Factors affecting adherence to asthma treatment: patient and physician perspectives

Design of dry powder inhalers to improve patient outcomes: it's not just about the device

INTRODUCTION

Up to 50% of asthma/COPD patients make critical errors in dose preparation and dose inhalation with current marketed DPIs which negatively impact clinical outcomes. Others fail to adhere to their chronic treatment regimen.

AREAS COVERED

For this review, we describe how a human-factors approach to design of a dry powder inhaler can be used to improve usability, proficiency, and functionality of DPIs, while effectively mitigating critical errors associated with DPIs. The review highlights the critical importance of utilizing improved formulations with monomodal aerodynamic particle size distributions to reduce variability associated with oropharyngeal filtering of particles, flow rate dependence, and co-formulation effects.

EXPERT OPINION

Much of the variability in dose delivery with DPIs is associated with limitations of the bimodal APSDs inherent in current lactose blend formulations. Evidence supports that improved lung targeting and dose consistency can be achieved with drug-device combination products comprising spray-dried powders. Unfortunately, no data exists to assess whether these advances observed in in vitro and in vivo dose delivery studies will translate into improved clinical outcomes. Given the significant percentage of patients that receive suboptimal drug delivery with current DPIs it would behoove the industry to assess the efficacy of new approaches.

Intimate partner violence and asthma in pediatric and adult populations

OBJECTIVE

To evaluate the relationship between intimate partner violence (IPV) and adult and childhood asthma outcomes.

DATA SOURCES

We conducted a systematic literature review using 4 databases (PubMed, Ovid MEDLINE, Ovid Embase, and Ovid PsycINFO) with asthma and IPV-associated terms.

STUDY SELECTIONS

We included published studies, available in English, to October 2021, which included IPV as an exposure and asthma as an outcome. Both adult and pediatric populations were included in the following settings: community, health care, and home.

RESULTS

There were 37 articles identified. There was evidence among multiple studies to support increased prevalence of asthma in adults exposed to IPV and prevalence and incidence in children with parental IPV exposure. There were fewer studies evaluating IPV exposure and adult asthma morbidity, but they found statistically significant associations between IPV and increased rate of asthma exacerbations and worsened asthma control. There was sparse evidence evaluating a relationship between IPV and adult asthma mortality. There were no studies identified evaluating IPV and childhood asthma morbidity or mortality.

CONCLUSION

The association between IPV and increased asthma prevalence, incidence, and worsened morbidity merits recognition and further investigation into potential mechanisms. Health care providers can implement practical strategies to help mitigate the negative effects of IPV on health and asthma. These include addressing potential impactful biopsychosocial factors and comorbidities, implementing routine screening and referrals, and partnering with community advocacy organizations. Given their positions of respect and power in society, health care providers can have lasting impacts on the lives of pediatric and adult patients affected by IPV.

Revisiting Mild Asthma: Current Knowledge and Future Needs

Asthma is a common chronic airways disease with significant impact on patients, caregivers, and the health-care system. Although most research and novel interventions mainly have focused on patients with uncontrolled severe asthma, most patients with asthma have mild disease. Epidemiologic studies suggest that many patients with mild asthma report frequent exacerbations of the disease and uncontrolled symptoms. However, despite its impact, mild asthma does not have either a uniformly agreed on definition for or a consensus on its clinical and pathophysiologic progression. More recently, the approach to treatment of patients with mild asthma has undergone significant changes primarily based on emerging evidence that airway inflammation in this population is important. This led to clinical research studies that explored the efficacy of as-needed inhaled corticosteroids along with the rescue medications that traditionally have been the mainstay of treatment. Despite some advancement in the field in recent years, many controversies and unmet needs remain. In this review, we examine the current understanding of the pathophysiologic features and management of mild asthma. In addition, we outline unmet needs for future research. We conclude that mild asthma contributes significantly to the morbidity and mortality of asthma and should be the focus of future research.

Medication Adherence in Patients With Severe Asthma Prescribed Oral Corticosteroids in the U-BIOPRED Cohort

BACKGROUND

Although estimates of suboptimal adherence to oral corticosteroids in asthma range from 30% to 50%, no ideal method for measurement exists; the impact of poor adherence in severe asthma is likely to be particularly high.

RESEARCH QUESTIONS

What is the prevalence of suboptimal adherence detected by self-reporting and direct measures? Is suboptimal adherence associated with disease activity?

STUDY DESIGN AND METHODS

Data were included from individuals with severe asthma taking part in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes) study and prescribed daily oral corticosteroids. Participants completed the Medication Adherence Report Scale, a five-item questionnaire used to grade adherence on a scale from 1 to 5, and provided a urine sample for analysis of prednisolone and metabolites by liquid chromatography-mass spectrometry.

