lived experiences of asthma and patients' attitudes towards medications. Many previous studies have focused on individual aspects of asthma management, such as the use of preventer and reliever inhalers. The aim of this qualitative study was to explore the preferences of patients with mild-moderate asthma for asthma management as a whole and factors that influenced these preferences.

DESIGN

A qualitative study employing qualitative descriptive analysis situated within a constructionist epistemology to analyse transcribed audio recordings from focus groups.

SETTING

Three locations within the greater Wellington area in New Zealand.

PARTICIPANTS

Twenty-seven adults with self-reported doctor's diagnosis of asthma, taking short-acting beta-agonists alone or inhaled corticosteroids with or without long-acting beta2-agonist, who had used any inhaled asthma medication within the last month.

RESULTS

Four key areas described preferences for asthma management. Preferences for self-management: participants wanted to be in control of their asthma and developed personal strategies to achieve this. Preferences for the specific medications or treatment regimen: participants preferred regimens that were convenient and reliably relieved symptoms. Preferences for inhaler devices: devices that had dose counters and were easy to use and portable were important. Preferences for asthma services: participants wanted easier access to their inhalers and to be empowered by their healthcare providers. Participant preferences within each of these four areas were influenced by the impact asthma had on their life, their health beliefs, emotional consequences of asthma and perceived barriers to asthma management.

CONCLUSIONS

This study illustrates the interaction of the lived experience of asthma, factors specific to the individual, and factors relating to asthma treatments in shaping patient preferences for asthma management. This aids our understanding of preferences for asthma management from the patient perspective.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619000601134).

Prevalence of modifiable factors limiting treatment efficacy of poorly controlled asthma patients: EFIMERA observational study

Several modifiable factors leading to poor asthma control have been described. We aimed to determine the proportion of patients with inadequate treatment, adherence to it, or critical mistakes with inhaler technique, and their impact on asthma control. We conducted a cross-sectional multicenter observational study including asthma patients referred from primary to specialist care for the first time. Data collected were adequate prescription according to guidelines, treatment adherence, and disease control. Of the 1682 patients (age 45 ± 17 years, 64.6% men), 35.9% showed inadequate prescription, 76.8% low adherence, and 17% critical mistakes with inhaler technique, with significantly less critical mistakes among Easyhaler users versus other dry powder inhaler users (10.3 versus 18.4%; p < 0.05). Factors related to bad asthma control were inadequate prescription (OR: 3.65), non-adherence to treatment (OR: 1.8), and inhaler misuse (OR: 3.03). A higher number of risk factors were associated with a higher probability of having badly controlled asthma.

Measuring and reporting treatment adherence: What can we learn by comparing two respiratory conditions?

Medication non-adherence, defined as any deviation from the regimen recommended by their healthcare provider, can increase morbidity, mortality and side effects, while reducing effectiveness. Through studying two respiratory conditions, asthma and tuberculosis (TB), we thoroughly review the current understanding of the measurement and reporting of medication adherence. In this paper, we identify major methodological issues in the standard ways that adherence has been conceptualised, defined and studied in asthma and TB. Between and within the two diseases there are substantial variations in adherence reporting, linked to differences in dosing intervals and treatment duration. Critically, the communicable nature of TB has resulted in dose-by-dose monitoring becoming a recommended treatment standard. Through the lens of these similarities and contrasts, we highlight contemporary shortcomings in the generalised conceptualisation of medication adherence. Furthermore, we outline elements in which knowledge could be directly transferred from one condition to the other, such as the application of large-scale cost-effective monitoring methods in TB to resource-poor settings in asthma. To develop a more robust evidence-based approach, we recommend the use of standard taxonomies detailed in the ABC taxonomy when measuring and discussing adherence. Regimen and intervention development and use should be based on sufficient evidence of the commonality and type of adherence behaviours displayed by patients with the relevant condition. A systematic approach to the measurement and reporting of adherence could improve the value and generalisability of research across all health conditions.

Inhaled corticosteroid beliefs, complementary and alternative medicine in children presenting to the emergency department for asthma

OBJECTIVE

Negative beliefs about inhaled corticosteroids (ICS) and endorsement of complementary and alternative medicine (CAM) have been associated with medication non-adherence and uncontrolled asthma. The association of CAM and negative health beliefs is not described in children in acute care settings. Our study objective is to determine the relationship between negative ICS beliefs, CAM use and poorly controlled asthma among a predominantly Latino population in an acute care setting.

