Medication adherence in patients with asthma using once-daily versus twice-daily ICS/LABAs

Qualitative study of patients experiences and perceptions of stepping down asthma medication in primary care across England

BACKGROUND

Guidelines recommend that asthma medication should be stepped down to the minimally effective dose that achieves symptom control. Stepping down aims to prevent adverse medication effects and unnecessary costs but is often not implemented in primary care, where most patients with asthma are managed. Little is known about the experiences and views of patients regarding stepping down.

METHODS

Patients with stable asthma, with regular use of a preventer inhaler, from general practitioner practices across England, participated in a survey and/or semi-structured interview. Questions explored the patient's understanding of their asthma, views and knowledge of preventer inhalers, experiences and perceptions of stepping down asthma medication. Qualitative group-based multidisciplinary thematic analysis by two healthcare professionals and a patient were performed.

RESULTS

143 patients responded to the survey, 63% were female, between the ages 18-80 years and including geographical areas across the UK, 17 of whom participated in an interview. Half of these patients with stable asthma, most with asthma for more than 10 years, had never had a discussion regarding stepping down asthma medication. Most stepping down that had occurred was related to seasonal changes in asthma control. Four overarching themes from the interviews were identified, (1) experiences of living with asthma and needing inhalers, (2) insufficient education regarding preventer inhalers, (3) stepping down is agreeable and possible and (4) current asthma care is suboptimal.

CONCLUSION

Patients with stable asthma were able to self-manage their asthma well. They had little awareness of medication adverse effects and minimal experience of having their medication stepped down by a healthcare professional. Most were inclined to step down, if clinically safe to do so, indeed some had reduced their medication doses themselves, without professional guidance.

Comparative effectiveness and safety of single inhaler triple therapies for chronic obstructive pulmonary disease: new user cohort study

OBJECTIVE

To compare the effectiveness and safety of budesonide-glycopyrrolate-formoterol, a twice daily metered dose inhaler, and fluticasone-umeclidinium-vilanterol, a once daily dry powder inhaler, in patients with chronic obstructive pulmonary disease (COPD) treated in routine clinical practice.

DESIGN

New user cohort study.

SETTING

Longitudinal commercial US claims data.

PARTICIPANTS

New initiators of budesonide-glycopyrrolate-formoterol or fluticasone-umeclidinium-vilanterol between 1 January 2021 and 30 September 2023 who had a diagnosis of COPD and were aged 40 years or older.

MAIN OUTCOME MEASURES

In this 1:1 propensity score matched study, the main outcome measures were first moderate or severe COPD exacerbation (effectiveness) and first admission to hospital with pneumonia (safety) while on treatment. Potential confounders were measured in the 365 days before cohort entry and included in propensity scores. Hazard ratios and 95% confidence intervals (CIs) were estimated using a Cox proportional hazards regression model.

RESULTS

The study cohort included 20 388 propensity score matched pairs of new users initiating single inhaler triple therapy. Patients who received budesonide-glycopyrrolate-formoterol had a 9% higher incidence of first moderate or severe COPD exacerbation (hazard ratio 1.09 (95% CI 1.04 to 1.14); number needed to harm 38) compared with patients receiving fluticasone-umeclidinium-vilanterol and an identical incidence of first admission to hospital with pneumonia (1.00 (0.91 to 1.10)). The hazard of first moderate COPD exacerbation was 7% higher (1.07 (1.02 to 1.12); number needed to harm 54) and the hazard of first severe COPD exacerbation 29% higher (1.29 (1.12 to 1.48); number needed to harm 97) among those receiving budesonide-glycopyrrolate-formoterol compared to fluticasone-umeclidinium-vilanterol. Prespecified sensitivity analyses yielded similar findings to the primary analysis.

CONCLUSIONS

Budesonide-glycopyrrolate-formoterol was not associated with improved clinical outcomes compared with fluticasone-umeclidinium-vilanterol. Given the added climate impact of metered dose inhalers, health systems seeking to decrease use of these products may consider steps to promote further prescribing of fluticasone-umeclidinium-vilanterol compared with budesonide-glycopyrrolate-formoterol in people with COPD.

STUDY REGISTRATION

Center for Open Science Real World Evidence Registry (https://osf.io/6gdyp/).

Factors Affecting Adherence in Allergic Disorders and Strategies for Improvement

Addressing patient adherence is a key element in ensuring positive health outcomes and improving health-related quality of life for patients with atopic and immunologic disorders. Understanding the complex etiologies of patient nonadherence and identifying real-world solutions is important for clinicians, patients, and systems to design and effect change. This review serves as an important resource for defining key issues related to patient nonadherence and outlines solutions, resources, knowledge gaps, and advocacy areas across five domains: health care access, financial considerations, socioenvironmental factors, health literacy, and psychosocial factors. To allow for more easily digestible and usable content, we describe solutions based on three macrolevels of focus: patient, clinician, and system. This review and interactive tool kit serve as an educational resource and call to action to improve equitable distribution of resources, institutional policies, patient-centered care, and practice guidelines for improving health outcomes for all patients with atopic and immunologic disorders.

Asthma prescribing trends, inhaler adherence and outcomes: a Real-World Data analysis of a multi-ethnic Asian Asthma population

Inhaled corticosteroid (ICS) is the mainstay therapy for asthma, but general adherence is low. There is a paucity of real-world inhaler prescribing and adherence data from Asia and at the population level. To address these gaps, we performed a real-world data analysis of inhaler prescribing pattern and adherence in a multi-ethnic Asian asthma cohort and evaluated the association with asthma outcomes. We performed a retrospective analysis of adult asthma patients (aged ≥18 years) treated in the primary and specialist care settings in Singapore between 2015 to 2019. Medication adherence was measured using the medication possession ratio (MPR), and categorised into good adherence (MPR 0.75-1.2), poor adherence (MPR 0.75) or medication oversupply (MPR > 1.2). All statistical analyses were performed using R Studio. 8023 patients, mean age 57 years, were evaluated between 2015 and 2019. Most patients were receiving primary care (70.4%) and on GINA step 1-3 therapies (78.2%). ICS-long-acting beta-2 agonist (ICS-LABA) users increased over the years especially in the primary care, from 33% to 52%. Correspondingly, inpatient admission and ED visit rates decreased over the years. Between 2015 and 2019, the proportion of patients with poor adherence decreased from 12.8% to 10.5% (for ICS) and from 30.0% to 26.8% (for ICS-LABA) respectively. Factors associated with poor adherence included minority ethnic groups (Odds ratio of MPR 0.75-1.2: 0.73-0.93; compared to Chinese), presence of COPD (OR 0.75, 95% CI 0.59-0.96) and GINA step 4 treatment ladder (OR 0.71, 95% CI 0.61-0.85). Factors associated with good adherence were male gender (OR 1.14, 95% CI 1.01-1.28), single site of care (OR 1.22 for primary care and OR 1.76 for specialist care), GINA step 2 treatment ladder (OR 1.28, 95% CI 1.08-1.50). Good adherence was also associated with less frequent inpatient admission (OR 0.91, 95% CI 0.84-0.98), greater SABA overdispensing (OR 1.66, 95% CI 1.47-1.87) and oral corticosteroids use (OR 1.10, 95% CI 1.05-1.14). Inhaled corticosteroid (ICS) adherence has improved generally, however, poor adherence was observed for patients receiving asthma care in both primary and specialist care, and those from the minority ethnicities.