RESULTS

Data from 166 participants were included in this study: mean (SD) age, 54.2 (± 11.9) years; FEV₁, 65.1% (± 20.5%) predicted; female, 58%; 37% completing the Medication Adherence Report Scale reported suboptimal adherence; and 43% with urinary corticosteroid data did not have detectable prednisolone or metabolites in their urine. Good adherence by both methods was detected in 49 of the 142 (35%) of participants in whom both methods were performed; adherence detection did not match between methods in 53%. Self-reported high adherers had better asthma control and quality of life, whereas directly measured high adherers had lower blood eosinophil levels.

INTERPRETATION

Low adherence is a common problem in severe asthma, whether measured directly or self-reported. We report poor agreement between the two methods, suggesting some disassociation between self-assessment of medication adherence and regular oral corticosteroid use, which suggests that each approach may provide complementary information in clinical practice.

A Scoping Review of International Barriers to Asthma Medication Adherence Mapped to the Theoretical Domains Framework

BACKGROUND

Internationally, adult asthma medication adherence rates are low. Studies characterizing variations in barriers by country are lacking.

OBJECTIVE

To conduct a scoping review to characterize international variations in barriers to asthma medication adherence among adults.

METHODS

MEDLINE, EMBASE, Web of Science (WOS), and CINAHL were searched from inception to February 2017. English-language studies employing qualitative methods (eg, focus groups, interviews) were selected to assess adult patient- and/or caregiver-reported barriers to asthma medication adherence. Two investigators independently identified, extracted data, and collected study characteristics, methodologic approach, and barriers. Barriers were mapped using the Theoretical Domains Framework and findings categorized according to participants' country of residence, countries' gross national income, and the presence of universal health care (World Health Organization definitions).

RESULTS

Among 2942 unique abstracts, we reviewed 809 full texts. Among these, we identified 47 studies, conducted in 12 countries, meeting eligibility. Studies included a total of 2614 subjects, predominately female (67%), with the mean age of 19.1 to 70 years. Most commonly reported barriers were beliefs about consequences (eg, medications not needed for asthma control, N = 29, 61.7%) and knowledge (eg, not knowing when to take medication, N = 27, 57.4%); least common was goals (eg, asthma not a priority, N = 1, 2.1%). In 27 studies conducted in countries classified as high income (HIC) with universal health care (UHC), the most reported barrier was participants' beliefs about consequences (N = 17, 63.3%). However, environmental context and resources (N = 12, 66.7%) were more common in HIC without UHC.

CONCLUSION

International adherence barriers are diverse and may vary with a country's sociopolitical context. Future adherence interventions should account for trends.

Expert Nordic perspectives on the potential of novel inhalers to overcome unmet needs in the management of obstructive lung disease

The effective self-management of obstructive lung disease is dependent upon the patient achieving good inhaler technique. However, many current inhalers are complicated to use, which may lead to handling difficulties. These difficulties can cause clinically relevant errors, whereby pharmacotherapy fails to achieve adequate lung deposition and therapeutic effect. In this report, the potential of novel inhaler devices to overcome unmet needs in the management of obstructive lung disease is considered by a panel of Nordic experts. The panel concludes that innovative inhalers can contribute to good disease management and better use of healthcare resources.

A review of the value of innovation in inhalers for COPD and asthma

BACKGROUND

Appropriate use of inhaled therapies for asthma and chronic obstructive pulmonary disease (COPD) is critical to ensuring good patient outcomes, efficient use of healthcare resources and limiting the effects of high-morbidity. The appropriate choice of inhaler and active therapy, incorporating patient preferences, can help improve treatment adherence and long-term outcomes. Despite this, many current inhalers are non-intuitive to use, and require extensive training.

METHODS

In this review, an expert panel considers the evidence for the use of inhaler devices in management of COPD and asthma. The panel also evaluates the value of innovation in inhaler technologies, which optimise the use of existing molecules from a clinical, economic and societal perspective.

CONCLUSIONS

The panel conclusion is that there remains a substantial unmet need in inhaler technology and that innovation in inhaler devices can provide real-world health benefits to patients. Furthermore, we recommend that these innovations should be supported by healthcare systems through appropriate pricing and reimbursement mechanisms.

[Deliberate interruptions and changes of dose of inhaled corticosteroids by asthma patients: "a community pharmacy study"]

BACKGROUND

Adherence to inhaled corticosteroids (ICS) remains a major issue for asthma management, even among patients receiving a regular prescription from their doctor. The frequency of deliberate interruption of ICS, and of spontaneous changes of dose, were studied in a population of asthma patients recruited in community pharmacies.

METHODS

Asthma patients (aged 18-50) recruited in community pharmacies reported in self-administered questionnaires their spontaneous interruptions and changes of doses of ICS during the past 3 months. The characteristics of patients who interrupted their therapy or who modified the dose were compared with other patients.