METHODS

The study was conducted in the pediatric emergency department of a children's hospital. During an ED asthma encounter, validated questionnaires surveyed parents about negative ICS beliefs, CAM use, and asthma health and control. We compared asthma health reports between parents who did or did not endorse negative ICS beliefs or CAM use, by chi-squared test (or a Fisher's exact test where appropriate).

RESULTS

Parents of 174 children identified mostly as Latino with Medicaid insurance and high asthma morbidity. CAM endorsement and negative ICS beliefs were both associated with increased use of lifetime glucocorticoid (p = 0.03 and p=0.01 respectively). While CAM endorsement was associated with less hospitalizations (p = 0.04) and parental report of asthma "getting better" (p = 0.01), CAM users reported trouble with paying for rent or food (p = 0.02). Negative ICS beliefs and CAM endorsement were not associated with medication adherence.

CONCLUSIONS

Negative ICS beliefs are associated with higher number of oral glucocorticoid courses. The association between CAM endorsement and asthma control is varied, but mostly in favor of improved control. Financial difficulties may make CAM use more likely.

Longitudinal Relationships Between Depression and Chronic Illness in Adolescents: An Integrative Review

INTRODUCTION

Depression is prevalent among adolescents with chronic illness. However, little is known about how depression affects chronic illness over time. This review aimed to synthesize longitudinal relationships between depression and disease control, self-management behaviors, illness-related morbidity, and quality of life.

METHOD

Four databases were searched, including PubMed, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and EMBASE. Inclusion criteria were cohort studies examining depression among adolescents aged 10-21 years with a chronic illness and studies published in English. Study quality was appraised using the Newcastle-Ottawa scale and data was synthesized by the outcome.

RESULTS

Of the 3,463 articles identified, 11 were included in the review. For adolescents with diabetes, increased depressive symptoms predicted decreased metabolic control and monitoring, medication adherence, quality of life, and increased hospitalization. Studies on cystic fibrosis, congenital heart disease, sickle cell disease, and juvenile idiopathic arthritis were limited but demonstrated that depressive symptoms affected the quality of life, disability, pain, and hospitalization rates/costs.

DISCUSSION

Evidence supports the need for mental health care strategies suitable for adolescents with chronic illness. Future research is needed to examine the effects of depressive symptoms across diversified chronic illness populations.

The management of severe asthma in 2020

Asthma is a chronic inflammatory disease of the airways affecting more than 300 million patients worldwide. The disease can be of various severity ranging from very mild to severe. The severe form of the disease only affects about 5% of patients but is responsible for a large component of the overall disease burden and results in about half of direct asthma-related costs. This led to important investments in research, which allowed better understanding of its pathophysiology and the development of new therapeutic strategies. Despite those breakthroughs, recent guidelines still emphasize the need to distinguish uncontrolled or difficult-to-control asthma from severe asthma. Indeed, a significant number of patients referred to severe asthma clinics are non-severe uncontrolled patients. However, the basics of asthma management such as ensuring that the patient has the right diagnosis, recognition of contributing comorbidities, avoidance of exposure to sensitizing agents in allergic individuals, regular assessment of control, and patient education should not be forgotten. The major improvements in pathophysiology arose from the evidences that asthma is of heterogeneous nature. Such heterogeneity has been particularly studied in severe asthma, leading to the recognition of more homogeneous groups referred to as phenotypes. Appropriate phenotyping of individual patients allows enforcing more specific treatment plans for patients, which is a step toward precision medicine. The high morbidity and socioeconomic burden of severe asthma has led to the development of optimized therapeutic strategies in addition to the commercialization of new drugs. Many of these have targeted the eosinophilic component of inflammatory asthma phenotypes while there is still a need to develop new therapies for non-eosinophilic asthma. When asthma is not controlled by optimal therapy, including a high-dose of inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA), a long acting anticholinergic agent can be added and if insufficient, a variety of biologic agents is now available in many countries. When biologics are not an option, thermoplasty and macrolides have also become available. Despite many recent breakthroughs in severe asthma, much research needs to be done. Improvement in availability of targeted asthma medications and asthma prevention should be top priorities.