Efficacy and safety of Once-Daily Vilanterol/Fluticasone furoate MDI in persistent asthma: Phase 3 OD-INHALE Study

INTRODUCTION

Once-daily inhalers have been shown to improve adherence leading to lesser discontinuation compared to twice- or thrice-daily inhalers in management of asthma. Combination of Vilanterol and Fluticasone Furoate (VI/FF) is approved for management of asthma and COPD and is available as a dry powder inhaler. Pressurized-Metered Dose Inhalers (pMDIs) offer ease-of-use and therapy alternatives for patients with low inspiratory flow. This study assessed the efficacy and safety of a new once-daily pMDI containing VI/FF in individuals diagnosed with persistent asthma.

METHODS

This phase 3, double-blind, randomized controlled study assessed the non-inferiority of VI/FF (12.5 mcg/50 mcg & 12.5 mcg/100 mcg; 2 puffs once-daily) over Formoterol Fumarate and Fluticasone Propionate (FOR/FP, 6 mcg/125 mcg & 6 mcg/250 mcg; 2 puffs twice-daily) in patients with persistent asthma. Primary outcome was change from baseline in trough FEV1 at the end of study (12 weeks). Adverse events and number of exacerbations were used to evaluate safety.

RESULTS

A total of 330 patients were randomized into VI/FF (165) and FOR/FP (165). Trough FEV1 significantly improved in both the groups at week 12, with a mean difference (VI/FF minus FOR/FP) being 54.75 mL (95% CI, 8.42-101.08 mL, p = 0.02). The low dose VI/FF had similar efficacy to that of low dose FOR/FP and high dose VI/FF had similar efficacy to high dose FOR/FP. No serious adverse events were reported during the study.

CONCLUSION

Once daily VI/FF pMDI was non-inferior to twice daily FOR/FP pMDI in patients with persistent asthma.

Smaller Differences in the Comparative Effectiveness of Biologics in Reducing Asthma-Related Hospitalizations Compared With Overall Exacerbations

BACKGROUND

Evidence on the comparative effectiveness of respiratory biologics remains sparse.

OBJECTIVE

We sought to evaluate the comparative effectiveness of omalizumab, mepolizumab, benralizumab, and dupilumab in a matched retrospective cohort of patients with asthma.

METHODS

We identified patients with asthma aged ≥18 years who were incident users of these biologics between November 1, 2018, and June 30, 2023, in administrative claims data from the Food and Drug Administration's Sentinel System and Merative MarketScan Commercial Database. We compared asthma-related exacerbations and hospitalizations in the 12 months since biologic prescription in pairwise comparisons of propensity score-matched cohorts. Covariates used in matching included age, sex, allergic comorbidities, baseline asthma medications use, and the Charlson Comorbidity Index. Incidence rate ratios (IRR) and 95% confidence intervals (CI) were estimated using negative binomial regression models.

RESULTS

A total of 893 patients on mepolizumab, 1300 on benralizumab, 1170 on omalizumab, and 1863 on dupilumab were identified. The average age was 55 years, and two-thirds of the participants were female. At baseline, over 80% of these individuals had an active prescription for an inhaled corticosteroid. Almost half of patients on dupilumab had concomitant nasal polyposis compared with 6% to 13% of patients on the other biologics. Covariates were balanced after matching. In matched analyses, dupilumab was associated with the lowest incidence of exacerbations over the follow-up period (vs dupilumab): mepolizumab (IRR: 1.36; 95% CI: 1.12, 1.64), omalizumab (IRR: 1.33; 95% CI: 1.13, 1.58), benralizumab (IRR: 1.19; 95% CI: 1.00, 1.41). For exacerbations leading to hospitalizations, benralizumab and mepolizumab were associated with the lowest incidence of hospitalizations, and the greatest difference was between mepolizumab versus dupilumab (IRR: 0.76; 95% CI: 0.56, 1.03).

CONCLUSIONS

Dupilumab was associated with the lowest incidence of overall exacerbations, and mepolizumab with the lowest incidence of asthma hospitalizations in this administrative claims-based cohort of individuals with asthma. Despite matching propensity scores, residual confounding, such as baseline eosinophil count, may explain some of these findings.

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Efficacy, Safety, and Systemic Exposure of Once-Daily Indacaterol Acetate in Pediatric Asthma: A Randomized, Double-Blind, Controlled Dose-Finding Study

BACKGROUND

Indacaterol acetate (IND), a long-acting β2-agonist in combination with mometasone furoate (MF), an inhaled corticosteroid (ICS), is being explored as a once-daily (od) treatment for asthma in children. This study examined the efficacy, safety, and systemic exposure of IND 75 µg and IND 150 µg in children with persistent asthma.

METHODS

In this Phase IIb, multicenter, randomized, double-blind, parallel-group study, pediatric patients (aged ≥ 6 to < 12 years) with persistent asthma were randomized (1:1) to receive either IND 75 µg od or IND 150 µg od via Breezhaler® in combination with ICS background therapy. The primary endpoint was change from baseline in pre-dose trough forced expiratory volume in one second (FEV1) after two weeks of treatment.

RESULTS

In total, 80 patients received IND 75 µg (n = 39) or IND 150 µg (n = 41). The study met its primary endpoint; both doses demonstrated improvements in pre-dose trough FEV1 from baseline to Day 14 (mean change [Δ]: 212 mL, IND 75 µg; 171 mL, IND 150 µg). The secondary spirometry parameters (post-dose FEV1 after 1-h, post-dose forced vital capacity; morning and evening peak expiratory flow) also improved. Overall, 36.1% in IND 75 μg group and 25% patients in IND 150 μg group achieved a decrease from baseline in Pediatric Interviewer-administered Asthma Control Questionnaire score of ≥ 0.5 units. A dose-dependent increase in plasma IND concentration was noted between the two groups. Both IND doses demonstrated an acceptable safety profile.

CONCLUSIONS

Once-daily IND 75 μg and IND 150 μg via Breezhaler® in combination with background ICS therapy provided substantial bronchodilation in children with asthma and were well tolerated. Taken together, these clinical and systemic exposure findings support IND 75 μg as the most appropriate dose for evaluation in Phase III trials in combination with MF in pediatric asthma.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02892019; 08-Sep-2016).

