Treatment adherence in asthmatic patients: the last frontier?

Toward the Design of Sensing-Based Medication Adherence Aids That Support Individualized Activities of Daily Living: Survey and Interviews With Patients and Providers

BACKGROUND

Nearly half of Americans taking prescription medications do not take them properly. The resulting implications have a broad impact. Nonadhering patients develop worsened medical conditions and increased comorbidity of disease or die.

OBJECTIVE

Clinical studies have shown that the most effective strategies for addressing adherence are those that are individualized to the context that each patient and situation require. However, existing aids for adherence are relatively ridged and poorly support adaptation to individual behaviors and lifestyles. The aim of our study was to better understand this design tension.

METHODS

A series of 3 qualitative studies was conducted: a web-based survey of 200 Americans that investigated existing adherence strategies and behaviors and perception of how hypothetical in-home tracking technologies would assist adherence; in-person semistructured interviews with 20 medication takers from Pittsburgh, PA, that investigated personal adherence behaviors, which included demonstration of medication locations and routines as well as an assessment of hypothetical technologies; and semistructured interviews with 6 pharmacists and 3 family physicians to gain a provider perspective on patient adherence strategies, which included feedback on hypothetical technologies in the context of their patient populations. Inductive thematic coding of all interview data was performed. Studies were conducted consecutively, with the results informing the subsequent studies.

RESULTS

Synthesized, the studies identified key medication adherence behaviors amenable to technological interventions, distilled important home-sensing literacy considerations, and detailed critical privacy considerations. Specifically, 4 key insights were obtained: medication routines are heavily influenced and adapted by and through the physical location and placement of medications relative to activities of daily living, routines are chosen to be inconspicuous to maintain privacy, the value of provider-involved routines is motivated by a desire to build trust in shared decision-making, and the introduction of new technologies can create further burden on patients and providers.

CONCLUSIONS

There is considerable potential to improve individual medication adherence by creating behavior-focused interventions that leverage emerging artificial intelligence (AI), machine learning (ML), and in-home Internet of Things (IoT) sensing technologies. However, success will be dependent on the technology's ability to learn effectively and accurately from individual behaviors, needs, and routines and tailor interventions accordingly. Patient routines and attitudes toward adherence will likely affect the use of proactive (eg, AI-assistant routine modification) versus reactive (eg, notification of associated behaviors with missed dosages) intervention strategies. Successful technological interventions must support the detection and tracking of patient routines that can adjust to variations in patient location, schedule, independence, and habituation.

GINA Implementation Improves Asthma Symptoms Control and Lung Function: A Five-Year Real-World Follow-Up Study

Symptoms control remains challenging for most patients with asthma. This study was conducted to evaluate the level of asthma symptoms control and lung function over 5 years of GINA (Global INitiative for Asthma) implementation. We included all patients with asthma who had been managed following GINA recommendations at the Asthma and COPD Outpatient Care Unit (ACOCU) of the University Medical Center in Ho Chi Minh City, Vietnam from October 2006 to October 2016. Of 1388 patients with asthma managed following GINA recommendations, the proportion of patients with well-controlled asthma significantly improved from 2.6% at baseline to 66.8% at month 3, 64.8% at year 1, 59.6% at year 2, 58.6% at year 3, 57.7% at year 4, and 59.5% at year 5 (p < 0.0001 for all comparisons). The proportion of patients with persistent airflow limitation significantly decreased from 26.7% at baseline to 12.6% at year 1 (p < 0.0001), 14.4% at year 2 (p < 0.0001), 15.9% at year 3 (p = 0.0006), 12.7% at year 4 (p = 0.0047), and 12.2% at year 5 (p = 0.0011). In patients with asthma managed according to GINA recommendations, asthma symptoms control and lung function improved after 3 months and the improvement was sustained over 5 years.

Prevalence of asthma-like symptoms with ageing

Background

Change in the prevalence of asthma-like symptoms in populations of ageing adults is likely to be influenced by smoking, asthma treatment and atopy.

Methods

The European Community Respiratory Health Survey collected information on prevalent asthma-like symptoms from representative samples of adults aged 20–44 years (29 centres in 13 European countries and Australia) at baseline and 10 and 20 years later (n=7844). Net changes in symptom prevalence were determined using generalised estimating equations (accounting for non-response through inverse probability weighting), followed by meta-analysis of centre level estimates.

Findings

Over 20 years the prevalence of ‘wheeze’ and ‘wheeze in the absence of a cold’ decreased (−2.4%, 95% CI −3.5 to −1.3%; −1.5%, 95% CI −2.4 to −0.6%, respectively) but the prevalence of asthma attacks, use of asthma medication and hay fever/nasal allergies increased (0.6%, 95% CI 0.1 to 1.11; 3.6%, 95% CI 3.0 to 4.2; 2.7%, 95% CI 1.7 to 3.7). Changes were similar in the first 10 years compared with the second 10 years, except for hay fever/nasal allergies (increase seen in the first 10 years only). Decreases in these wheeze-related symptoms were largely seen in the group who gave up smoking, and were seen in those who reported hay fever/nasal allergies at baseline.

Interpretation

European adults born between 1946 and 1970 have, over the last 20 years, experienced less wheeze, although they were more likely to report asthma attacks, use of asthma medication and hay fever. Decrease in wheeze is largely attributable to smoking cessation, rather than improved treatment of asthma. It may also be influenced by reductions in atopy with ageing.

Asthma control: the right inhaler for the right patient

Inhaled therapy is the cornerstone of asthma management in that it optimizes the delivery of the medication to the site of action. The effectiveness of inhaled therapy is affected by the correct choice of the device and proper inhalation technique. In fact, this influences the drug delivery and distribution along the bronchial tree, including the most peripheral airways. In this context, accumulating evidence supports the contribution of small airways in asthma, and these have become an important target of treatment. In reality, the "ideal inhaler" does not exist, and not all inhalers are the same. Advances in technology has highlighted these differences, and have led to the design of new devices and the development of formulations characterized by extrafine particles that facilitate the distribution and deposition of the drug particles along the respiratory tract. In addition, efforts have been made to implement adherence to chronic treatment, which translates into clinical benefit. Taken together, the optimal control of asthma depends on the drug that is selected, the device that is employed and the removal of factors that reduce patient's adherence to therapy.

A review of standard pharmacological therapy for adult asthma – Steps 1 to 5

The aim of pharmacological therapy for asthma is to improve symptoms and lung function and minimize the risk of asthma attacks. The intensity of treatment is based on the level of asthma control and the potential risk of future deterioration. In the British asthma guidelines, treatments are divided into steps 1 to 5, with each step signifying a need for an increase in therapy in response to symptoms or to prevent exacerbations. Treatments comprise of inhaled or systemic medications. Inhaled therapy includes short-acting and long-acting medication to improve symptoms and inhaled corticosteroids that reduce airway inflammation. Systemic treatments include medications that act on specific biological pathways, such as the leukotriene or immunoglobulin E pathways, or systemic corticosteroids. In choosing a particular therapy, treatment benefits are balanced by the potential risks of medication-related adverse effects. This review will provide a practical guide to the key pharmacological therapies for adult asthma at steps 1 to 5 based on British guidelines and consider future options for new treatments.