Persistence and Adherence to ICS/LABA Drugs in UK Patients with Asthma: A Retrospective New-User Cohort Study

Introduction

Asthma is associated with significant economic burden. Inhaled corticosteroid and long-acting beta₂-agonist (ICS/LABA) combination therapies are considered mainstays of treatment. We describe real-world use of ICS/LABAs by comparing treatment persistence and adherence among patients with asthma in the United Kingdom initiating fluticasone furoate/vilanterol (FF/VI) versus budesonide/formoterol (BUD/FM) or beclometasone dipropionate/formoterol (BDP/FM).

Methods

A retrospective new-user active comparator database study was conducted in the IQVIA Medical Research Database. Propensity score (PS) matching was performed for FF/VI versus BUD/FM, and FF/VI versus BDP/FM. The primary objective was to compare patient treatment persistence (time to discontinuation), while secondary objectives included assessing adherence (mean proportion of days covered [PDC] with medication in the study period) and the proportions of patients achieving ≥ 50% and ≥ 80% PDC.

Results

New users of FF/VI (N = 966), BUD/FM (N = 5931) and BDP/FM (N = 9607) were identified and PS-matched: FF/VI (n = 945) versus BUD/FM (n = 3272), and FF/VI (n = 902) versus BDP/FM (n = 3465). At 12 months, treatment persistence was 69% (FF/VI), 53% (BUD/FM) and 57% (BDP/FM). The likelihood of treatment discontinuation within 12 months after initiation with FF/VI was 35% lower than with BUD/FM and 31% lower than for BDP/FM (both p < 0.001). Mean PDC was higher for FF/VI compared with BUD/FM (77.7 vs 72.4; p < 0.0001) and BDP/FM (78.2 vs 71.0; p < 0.0001). The odds of achieving ≥ 50% and ≥ 80% PDC were greater for FF/VI than for BUD/FM and BDP/FM.

Conclusions

In this study, patients who initiated FF/VI were less likely to discontinue treatment and showed greater treatment adherence versus patients who initiated BUD/FM or BDP/FM.

Electronic supplementary material

The online version of this article (10.1007/s12325-020-01344-8) contains supplementary material, which is available to authorized users.

Using fractional exhaled nitric oxide to guide step-down treatment decisions in patients with asthma: a systematic review and individual patient data meta-analysis

BACKGROUND

High exhaled nitric oxide fraction (F _ENO) levels are associated with greater risk of asthma exacerbation. However, it is not clear how F _ENO can be used to guide safe reductions in inhaled corticosteroid (ICS) doses in asthma patients. This study assesses the ability of F _ENO to guide ICS reductions.

METHODS

Systematic searching of electronic databases identified prospective observational studies and randomised controlled trials which recruited participants with mild-to-moderate asthma aged ≥12 years and measured F _ENO before reducing ICS. We performed multilevel mixed-effects logistic regression in relation to acute exacerbations and estimated each participant's exacerbation risk using our logistic regression model.

RESULTS

We included data from seven out of eight eligible studies, representing 384 participants. ICS doses were halved in four studies and withdrawn in three studies. A baseline F _ENO measurement of ≥50 ppb was associated with increased risk of exacerbations (crude OR 3.14, 95% CI 1.41-7.00, p=0.005; adjusted OR 3.08, 95% CI 1.36-6.98, p=0.007) and corresponded to an estimated exacerbation risk cut-off of 15%. Reducing ICS when estimated exacerbation risk was <15% versus <10% would result in fewer patients remaining on the same ICS dose (40 (10.4%) out of 384 versus 141 (36.7%) out of 384), but similar proportions of patients avoiding exacerbations (222 (91.4%) out of 243, 95% CI 87.1-94.6% versus 311 (90.4%) out of 344, 95% CI 86.8-93.3%).

CONCLUSION

In patients with mild-to-moderate asthma, gradual ICS reduction when F _ENO is <50 ppb may help decrease ICS use without increasing exacerbations. Future research should aim to validate these findings in larger populations.