Assessing the Effects of Changing Patterns of Inhaled Corticosteroid Dosing and Adherence with Fluticasone Furoate and Budesonide on Asthma Management

INTRODUCTION

Pharmacological asthma management focuses on the use of inhaled corticosteroid (ICS)-containing therapies, which reduce airway inflammation and provide bronchoprotection, improving symptom control and reducing exacerbation risk. ICS underuse due to poor adherence is common, leading to poor clinical outcomes including increased risk of mortality. This article reviews efficacy versus systemic activity profiles for various adherence patterns and dosing regimens of fluticasone furoate (FF)-containing and budesonide (BUD)-containing asthma therapies in clinical trials and real-world studies.

METHODS

We performed a structured literature review (1 January 2000-3 March 2022) and mathematical modelling analysis of FF-containing and BUD-containing regular daily dosing in patients with mild-to-severe asthma, as-needed BUD/formoterol (FOR) in mild asthma, and BUD/FOR maintenance and reliever therapy (MART) dosing in moderate-to-severe asthma, to assess efficacy (bronchoprotection) and systemic activity (cortisol suppression) profiles of dosing patterns of ICS use in multiple adherence scenarios.

RESULTS

A total of 22 manuscripts were included in full-text review and 18 in the model simulations. Focusing on FF-containing or BUD-containing treatments at comparable adherence rates, regular daily FF or FF/vilanterol (VI) dosing provided more prolonged bronchoprotection and fewer systemic effects than daily BUD, daily BUD/FOR, or BUD/FOR MART dosing, especially in low adherence scenarios. In model simulations and the real-world setting, FF/VI generally provided longer bronchoprotection, lower systemic activity, and greater clinical benefits over BUD/FOR as well as consistently higher adherence.

CONCLUSION

In this literature review and modelling analysis, FF/VI was found to show clinical advantages on asthma control over BUD/FOR. These findings have implications for helping clinicians select the most suitable inhaled therapy for their patients with asthma.

Is Once Versus Twice Daily Dosing Better for Adherence in Asthma and Chronic Obstructive Pulmonary Disease?

BACKGROUND

Patients with asthma and chronic obstructive pulmonary disease (COPD) may be prescribed once- or twice-daily dosing of controller inhalers.

OBJECTIVE

To assess differences in controller adherence by dosing schedule and age.

METHODS

Electronic medication monitors (EMMs) captured the date and time of inhaler actuations over 90 days in patients using the Propeller Health platform. Prescribed inhaler schedule was self-reported. Once- versus twice-daily schedule comparisons were assessed retrospectively using regressions adjusting for age.

RESULTS

A total of 6294 patients with asthma and 1791 patients with COPD were included. On average, once-daily users had significantly higher median (interquartile range [IQR]) daily adherence than twice-daily users (asthma: 63.3 [IQR: 31.1, 86.7]% vs 50.3 [IQR: 21.1, 78.3]%, P < .001; COPD: 83.3 [IQR: 57.2, 95.6]% vs 64.7 [IQR: 32.8, 88.9]%, P < .001). This pattern persisted in all age groups, with the exception of 4- to 17-year-olds in asthma. The lowest adherence was in the young adult population (18- to 29-year-olds). The percentage of patients who achieved ≥80% adherence was significantly higher among once- versus twice-daily users in asthma (34.3% vs 23.6%, P < .001) and COPD (54.8% vs 38.6%, P < .001). The adjusted odds of once- versus twice-daily users achieving ≥80% adherence was 1.36 (95% confidence interval: 1.19-1.56, P < .001) in asthma and 1.73 (95% confidence interval: 1.38-2.17, P < .001) in COPD. Most once-daily patients with COPD took their medication in the morning versus at night; there was no difference in morning versus afternoon/evening administration in all other asthma and COPD groups.

CONCLUSION

Patients with asthma and COPD who were prescribed once-daily versus twice-daily medications were more likely to adhere to their inhalers. Patients with COPD had higher adherence than those with asthma, possibly reflecting, in part, the older cohort age. The effect of greater adherence on exacerbations is a topic for future analysis.

Up-to-date guidance towards improving medication adherence in patients with chronic obstructive pulmonary disease

INTRODUCTION

Despite efficacious treatment for chronic obstructive pulmonary disease (COPD), medication adherence remains quite poor, with most estimates based on electronic monitoring devices ranging from 20-30%. This degree of nonadherence represents a significant missed opportunity to realize the benefits of treatment of this disease.

AREAS COVERED

In this article, we review research on the prevalence of nonadherence among patients with COPD, the association of nonadherence with health outcomes, barriers to adherence in this patient population, and potential interventions.

EXPERT OPINION

Integrating research into practice involves assessing patients' adherence, identifying modifiable barriers to adherence, open discussion of these barriers with patients, and tailored interventions to address them. These interventions may include treatment of previously unrecognized comorbid disease, providing educational or behavioral interventions, optimizing prescribing strategies, use of adherence aids, or addressing cost and other access barriers. Electronic inhaler monitors are promising interventions for both monitoring and improving adherence. However, remaining concerns about integration into patient care, data management, cost, acceptability, and ethical and privacy issues must be overcome prior to their implementation in clinical practice.

Mometasone/Indacaterol/Glycopyrronium (MF/IND/GLY) and MF/IND at Different MF Strengths versus Fluticasone Propionate/Salmeterol Xinafoate (FLU/SAL) and FLU/SAL+ Tiotropium in Patients with Asthma

Background

Once-daily, single-inhaler mometasone furoate/indacaterol acetate/glycopyrronium bromide (MF/IND/GLY, an ICS/LABA/LAMA) and MF/IND (an ICS/LABA) via Breezhaler® have been approved for the maintenance treatment of patients with asthma inadequately controlled with medium-or high-dose ICS or medium-or high-dose ICS/LABA treatment.

Objective

Once-daily (o.d.) formulations of MF/IND/GLY and MF/IND at different MF dose strengths have been compared with twice-daily (b.i.d.) fluticasone propionate/salmeterol xinafoate (FLU/SAL), and b.i.d. FLU/SAL+ o.d. tiotropium (TIO) in the PALLADIUM, IRIDIUM and ARGON studies.

Methods

The similarity in study design and consistent outcomes in these studies prompted the pooling of data in this review to better characterise these novel once-daily controller formulations.

Results

Pooled data from PALLADIUM and IRIDIUM studies showed comparable or greater efficacy with o.d. MF/IND formulations versus b.i.d. FLU/SAL. The o.d. MF/IND/GLY was superior to b.i.d. FLU/SAL in the IRIDIUM study, and similar to, if not more efficacious than b.i.d. FLU/SAL + o.d. TIO in the ARGON study.