RESULTS

The studied population included 252 patients (mean age 35 year-old, females: 59%), of whom 62% had inadequately controlled asthma. Among these patients, 25% had interrupted ICS therapy during the past 3 months, while 21% spontaneously changed the dose. The most reported reason for interrupting ICS was the cessation of symptoms (50%). In multivariate analysis, interrupting ICS was mainly associated with inadequate asthma control (OR=3.1, 95% CI 1.5-6.4), while the strongest association with changing ICS doses was the patients' perception of asthma as a concern in their lives (OR=3.2, 95% CI 1.2-8.4).

CONCLUSION

These results underline a poor understanding of the purpose of ICS therapy by patients. They also highlight the need of therapeutic education to improve the management of the disease.

Adherence to oral second-generation antipsychotic medications in patients with schizophrenia and bipolar disorder: physicians' perceptions of adherence vs. pharmacy claims

OBJECTIVE

To compare physician-reported adherence of specific patients to oral second-generation antipsychotics vs. actual adherence rates determined from the patients' pharmacy claims.

METHODS

Claims data from the HealthCore Integrated Research Database identified patients with schizophrenia or bipolar disorder with ≥ 1 oral second-generation antipsychotic prescription. The prescribing physicians were identified from the pharmacy claims and asked to complete an Internet survey assessing their perception of medication adherence for 1-2 of their patients and their beliefs regarding adherence to second-generation antipsychotics in general for a 1-year period. Adherence to second-generation antipsychotics was determined for each patient by pharmacy claims for the same period. Physician survey data were merged with patient claims data via unique patient identifiers, and physician-reported adherence rates were compared with claims-based rates as measured by the medication possession ratio.

RESULTS

One hundred and fifty-three physicians responded to the survey, representing 214 patients (44 with claims for schizophrenia, 162 with bipolar disorder, 8 with claims for bipolar disorder and schizophrenia). Most physicians (60%) had no formal adherence training. More than two-thirds (68%) reported emphasising the importance of adherence and reported approximately 76% of their patients were adherent (≥ 71% of the time). In the schizophrenia group, 16 of 17 (94%) patients with low-to-moderate (≤ 70%) adherence levels had high (≥ 71%) physician-estimated adherence. In the bipolar disorder group, 62 of 92 (67%) patients with low-to-moderate adherence levels had high physician-estimated adherence.

CONCLUSIONS/INTERPRETATION

These analyses suggest that, even when physicians are asked about specific patients in their practice, there is discordance between physician perceptions and adherence as measured through pharmacy claims. This disparity may delay appropriate interventions, potentially contributing to relapses.

[Patients'illness perceptions and adherence to treatment with inhaled corticosteroids in asthma]

INTRODUCTION

Regular use of inhaled corticosteroids as preventive treatment of asthma is an integral part of management but remains inadequate among adults. Studying the perceptions of illness and treatment beliefs is one way to understand the patient's adherence to medication.

METHOD

A systematic review was performed of empirical studies in adults published between 1999 and 2009, and indexed in the Pubmed, PsycInfo and Scopus databases. We investigated the associations between (1) perceptions of asthma and treatment beliefs and (2) adherence to inhaled corticosteroids. Eighteen articles meet these criteria.

RESULTS

Perception of the chronicity of asthma and its consequences on daily life, as well as the concept that it is necessary to continue treatment in the absence of symptoms, are associated with better adherence. On the contrary, fear of side effects and the belief that treatment is ineffective in controlling symptoms, are associated with poor adherence.

CONCLUSION

Patients' perceptions of asthma and inhaled corticosteroids are predictors of adherence to treatment. The identification and discussion of these issues is an essential part of building a therapeutic relationship that facilitates adherence.

Quality of asthma care: results from a community pharmacy based survey

BACKGROUND

Optimal control is a major objective of disease management of asthma. The aim of the present study was to provide descriptive data on disease management in asthma patients, including medical resource utilization.

METHODS

Asthma patients (age 18-50 years) were consecutively recruited in 348 dispensing pharmacies. They completed a questionnaire which collected data on personal characteristics, asthma management, including medical resource utilization, including asthma management. Asthma control was measured with the Asthma Control Test. Data from computerized pharmacy records of medications, dispensed before inclusion, were also collected.

RESULTS

In 1791 eligible patients, 1559 accepted to participate in the study (mean age = 36.5, 56.1% of females). During the previous 4 weeks, the asthma control was satisfactory for only 28% of the patients, despite extensive provision of anti-inflammatory asthma control treatments (89%). Combinations of long acting beta agonists (LABA) and inhaled corticosteroids (ICS) were commonly used (59%), while fewer patients received LABA and ICS as two separate medications (15%). In addition, short-acting beta agonists, were frequently dispensed (71%). A substantial number of patients consulted their GPs on a monthly basis. Patients commonly reported daily shortness of breath (30%), daily use of rescue medication (29%) and weekly nocturnal symptoms (32%). Surprisingly, most patients considered their asthma as completely or well controlled (76%).

CONCLUSIONS

Our results clearly identify a need to improve the management of asthma. Education programmes would be beneficial to improve asthma control.