Factors Associated with Acute Health Care Use in Children and Adolescents with Asthma

Asthma is a leading cause of acute health care use (AHCU) as defined by hospitalization and emergency department visits (ED). Little was known about factors associated with asthma-related AHCU. This study aimed to identify factors determining AHCU in children and adolescents with asthma. A descriptive study was conducted among children with mild to severe asthma referred to the pediatric outpatient clinic of "Farhat Hached" University Hospital of Sousse (Tunisia) over a period of three months (April-June 2018). We collected data regarding clinical information, the number of hospitalizations and ED visits related to asthma in the past 12 months, asthma management behaviors, and quality of life of children. Multivariable logistic regression was performed using SPSS (20.0). A total of 90 children have participated in the study. The percentage of children aged 7 to 11 years was higher than the percentage of adolescents aged 12 to 17 years (67.8%; 32.2%, respectively). The final logistic regression model demonstrated that asthma severity and inhaler technique increased the odds of AHCU (OR a = 4.6; 95% CI: 1.1-18.1; p = .03, OR a = 2.9; 95% CI: 1.1-7.8; p = .02, respectively). Also, increased quality of life score reduced the odds of AHCU (OR a = 0.6; 95% CI: 0.4-0.9; p = .01). These results suggest that the organization of programs targeting the management of these factors can reduce the workload on hospital services and emergencies.

Knowledge, practice pattern and attitude toward asthma management amongst physicians from Nepal, Malaysia, Lebanon, Myanmar and Morocco

OBJECTIVE

This survey aimed to understand the physicians' practice pattern and challenges faced while treating their patients with asthma in five countries-Malaysia, Nepal, Myanmar, Morocco and Lebanon.

METHODS

Questionnaire-based data was gathered from internal medicine doctors (209), general practitioners (206), chest physicians (152) and pediatricians (58) from 232 locations from across the five countries.

RESULTS

Of the 816 physicians, 374 physicians encountered at least 5 asthma patients daily. Approximately, 38% physicians always used spirometry for diagnosis and only 12% physicians always recommended Peak flow meter (PFM) for home-monitoring. Salmeterol/fluticasone (71%) followed by formoterol/budesonide (38%) were the most preferred ICS/long-acting beta₂-agonists (LABA); Salbutamol (78%) was the most preferred reliever medication. 60% physicians said >40% of their patients were apprehensive to use inhalers. 72% physicians preferred a pressurized metered-dose inhaler (pMDI) to a dry powder inhaler (DPI) with only a third of them using a spacer with the pMDI. 71% physicians believed that using similar device for controller and reliever can be beneficial to patients. Skipping medicines in absence of symptoms (64%), incorrect inhaler technique (48%) and high cost of medication (49%) were considered as major reasons for non-adherence by most physicians. Incorrect inhaler technique (66%) and nonadherence (59%) were considered the most common causes of poor asthma control.

CONCLUSIONS

There are opportunities to improve the use of diagnostic and monitoring tools for asthma. Non-adherence, incorrect inhaler technique and cost remain a challenge to achieve good asthma control. Asthma education, including correct demonstration of inhaler, can potentially help to improve inhaler adherence.

Patient preferences for symptom-driven or regular preventer treatment in mild to moderate asthma: findings from the PRACTICAL study, a randomised clinical trial

Symptom-driven low-dose inhaled corticosteroid-formoterol is safe and effective in mild asthma and has been recommended as one of the preferred treatment regimens at steps 1 and 2 in the 2019 update of the Global Initiative for Asthma. However, there are no data on patient preferences for this regimen.A subgroup of participants in the PRACTICAL study (ACTRN12616000377437), a randomised controlled trial comparing symptom-driven budesonide-formoterol with maintenance budesonide plus as-needed terbutaline completed a survey on treatment preferences, satisfaction, beliefs and experience at their final study visit.306 (75%) out of 407 eligible participants completed the survey. Regimen preference was strongly associated with randomised treatment, as were preferences for and beliefs about preventer inhaler use. Combination preventer and reliever as-needed therapy was preferred by 135 (90%, 95% CI 85.2-94.8%) out of 150 who were randomised to as-needed budesonide-formoterol, and by 63 (40%, 95% CI 32.7-48.1%) out of 156 who were randomised to maintenance budesonide. By contrast, twice-daily preventer inhaler with a reliever inhaler as required was preferred by 15 (10%) out of 150 of those randomised to as-needed budesonide-formoterol and 93 (60%) out of 156 of those randomised to maintenance budesonide. Satisfaction with all study inhalers was high. Of patients randomised to as-needed budesonide-formoterol 92% (n=138) were confident using it as a reliever at the end of the study.Although most participants preferred the regimen to which they had been randomised, this association was much stronger for those randomised to budesonide-formoterol as needed, indicating that most patients preferred as-needed corticosteroid-formoterol therapy if they had experienced it.