Conclusion

These formulations therefore provide novel once-daily treatment options for patients across asthma severity and flexibility for clinicians to step-up or step-down the treatment using the same device and formulations.

Adherence and Persistence to Single-Inhaler Versus Multiple-Inhaler Triple Therapy for Asthma Management

BACKGROUND

Treatment guidelines recommend triple therapy for patients with asthma who remain uncontrolled on inhaled corticosteroid/long-acting β₂-agonist therapy. Previously, triple therapy was only available via multiple inhalers. Single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) is approved as maintenance treatment for asthma; however, real-world information on adherence and persistence is limited.

OBJECTIVE

To compare adherence and persistence among adult patients with asthma receiving single-inhaler FF/UMEC/VI versus multiple-inhaler triple therapy (MITT) in the United States.

METHODS

This retrospective cohort study used IQVIA PharMetrics Plus data to evaluate patients with asthma who initiated once-daily FF/UMEC/VI 100/62.5/25 mcg or MITT between September 18, 2017, and September 30, 2019. Inverse probability weighting and multivariable regression adjusted for differences in characteristics between the FF/UMEC/VI and MITT cohorts. Adherence was assessed using proportion of days covered (PDC) and proportion of patients achieving PDC ≥0.8 and PDC ≥0.5. Non-persistence was identified as a >45-day gap between fills.

RESULTS

The study included 1396 FF/UMEC/VI and 5115 MITT initiators. Three months after initiation, FF/UMEC/VI users had significantly higher mean PDC versus MITT users (0.68 vs 0.59; P < .001) and 31% more likely to be adherent (PDC ≥0.8; 40.6% vs 31.3%; adjusted risk ratio [95% confidence interval (CI)]: 1.31 [1.13-1.54]; P < .001). Similar patterns were observed at 6 and 12 months post initiation. In addition, FF/UMEC/VI users were 49% more likely to persist at 12 months than MITT users (25.9% vs 15.1%, adjusted hazard ratio [95% CI]: 1.49 [1.39-1.60]; P < .001).

CONCLUSIONS

Patients with asthma initiating triple therapy with FF/UMEC/VI had significantly better adherence and persistence compared with MITT initiators.

Association Between Medication Adherence and Risk of COPD in Adult Asthma Patients: A Retrospective Cohort Study in Canada

Background

Poor adherence to prescribed asthma medications and risk of severe asthma exacerbations have been well established. However, the effects of changes in asthma medication compliance levels and subsequent risk of COPD is unknown and yet to be investigated. This study investigated the independent effect of medication adherence (MA) and asthma severity levels on the risk of COPD.

Methods

We used four linked administrative health databases from the Population data BC to identify asthma patients aged 18 years and older between January 1, 1998 and December 31, 1999 without diagnosis of COPD. The primary event was time-to-COPD diagnosis during the follow-up period (January 1, 2000 to December 31, 2018). The proportion of days covered (PDC) – was used as a surrogate measure for medication adherence (MA) assessed at optimal-level (≥ 0.80), Intermediate-level (0.50–0.79), and low-level (< 0.5) of adherence. A propensity adjusted analysis with Marginal Structural Cox (MSC) model was employed to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) for the effect of medication adherence and asthma severity over time.

Results

At cohort entry, the sample included 68,211 asthma patients with an overall mean age of 48.2 years. The 18-year incidence of COPD in asthma patients was 9.8 per 1000-persons year. In an inverse weighted propensity adjusted analysis of the MSC model, higher MA levels were significantly associated with decreased risk of COPD as follows: optimal-level (aHR: 0.19, 95% CI: 0.17–0.24); Intermediate-level (aHR: 0.20, 95% CI: 0.18, 0.23) compared to the low-level adherence group. A significant increase in COPD risk was observed in severe asthma patients with low medication adherence (aHR: 1.72, 95% CI: 1.52–1.93), independent of other patient factors.

Conclusion

Optimal (≥ 0.80) and intermediate adherence (0.5 to 0.79) levels were associated with reduced risk of COPD incidence over time. Interventions aimed at improving adherence to prescribed medications in adult asthma patients should be intensified to reduce their risk of COPD.

Improving Medication Adherence in Asthma

In little over a generation, the ingenuity of scientists and clinician researchers has developed inhaled medications and pathway-specific biological agents that control the inflammation and physiology of asthma. Unfortunately, whether it is because of cost or difficulty understanding why or how to use inhaled medications, patients often do not take these medications. The consequences of poor treatment adherence, loss of control and exacerbations, are the same as if the condition remained untreated. Furthermore, poor adherence is difficult to detect without direct measurement. Together this means that poor treatment adherence is easily overlooked and, instead of addressing the cause of poor adherence, additional medicines may be prescribed. In other words, poor treatment adherence is a risk for the patient and adds cost to healthcare systems. In this article, we discuss the rationale for and the delivery of successful interventions to improve medication adherence in asthma. We contextualize these interventions by describing the causes of poor treatment adherence and how adherence is assessed. Finally, future perspectives on the design of new interventions are described.

Adherence to inhaled corticosteroids prescribed once vs twice daily in children with asthma

BACKGROUND

Suboptimal adherence to inhaled corticosteroids (ICS) is associated with poor asthma control. Adult studies suggest that simplification of ICS regimen leads to better adherence.

OBJECTIVE

We aimed to determine whether once-daily, compared with twice-daily, ICS dosing was associated with better adherence among children with asthma.

METHODS

We conducted a retrospective observational study of children with asthma prescribed with either once-daily or twice-daily ICS monotherapy between 2011 and 2019. Our primary adherence outcome was the proportion of prescribed days covered (PPDC)-that is, the number of days for which the drug was dispensed by the pharmacy divided by the number of days for which it was prescribed. The impact of once-daily vs twice-daily ICS regimen on adherence was evaluated using linear multivariable regression analysis adjusting for covariates. Secondary outcomes included the proportion of patients with greater than or equal to 75% adherence analyzed using logistic regression models.

RESULTS

A total of 232 children (61% boys; mean age of 5.8 [3.6] years) were included; 120 children were prescribed once-daily, and 112 twice-daily, ICS. The median PPDC was 66.8% for the once-daily and 57.9% for the twice-daily group (P = .03). Children prescribed once-daily ICS had a 7.2% (95% confidence interval, 1.3-13.1) greater mean PPDC compared with the twice-daily group and greater odds of having PPDC greater than or equal to 75% (71.4% vs 45.5%; odds ratio, 1.80; 95% confidence interval, 1.01-3.26).

CONCLUSION

Our findings suggest that once-daily dosing of ICS is associated with better medication adherence than twice-daily dosing. Whether the gain in adherence leads to better asthma control and health outcomes remains to be evaluated.