Development and Clinical Application of a Prednisolone/Cortisol Assay to Determine Adherence to Maintenance Oral Prednisolone in Severe Asthma

BACKGROUND

Nonadherence to oral prednisolone is an important driver of poor control in severe asthma, and its detection is warranted to guide management.

RESEARCH QUESTION

The goal of this study was to evaluate the utility of liquid chromatography and tandem mass spectrometry (LC-MS/MS) in determining the adherence status to oral prednisolone in severe asthma.

STUDY DESIGN AND METHODS

Timeline serum levels of prednisolone, cortisol, and metabolites were measured by using a validated LC-MS/MS assay following observed intake of prednisolone in patients receiving maintenance oral prednisolone. Patterns of adherence and nonadherence were determined from analysis of peak blood levels. The performance of a spot test for adherence (detectable prednisolone and suppressed cortisol) was assessed in a second cohort of patients receiving maintenance prednisolone and a control group.

RESULTS

In the prednisolone absorption test, 27 patients (mean age, 38.6 years; age range, 17-63 years; 83% female) were included. We identified adherence in 13 (48%), nonadherence in 13 (48%), and malabsorption in one (3.7%). The median [interquartile range] peak serum assays of the adherent group compared with the nonadherent group were: cortisol, 36 [39.5] vs 295 [153] nmol/L; and prednisolone, 1,810 [590] vs 1,730 [727] nmol/L. The spot test cohort included 111 patients (67 on maintenance prednisolone and 44 control subjects); the mean age was 42.4 years, and 79% were female. Nonadherence was detected in 40.3% of patients; comparison of the adherent vs nonadherent groups revealed median [interquartile range] levels for cortisol of 27 [48] nmol/L vs 211 [130] nmol/L and for prednisolone of 259 [622] nmol/L vs < 20 nmol/L, respectively. Adherent patients had higher mean BMI (38.4 ± 8.7 vs 32 ± 7.5 kg/m²; P = .03), lower median blood eosinophils (0.09 [0.31] vs 0.51 [0.53] × 10⁹/L; P < .001), and a trend toward reduced mean annual severe exacerbations (3.0 ± 2.6 vs 4.3 ± 2.4; P = .3) than nonadherent patients.

INTERPRETATION

Nonadherence to oral prednisolone is common in severe asthma and can be reliably detected in the clinic by using the LC-MS/MS assay.

Striving for perfection, accepting the reality: A reflection on adherence to airway clearance and inhalation therapy for paediatric patients with chronic suppurative lung disease

Non-adherence to prescribed treatment is considered the foremost cause of treatment failure in chronic medical conditions. Airway clearance techniques (ACT) play a key role in the management of chronic suppurative lung disease yet, along with inhaled therapies such as nebulised antibiotics, adherence to these is often lower than to other treatments. In this review we discuss methods of monitoring adherence to these therapies and potential barriers and outline suggestions for improving adherence in the paediatric population.

Effective Asthma Management: Is It Time to Let the AIR out of SABA?

For years, standard asthma treatment has included short acting beta agonists (SABA), including as monotherapy in patients with mild asthma symptoms. In the Global Initiative for Asthma 2019 strategy for the management of asthma, the authors recommended a significant departure from the traditional treatments. Short acting beta agonists (SABAs) are no longer recommended as the preferred reliever for patients when they are symptomatic and should not be used at all as monotherapy because of significant safety concerns and poor outcomes. Instead, the more appropriate course is the use of a combined inhaled corticosteroid–fast acting beta agonist as a reliever. This paper discusses the issues associated with the use of SABA, the reasons that patients over-use SABA, difficulties that can be expected in overcoming SABA over-reliance in patients, and our evolving understanding of the use of “anti-inflammatory relievers” in our patients with asthma.

Patterns of oral corticosteroids use in primary care patients with severe asthma

AIM

To assess the pattern of use of oral corticosteroids (OC) in primary care patients with severe asthma.

METHODS

Data derived from the Health Search Database (HSD) gathering information on 700 Italian general practitioners. A cohort of severe asthma patients was identified between 2013 and 2017 and followed-up for one year. The association between candidate predictors and the incident escalation to OC was tested through a multivariate Cox regression model.

RESULTS

Among patients with asthma (N = 55,075), 284 were diagnosed with severe asthma. Among them, the proportion of OC users decreased from 82.2% in 2013 to 75.3% in 2017. For what concerns the determinants of OC prescriptions, among 284 patients being defined at baseline (2013-2016) as those suffering from severe asthma, 216 (76.1%) were first-ever prescribed with OC at least once during one year of follow-up. The presence of gastroesophageal reflux disease (HR 1.37; 95% CI 1.02-1.85), osteoarthritis (HR 1.54; 95% CI 1.12-2.12) and moderate asthma exacerbations (HR 1.72; 95% CI 1-02-2.93) was significantly associated with the outcome.

CONCLUSIONS

The optimization of asthma treatment and the management of comorbidities may be potential leverages to reduce the inappropriate use of OC in patients with severe asthma.

12-year adherence to inhaled corticosteroids in adult-onset asthma

Adherence to inhaled corticosteroids (ICS) has been suggested to be poor but long-term follow-ups are lacking. The objective of the present study was to assess adherence to ICS treatment in patients with adult-onset asthma during 12-year follow-up.

A total of 181 patients with clinically confirmed, new-onset adult asthma were followed for 12 years as part of the Seinäjoki Adult Asthma Study. Adherence to ICS was assessed individually as the percentage of true dispensed ICS in micrograms per true prescribed daily ICS in micrograms over 12 years.

Mean 12-year adherence to ICS was 69% (mean±sd dispensed 2.5±1.8 g and prescribed 3.6±1.5 g budesonide equivalent per patient for 12 years), annual adherence varying between 81% (year 1) and 67% (year 12). Patients with good 12-year adherence (≥80%) used oral corticosteroids more often, and had add-on drugs in use and asthma-related visits to healthcare more often. In addition, they showed less reversibility in forced expiratory volume in 1 s and had higher peripheral blood neutrophil counts. However, lung function decline was steeper in patients with poorer adherence (<80%) and this association remained in multiple linear regression analysis. No difference was found in symptom scores, blood eosinophil counts, exhaled nitric oxide or immunoglobulin E between the patients with different levels of adherence.

In patients with adult-onset asthma, adherence to ICS was moderate. Poorer adherence (<80%) to ICS was associated with more rapid decline in lung function but was not associated to symptoms or markers of inflammatory endotypes.

Mean long-term adherence to ICS treatment is 69% in patients with confirmed adult-onset asthma. While good ICS adherence (≥80%) is associated with features of more severe asthma, poorer adherence (<80%) predicts more rapid lung function decline.http://bit.ly/37mvh74

Association between adherence and severe asthma exacerbation: A systematic review and meta-analysis

OBJECTIVE

To assess the association between adherence levels and severe asthma exacerbation.

DESIGN

A systematic search was performed from inception to November 2018 on the following databases: PubMed, CENTRAL, EMBASE, and ClinicalTrials.gov.

SETTING AND PARTICIPANTS

Randomized-controlled trials (RCTs) and cohort and case-control studies that investigated the impact of adherence to controller medications on severe asthma exacerbation were included in the analysis. Data extraction was undertaken by 2 reviewers, and all studies were assessed for their qualities using the Cochrane risk of bias tool for RCT and the Newcastle-Ottawa scale for cohort and case-control studies. Random-effects model meta-analyses were performed.

OUTCOME MEASURES

Severe asthma exacerbation.