Challenges and recommendations for the management of asthma in the Middle East and Africa

Clinical presentation of asthma is variable, and its diagnosis can be a major challenge in routine health-care practice, especially in low-and-middle-income countries. The aim of asthma management is to achieve optimal asthma control and to reduce the risk of asthma exacerbations and mortality. In the Middle East and in Africa (MEA), several patient- and physician-related factors lead to misdiagnosis and suboptimal management of asthma. A panel of experts comprising of specialists as well as general health-care professionals met to identify challenges and provide recommendations for the management of asthma in MEA. The major challenges identified for diagnosis of asthma were lack of adequate knowledge about the disease, lack of specialized diagnostic facilities, limited access to spirometry, and social stigma associated with asthma. The prime challenges for management of asthma in MEA were identified as overreliance on short-acting β-agonists (SABAs), underprescription of inhaled corticosteroids (ICS), nonadherence to prescribed medications, and inadequate insurance coverage for its treatment. The experts endorsed adapting the Global Initiative for Asthma guidelines at country and regional levels for effective management of asthma and to alleviate the overuse of SABAs as reliever medications. Stringent control over SABA use, discouraging over-the-counter availability of SABA, and using as-needed low-dose ICS and formoterol as rescue medications in mild cases were suggested to reduce the overreliance on SABAs. Encouraging SABA alone-free clinical practice in both outpatient and emergency department settings is also imperative. We present the recommendations for the management of asthma along with proposed regional adaptations of international guidelines for MEA.

Impact of adherence to treatment with inhaled corticosteroids/long-acting β-agonists on asthma outcomes in the United States

BACKGROUND

Suboptimal adherence to maintenance medication has been associated with poor outcomes in asthma. This study examined single-inhaler inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA) adherence and asthma-related outcomes.

METHODS

This retrospective observational study of patients with asthma initiating ICS/LABA used data from IQVIA PharMetrics Plus (1 January 2014-31 March 2019). Patients included were ⩾18 years old and had ⩾12 months continuous eligibility before, and ⩾180 days follow-up after, the index date. Adherence was measured as proportion of days covered ([PDC] adherent ⩾ 0.8; non-adherent <0.8) each quarter, with outcomes measured each subsequent quarter. Endpoints were asthma-related overall and severe (inpatient/emergency department [ED] visit) exacerbations, rescue medication use, and asthma-related healthcare resource utilization and costs. Regression models evaluated associations between adherence and outcomes, controlling for repeated measures and differences in baseline characteristics.

RESULTS

Overall, 50,037 patients were included (mean age 45.3 years; mean follow-up 23.3 months). Adherent patients were less likely to experience asthma-related overall (adjusted odds ratio [aOR] 95% confidence interval [CI]: 0.942 [0.890, 0.998]; p = 0.041), or severe exacerbations (aOR [95% CI]: 0.778 [0.691, 0.877]; p < 0.001) per quarter versus non-adherent patients. Adherent patients had lower severe exacerbation rates (adjusted rate ratio [aRR] [95% CI]: 0.792 [0.702, 0.893]; p < 0.001) but similar overall exacerbation rates (aRR [95% CI]: 0.993 [0.945, 1.044]; p = 0.783) versus non-adherent patients. The odds of rescue medication use were lower per 20% PDC increase (aOR [95% CI] short-acting β2 agonist: 0.991 [0.985, 0.996]; p = 0.001; oral corticosteroid: 0.988 [0.982, 0.995]; p < 0.001). Adherent patients were less likely to visit EDs per quarter (aOR [95% CI]: 0.775 [0.680, 0.883]; p < 0.001) and odds of hospitalization were lower per 20% PDC increase (aOR [95% CI]: 0.930 [0.881, 0.982]; p = 0.009). Across most measures, adherent patients incurred lower costs.

CONCLUSION

This real-world study highlights the short-term clinical and economic benefits of ICS/LABA adherence in asthma, particularly in reducing severe exacerbations.

Improving the risk-to-benefit ratio of inhaled corticosteroids through delivery and dose: current progress and future directions

INTRODUCTION

Inhaled corticosteroids (ICS) are known to increase the risk of systemic and local adverse effects, especially with high doses and long-term use. Hence, considerable resources are invested to improve pharmacokinetic/pharmacodynamic (PK/PD) properties of ICS, effective delivery systems and novel combination therapies to enhance the risk-to-benefit ratio of ICS.

AREAS COVERED

There is an unmet need for new solutions to achieve optimal clinical outcomes with minimal dose of ICS. This paper gives an overview of novel treatment strategies regarding the safety of ICS therapy on the basis of the three most recent molecules introduced to our everyday clinical practice - ciclesonide, mometasone furoate, and fluticasone furoate. Advances in aerosol devices and new areas of inhalation therapy are also discussed.

EXPERT OPINION

Current progress in improving the risk-to-benefit ratio of ICS through dose and delivery probably established pathways for further developments. This applies both to the improvement of the PK/PD properties of ICS molecules but also includes technical aspects that lead to simplified applicability of the device with simultaneous optimal drug deposition in the lungs. Indubitably, the future of medicine lies not only in the development of new molecules but also in technology and digital revolution.

Measuring Medication Adherence in a Population-Based Asthma Administrative Pharmacy Database: A Systematic Review and Meta-Analysis

Background

Limited studies have systematically reviewed the literature to identify and compare the various database methods and optimal thresholds for measuring medication adherence specific to adolescents and adults with asthma. In the present study, we aim to identify the methods and optimal thresholds for measuring medication adherence in population-based pharmacy databases.

Methods

We searched PubMed, Embase, International Pharmaceutical Abstracts (IPA), Web of Science, Google Scholar, and grey literature from January 1, 1998, to March 16, 2021. Two independent reviewers screened the studies, extracted the data, and assessed the quality of the studies. A quantitative knowledge synthesis was employed.

Results

Thirty-eight (38) retrospective cohort studies were eligible. This review identified 20 methods for measuring medication adherence in adolescent and adult asthma administrative health records. Two measures namely the medication possession ratio (MPR) and proportion of days covered (PDC) were commonly reported in 87% of the literature included in this study. From the meta-analysis, asthma patients who achieved adherence threshold of "0.75-1.00" [OR: 0.56, 95% CI: 0.41 to 0.77] and ">0.5" [OR: 0.71, 95% CI: 0.54 to 0.94] were less likely to experience asthma exacerbation.

Conclusion

Despite their limitations, the PDC and the MPR still remain the most common measures for assessing adherence in asthma pharmacy claim databases. The evidence synthesis showed that an adherence threshold of at least 0.75 is optimal for classifying adherent and non-adherent asthma patients.

Recent Insights into the Management of Inflammation in Asthma

The present prevailing inflammatory paradigm in asthma is of T2-high inflammation orchestrated by key inflammatory cells like Type 2 helper lymphocytes, innate lymphoid cells group 2 and associated cytokines. Eosinophils are key components of this T2 inflammatory pathway and have become key therapeutic targets. Real-world evidence on the predominant T2-high nature of severe asthma is emerging. Various inflammatory biomarkers have been adopted in clinical practice to aid asthma characterization including airway measures such as bronchoscopic biopsy and lavage, induced sputum analysis, and fractional exhaled nitric oxide. Blood measures like eosinophil counts have also gained widespread usage and multicomponent algorithms combining different parameters are now appearing. There is also growing interest in potential future biomarkers including exhaled volatile organic compounds, micro RNAs and urinary biomarkers. Additionally, there is a growing realisation that asthma is a heterogeneous state with numerous phenotypes and associated treatable traits. These may show particular inflammatory patterns and merit-specific management approaches that could improve asthma patient outcomes. Inhaled corticosteroids (ICS) remain the mainstay of asthma management but their use earlier in the course of disease is being advocated. Recent evidence suggests potential roles for ICS in combination with long-acting beta-agonists (LABA) for as needed use in mild asthma whilst maintenance and reliever therapy regimes have gained widespread acceptance. Other anti-inflammatory strategies including ultra-fine particle ICS, leukotriene receptor antagonists and macrolide antibiotics may show efficacy in particular phenotypes too. Monoclonal antibody biologic therapies have recently entered clinical practice with significant impacts on asthma outcomes. Understanding of the efficacy and use of those agents is becoming clearer with a growing body of real-world evidence as is their potential applicability to other treatable comorbid traits. In conclusion, the evolving understanding of T2 driven inflammation alongside a treatable traits disease model is enhancing therapeutic approaches to address inflammation in asthma.

One time a day mometasone/indacaterol fixed-dose combination versus two times a day fluticasone/salmeterol in patients with inadequately controlled asthma: pooled analysis from PALLADIUM and IRIDIUM studies

BACKGROUND

Despite currently available standard-of-care inhaled corticosteroid (ICS)/long-acting β₂-agonist therapies, a substantial proportion of patients with asthma remain inadequately controlled. This pooled analysis evaluated efficacy and safety of mometasone furoate/indacaterol acetate (MF/IND) versus fluticasone propionate/salmeterol xinafoate (FLU/SAL) in patients with inadequately controlled asthma.

METHODS

This analysis included patients from PALLADIUM (NCT02554786) and IRIDIUM (NCT02571777) studies who received high-dose MF/IND (320/150 µg) or medium-dose MF/IND (160/150 µg) one time a day or high-dose FLU/SAL (500/50 µg) two times a day for 52 weeks. Reduction in asthma exacerbations, improvement in lung function, asthma control, and safety were evaluated for 52 weeks.

RESULTS

In total, 3154 patients (high-dose MF/IND, n=1054; medium-dose MF/IND, n=1044; high-dose FLU/SAL, n=1056) were included. High-dose MF/IND showed 26%, 22% and 19% reductions in rate of severe, moderate or severe, and all (mild, moderate and severe) exacerbations versus high-dose FLU/SAL, respectively, over 52 weeks (all, p<0.05). High-dose MF/IND improved trough FEV₁ versus high-dose FLU/SAL at weeks 26 (Δ, 43 mL, p=0.001) and 52 (Δ, 51 mL, p<0.001). Reductions in asthma exacerbation rate and improvement in trough FEV₁ with medium-dose MF/IND were comparable with high-dose FLU/SAL over 52 weeks. All treatments improved Asthma Control Questionnaire-7 score from baseline to 52 weeks with no difference between treatments. Safety was comparable between high-dose MF/IND and high-dose FLU/SAL.

CONCLUSIONS

One time a day, single-inhaler, high-dose MF/IND reduced asthma exacerbations and improved lung function versus two times a day, high-dose FLU/SAL in patients with inadequately controlled asthma. Similarly, improved outcomes were seen with one time a day, medium-dose MF/IND and two times a day, high-dose FLU/SAL, but at a lower ICS dose.

Symptom control in patients with asthma using inhaled corticosteroids/long-acting β2-agonists (fluticasone furoate/vilanterol or budesonide/formoterol) in the US: a retrospective matched cohort study

Objective: Treatment with fluticasone furoate/vilanterol (FF/VI), an inhaled corticosteroid/long-acting β₂-agonist therapy, reduces the risk of severe asthma exacerbations and improves lung function and symptom control in patients with asthma. However, real-world data remain limited among asthma patients in the United States (US).Methods: This retrospective cohort study propensity score (PS) matched adult asthma patients initiating once-daily FF/VI 100/25 mcg with patients initiating twice-daily budesonide/formoterol (B/F) 160/4.5 mcg using a US claims database (01/01/2015-12/31/2018). Asthma control was measured by the mean number of short-acting β₂-agonist (SABA) canisters dispensed per patient-year (PPY) during follow-up. Time to first, and rates of, overall and severe asthma exacerbations were also measured.Results: After PS matching, 18531 patients receiving FF/VI were matched to 18531 patients receiving B/F. Mean SABA canisters dispensed PPY was significantly lower for FF/VI compared with B/F users (FF/VI: 1.47, B/F: 1.64; p < 0.001). FF/VI use resulted in 13% significantly lower risk of having an overall asthma-related exacerbation and 22% lower risk of a severe exacerbation versus B/F use (overall exacerbation hazard ratio [HR] [95% confidence interval (CI)]: 0.87 [0.82-0.92], p < 0.001; severe exacerbation HR: 0.78 [0.63-0.97], p = 0.027). Asthma-related exacerbation rates per 100 patient-days were also significantly lower for the FF/VI compared with B/F group (overall: 0.0475 vs. 0.0558, p < 0.001; severe 0.0026 vs. 0.0033, p = 0.020).Conclusions: In real-world practice, initiation of once-daily FF/VI 100/25 mcg in adults with asthma was associated with lower use of SABA and fewer asthma-related exacerbations, which may indicate better asthma control, when compared with use of twice-daily B/F 160/4.5 mcg.