RESULTS

From 8061 articles, 8 studies were included in quantitative synthesis. The meta-analyses revealed that the odds of exacerbation among the patients with 80% or more adherence were lowered by 47% (odds ratio 0.53 [95% CI 0.42-0.66], P < 0.001) compared with less than 80%. When compared with less than 20% adherence, a 33% reduction in the odds (0.67 [0.53-0.86], P = 0.001) was associated with the patients achieving 50% or more, whereas a decrease in exacerbation was not associated with 20% to 49% adherence (0.94 [0.85-1.04], P = 0.22). In addition, a 2.4-fold increase in the odds (2.4 [2.1-2.7], P < 0.001) was associated with discontinuation of therapy.

CONCLUSION

The highest reduction in the odds of exacerbation was associated with patients achieving 80% or more adherence, and the odds also reduced among those with 50% or more adherence, whereas a substantial increase in exacerbation was associated with discontinuation of therapy.

Education makes people take their medication: myth or maxim?

Education on its own doesn't make people take their treatment as intended. However, when it follows shared decision making, in which patient and doctor together agree on the best course of therapeutic action, education helps patients take their treatment. http://bit.ly/2G2XswD.

They just don't take their medicines: Reframing medication adherence in asthma from frustration to opportunity

Assessing and addressing suboptimal adherence to asthma medications is a key component in the treatment of all children with asthma, particularly those with difficult-to-treat asthma. However, parents often overreport adherence to asthma medications. Increased medication adherence could lead to improved outcomes in the form of better asthma control and decreased asthma exacerbations, as well as decreased healthcare utilization costs. Yet there are many complex factors that affect medication adherence, and barriers are often different in each family. Social determinants of health, complex healthcare relationships, and patient-related factors may all affect medication adherence. Multicomponent patient-centered strategies, as well as strategies that utilize technology and habit formation strategies may be helpful in improving medication adherence. Further study is needed to reliably and sustainably improve medication adherence in children with asthma across the broader population; in some populations, alternate diagnoses, adjusting therapy, and other intervention may be required to improve asthma control and health.

Unexpected results of a randomized quality improvement program for children with severe asthma

Objective: To assess whether an asthma intervention program reduces treatment days outside the home among children with severe asthma receiving comprehensive care (CC) in our center.Methods: Between October 21, 2014 and September 28, 2016, children with severe asthma were randomized to receive CC alone (n = 29) or CC plus the asthma intervention program (n = 34) which involved collaboration with pharmacists and school nurses, motivational interviewing, and tracking the one-second forced expiratory volume at home. All patients were followed through March 31, 2017. Frequentist and Bayesian intent-to-treat analyses were performed.Results: The asthma intervention program doubled the telephone calls between the staff and families (753 vs 356 per 100 child years for the intervention group vs. control group; Rate Ratio [RR], 2.11 [95% confidence interval, 1.29-3.45]). Yet, we found no evidence that it reduced the composite number of days of healthcare outside home which includes: clinic visits, ED visits, and hospital admissions (1179 vs 958 per 100 child-years in the intervention group vs. control group; [RR], 1.23 [95% CI, 0.82-1.84]) or secondary outcomes which are individual components (clinic visits, ED visits, hospitalizations, PICU admissions and school absences; RR 1.15 - 2.30; p > 0.05). Bayesian analysis indicated a 67% probability that the intervention program increases total treatment days outside the home and only a 14% probability of a true decrease of >20% as originally hypothesized.Conclusion: A multi-component intervention program provided to children with severe asthma failed to reduce and may have increased days of healthcare outside home and school absenteeism.

Prevalence and predictors of adherence to inhaled corticosteroids in young adults (15-30 years) with asthma: a systematic review and meta-analysis