Once-daily, single-inhaler indacaterol/mometasone versus twice-daily salmeterol/fluticasone in Asian patients with inadequately controlled asthma: Post hoc pooled analysis from PALLADIUM and IRIDIUM studies

Objective: PALLADIUM and IRIDIUM studies demonstrated efficacy and safety of indacaterol/mometasone (IND/MF) versus salmeterol/fluticasone (SAL/FLU). This post hoc analysis of pooled data from PALLADIUM and IRIDIUM studies evaluated efficacy and safety of IND/MF versus SAL/FLU in Asian patients with inadequately controlled asthma.Methods: Both studies were Phase III, 52-week, randomized, double-blind, active-controlled that included patients with predicted pre-bronchodilator FEV₁ (PALLADIUM, ≥50%-<85%; IRIDIUM, <80%), ACQ-7 score ≥1.5. Patients treated with IND/MF high- (150/320μg) or medium-dose (150/160μg) or SAL/FLU high-dose (50/500μg) were included. Lung function, asthma control, and asthma exacerbations were evaluated.Results: In total, 323 patients (IND/MF high-dose, n = 107; IND/MF medium-dose, n = 106, SAL/FLU high-dose, n = 110) were included. IND/MF high-dose showed improvement in trough FEV₁ versus SAL/FLU high-dose at Weeks 26 (Δ, 42 mL; 95% CI, -35 to 120 mL), and 52 (Δ, 41 mL; 95% CI, -37 to 120 mL). IND/MF high-dose exhibited numerically greater improvement in ACQ-7 score versus SAL/FLU high-dose at Weeks 26 (Δ, -0.215; 95% CI, -0.385 to -0.044) and 52 (Δ, -0.176; 95% CI, -0.348 to -0.005). Improvements in trough FEV₁ and ACQ-7 score were comparable between IND/MF medium-dose and SAL/FLU high-dose. IND/MF high- and medium-dose showed reductions in moderate or severe (45%; 30%), severe (39%; 41%), and all (9%; 25%) exacerbations, respectively, versus SAL/FLU high-dose over 52 weeks. All treatments were well tolerated.Conclusions: Once-daily, single-inhaler IND/MF high-dose improved lung function with better asthma control, reduced asthma exacerbations with comparable safety versus twice-daily SAL/FLU high-dose. IND/MF medium-dose showed comparable outcomes to SAL/FLU high-dose at a reduced steroid dose.

Disease burden and treatment adherence among children and adolescent patients with asthma

OBJECTIVE

To assess asthma burden and medication adherence in a US de-identified patient level claims database.

METHODS

This retrospective observational study used the IQVIA PHARMETRICS PLUS database to identify patients aged 5-17 years, diagnosed with asthma between 01/01/2012-09/30/2017 (asthma cohort), and those initiating treatment with twice-daily inhaled corticosteroids (ICS) or twice-daily ICS/long-acting beta₂ agonists (LABA) (treatment cohorts; index date = first dispensing). Patient characteristics, asthma medication, and healthcare resource utilization were assessed over a 12-month baseline period. Treatment cohort endpoints were assessed in a 12-month follow-up period, including: adherence using proportion of days covered (PDC); persistence (no gap >45 days between dispensings).

RESULTS

The asthma cohort included 186,868 patients (112,689 children, mean age 7.9 years; 74,179 adolescents, mean age 14.3 years). During baseline, 34.5% used ICS or ICS/LABA, 24% used oral corticosteroids, 11.1% had ≥1 asthma-related emergency department visit, 2.2% had ≥1 asthma-related hospitalization. Among treatment cohorts, 47,276 and 10,247 patients initiated twice-daily ICS and ICS/LABA, respectively (mean ages: 9.9; 12.5 years). Mean PDC adherence to twice-daily ICS and ICS/LABA was 30% and 34% at 6 months (PDC ≥0.8: 4.3%; 6.1%); 21% and 24% at 12 months (PDC ≥0.8: 1.8%; 2.8%). Persistence with twice-daily ICS and ICS/LABA was 10.1% and 14.2% at 6 months; 5.6% and 8.0% at 12 months.

CONCLUSIONS

A large disease burden and unmet need exist among US children/adolescent asthma patients, evidenced by low use of, and poor adherence to, ICS-containing medication, the notable proportion of oral corticosteroid users, and higher-than-expected asthma-related emergency department and hospitalization rates.

Overview of severe asthma, with emphasis on pediatric patients: a review for practitioners

Asthma is the most common life-threatening chronic disease in children. Although guidelines exist for the diagnosis and treatment of asthma, treatment of severe, pediatric asthma remains difficult. Limited studies in the pediatric population on new asthma therapies, complex issues with adolescence and adherence, health disparities, and unequal access to guideline-based care complicate the care of children with severe, persistent asthma. The purpose of this review is to provide an overview of asthma, including asthma subtypes, comorbidities, and risk factors, to discuss diagnostic considerations and pitfalls and existing treatments, and then present existing and emerging therapeutic approaches to asthma management. An improved understanding of asthma heterogeneity, clinical characteristics, inflammatory patterns, and pathobiology can help further guide the management of severe asthma in children. More studies are needed in the pediatric population to understand emerging therapeutics application in children. Effective multimodal strategies tailored to individual characteristics and a commitment to address risk factors, modifiers, and health disparities may help reduce the burden of asthma in the USA.

Analysis of gaps in feline ectoparasiticide purchases from veterinary clinics in the United States

Background

The study objective was to examine cat owner ectoparasiticide purchases in the United States and estimate the impact of purchase gaps on timely ectoparasite protection administration. These purchase gaps lead to periods of time when cats are unprotected from ectoparasites.

Methods

Ectoparasiticide purchase transactions for individual cats from 671 U.S. veterinary clinics from January 1, 2017 through June 30, 2019 were evaluated to determine time “gaps” between doses of ectoparasiticides purchased in a defined 12-month period. Ectoparasiticides examined were topically applied products that contained fluralaner, fipronil/(S)-methoprene/pyriproxyfen, imidacloprid/pyriproxyfen or selamectin as active ingredients. The duration of protection following administration of one dose was 8–12 weeks for the fluralaner-containing product and one month for the other products.

Results

Ectoparasiticide purchase records were obtained from 114,853 cat owners and analysis found that most owners bought ≤ 6 months of protection during the year, with 61–75% (depending on the product) purchasing just 1–3 months of protection. The size of the average purchase gap was determined for all dose combinations out to 12 months of protection (5–7 doses for fluralaner and 12 doses for the other three products dosed monthly. The largest gaps occurred between the first and second doses and the second and third doses. Average purchase gaps for the four different products between doses 1 and 2 ranged from 11.2 to 13.9 weeks and between doses 2 and 3 ranged from 7.7 to 12.2 weeks. The fraction of purchases separated by gaps and the average length of the gap tended to decrease with increasing number of doses purchased. Owners purchasing the 8 to 12-week duration product containing fluralaner provided ectoparasite protection (“doses plus gap period”) for a larger proportion of each 2-dose period compared with owners purchasing products administered monthly.

Conclusions

When cat owners purchase flea and tick medication, gaps between subsequent purchases reduces the proportion of time ectoparasite protection can be provided. The duration of the gap between doses has an impact on the effectiveness of flea/tick medication because it inserts a period without flea and tick protection between doses of flea and tick medication. The gaps between purchases were shorter and the period of ectoparasite protection was larger for owners purchasing a 12-week product than for owners purchasing a monthly product.