Objective: Adherence to inhaled corticosteroids (ICS) is an essential part of asthma management throughout the lifespan; however, this may be particularly challenging during the transition into adulthood. This systematic review aimed to determine the prevalence and predictors of adherence to ICS in emerging adulthood.Data sources: MEDLINE, PsycINFO, EMBASE, Scopus, and CINAHL were searched with search terms for asthma, ICS, adherence, young adults, and predictors combined.Study selection: Studies with participants with diagnosed asthma, currently prescribed ICS, a mean age between 15 and 30 years and reporting the prevalence and/or assessing predictor(s) of adherence using quantitative methods were included.Results: Twenty-nine studies were identified for inclusion (K = 29, N = 187 401). A random effect meta-analysis revealed the pooled prevalence of adherence was 28% (95% CI = 20-38%, k = 16) in studies that provided quantitative information on adherence. Adherence was higher in studies with a mean age <18 years (36%; 95% CI = 36-37%, k = 4). Studies using self-report measures provided higher estimates of adherence (35%; 95% CI = 28-42%, k = 10) than studies using pharmacy refill data (20%; 95% CI = 9-38%, k = 6). A narrative review identified personality, illness perceptions, and treatment beliefs as potentially important predictors of adherence.Conclusion: Adherence is sub-optimal during emerging adulthood, particularly after age 18. More reliable and objective measures are needed to precisely characterize adherence. Greater research and practice attention to emerging adulthood are needed to guide self-management support in those living with asthma at this important lifespan stage.Systematic review registration number: CRD42018092401.

Efficacy of Optimized Treatment Protocol Using LAU-7b Formulation against Ovalbumin (OVA) and House Dust Mite (HDM) -Induced Allergic Asthma in Atopic Hyperresponsive A/J Mice

PURPOSE

To assess the efficacy of the novel clinical formulation of fenretinide (LAU-7b) for the treatment of allergic asthma. To study the association between LAU-7b treatment in allergic asthma and the modulation of very long chain ceramides (VLCC).

METHODS

We used two allergens (OVA and HDM) to induce asthma in mouse models and we established a treatment protocol with LAU-7b. The severity of allergic asthma reaction was quantified by measuring the airway resistance, quantifying lung inflammatory cell infiltration (Haematoxylin and eosin stain) and mucus production (Periodic acid Schiff satin). IgE levels were measured by ELISA. Immunophenotyping of T cells was done using Fluorescence-activated cell sorting (FACS) analysis. The analysis of the specific species of lipids and markers of oxidation was performed using mass spectrometry.

RESULTS

Our data demonstrate that 10 mg/kg of LAU-7b was able to protect OVA- and HDM-challenged mice against increase in airway hyperresponsiveness, influx of inflammatory cells into the airways, and mucus production without affecting IgE levels. Treatment with LAU-7b significantly increased percentage of regulatory T cells and CD4⁺ IL-10-producing T cells and significantly decreased percentage of CD4⁺ IL-4-producing T cells. Our data also demonstrate a strong association between the improvement in the lung physiology and histology parameters and the drug-induced normalization of the aberrant distribution of ceramides in allergic mice.

CONCLUSION

9 days of 10 mg/kg of LAU-7b daily treatment protects the mice against allergen-induced asthma and restores VLCC levels in the lungs and plasma.

Understanding Patient Perspectives on Medication Adherence in Asthma: A Targeted Review of Qualitative Studies

Adherence to asthma medications is generally poor and undermines clinical outcomes. Poor adherence is characterized by underuse of inhaled corticosteroids (ICS), often accompanied by over-reliance on short-acting β₂-agonists for symptom relief. To identify drivers of poor medication adherence, a targeted literature search was performed in MEDLINE and EMBASE for articles presenting qualitative data evaluating medication adherence in asthma patients (≥12 years old), published from January 1, 2012 to February 26, 2018. A thematic analysis of 21 relevant articles revealed several key themes driving poor medication adherence, including asthma-specific drivers and more general drivers common to chronic diseases. Due to the episodic nature of asthma, many patients felt that their daily life was not substantially impacted; consequently, many harbored doubts about the accuracy of their diagnosis or were in denial about the impact of the disease and, in turn, the need for long-term treatment. This was further compounded by poor patient-physician communication, which contributed to suboptimal knowledge about asthma medications, including lack of understanding of the distinction between maintenance and reliever inhalers, suboptimal inhaler technique, and concerns about ICS side effects. Other drivers of poor medication adherence included the high cost of asthma medication, general forgetfulness, and embarrassment over inhaler use in public. Overall, patients' perceived lack of need for asthma medications and medication concerns, in part due to suboptimal knowledge and poor patient-physician communication, emerged as key drivers of poor medication adherence. Optimal asthma care and management should therefore target these barriers through effective patient- and physician-centered strategies.