Efficacy and safety of fevipiprant in patients with uncontrolled asthma: Two replicate, phase 3, randomised, double-blind, placebo-controlled trials (ZEAL-1 and ZEAL-2)

BACKGROUND

These studies assessed the efficacy and safety of fevipiprant, an oral antagonist of the prostaglandin D₂ (PGD₂) receptor (DP₂), compared with placebo when added to standard-of-care (SoC) asthma therapy in patients with uncontrolled asthma.

METHODS

ZEAL-1 (NCT03215758) and ZEAL-2 (NCT03226392) are two replicate, phase 3, multicentre, randomised, double-blind, placebo-controlled, parallel-group studies in which fevipiprant 150 mg once daily (o.d.) or placebo was added to SoC asthma therapy in patients aged ≥12 years with uncontrolled asthma. Primary endpoint: change from baseline in pre-dose forced expiratory volume in 1 s (FEV₁) after 12 weeks' treatment. Key secondary endpoints: daytime asthma symptom score, short-acting β-agonist (SABA) use and Asthma Quality-of-Life Questionnaire (AQLQ+12) score after 12-weeks treatment.

FINDINGS

662 patients in ZEAL-1 and 685 patients in ZEAL-2 completed the treatment period. In ZEAL-1, the least squares (LS) mean change from baseline in pre-dose FEV₁ was 112 mL in fevipiprant vs 71 mL in placebo group (difference [∆]:41 mL; 95% CI: -6, 88; adjusted p-value 0·088). In ZEAL-2, the LS mean change in pre-dose FEV₁ was 126 mL and 157 mL in the fevipiprant and placebo groups, respectively (∆:-31 mL; 95% CI: -80, 18; adjusted p-value 0·214). For both studies, there were no statistically significant differences in the key secondary objectives between the treatment groups.

INTERPRETATION

The ZEAL studies did not demonstrate significant improvement in lung function or other clinical outcomes. These results suggest that DP₂ receptor inhibition with fevipiprant is not effective in the studied patient population.

Lung function improvements following inhaled indacaterol/glycopyrronium/mometasone furoate are independent of dosing time in asthma patients: a randomised trial

Once-daily asthma treatment should prevent night-time deterioration, irrespective of the time of dosing. IND/GLY/MF, a fixed-dose combination of inhaled indacaterol acetate (IND, long-acting β₂-agonist (LABA)), glycopyrronium bromide (GLY, long-acting muscarinic antagonist) and mometasone furoate (MF, inhaled corticosteroid (ICS)) delivered by Breezhaler, is indicated in adult asthma patients inadequately controlled on LABA/ICS.

A randomised, double-blind, placebo-controlled, three-period, crossover, phase II study was performed to investigate the bronchodilator effect of IND/GLY/MF (150/50/80 μg) dosed morning and evening versus placebo in patients with mild-moderate asthma. The primary end-point was weighted mean forced expiratory volume in 1 s (FEV₁) over 24 h following 14 days of IND/GLY/MF dosed a.m. and p.m. versus placebo. Secondary end-points included the effect of dosing time on peak expiratory flow (PEF) and safety/tolerability.

Of 37 randomised patients (age 18–72 years; 21 male, 16 female) 34 completed all three treatment periods. At screening, median (range) pre-bronchodilator FEV₁ was 75.8% (60–96%). Patients were using stable low- (83.8%) or medium-dose (16.2%) ICS. Morning and evening dosing of IND/GLY/MF improved FEV₁ (area under the curve from 0 to 24 h) by 610 mL (90% CI 538–681 mL) and 615 mL (90% CI 544–687 mL), respectively, versus placebo. Mean PEF over 14 days increased by 70.7 L·min⁻¹ (90% CI 60.5–80.9 L·min⁻¹) following a.m. dosing, and by 59.7 L·min⁻¹ (90% CI 49.5–69.9 L·min⁻¹) following p.m. dosing of IND/GLY/MF versus placebo. IND/GLY/MF demonstrated a safety profile comparable with placebo.

Once-daily inhaled IND/GLY/MF was well tolerated and provided sustained lung function improvements over 24 h, irrespective of a.m. or p.m. dosing, in patients with mild–moderate asthma.

This randomised study found single-inhaler indacaterol/glycopyrronium/mometasone furoate improved respiratory parameters FEV₁ and PEF in asthma patients, and showed similar efficacy when taken once daily in the morning or eveninghttps://bit.ly/3fH0I1K

Medication adherence/persistence among patients with active multiple sclerosis in Finland

Objectives

To explore adherence, persistence, and treatment patterns in patients with multiple sclerosis (MS) in Finland treated with disease‐modifying therapies (DMTs) for active MS in 2005‐2018.

Materials and Methods

The study cohort was identified using the Drug Prescription Register of Social Insurance Institute, Finland. All patients had at least one prescription of glatiramer acetate (GA), beta‐interferons, teriflunomide, or delayed‐release dimethyl fumarate (DMF). Adherence was calculated using proportion of days covered (PDC) (cutoff ≥0.8). Time to non‐persistence was calculated by the number of days on index DMT treatment before the first treatment gap (≥90 days) or switch and analyzed with time‐to‐event methodology.

Results

The cohort included 7474 MS patients (72.2% female; mean age 38.9 years). Treatment switches were steady over 2005‐2012, peaked in 2015. PDC means (standard deviations) were GA, 0.87 (0.17); beta‐interferons, 0.88 (0.15); DMF, 0.89 (0.14); teriflunomide, 0.93 (0.10). Adherence frequencies were GA, 78.4%; beta‐interferons, 81.3%; DMF, 86.9%; teriflunomide, 91.7%. Logistic regression showed that age group, DMT and the starting year, sex, and hospital district independently affected adherence. Patients receiving teriflunomide and DMF, males, and older patients were more likely to persist on treatment. There was no difference in persistence between patients prescribed teriflunomide and DMF, or between GA and beta‐interferons.

Conclusions

Oral DMTs had greater adherence and persistence than injectable DMTs.

Qualitative Study of Practices and Challenges of Stepping Down Asthma Medication in Primary Care Across the UK

Background

Guidelines recommend that asthma treatment should be stepped down to the minimally effective dose that achieves symptom control to prevent medication side effects and reduce unnecessary costs. Little is known about the practice of stepping down and the challenges in primary care, where most asthma patients are managed.

Objective

To explore views, experiences, barriers and ideas, of doctors, nurses and pharmacists working in primary care, related to step down of asthma medication.

Methods

Primary care practitioners from across the UK participated in a survey and/or semi-structured interview. Questions explored four main areas: how asthma medication is reviewed, views on asthma guidelines, perceived barriers faced by healthcare workers and facilitators of stepping down. Qualitative content analysis enabled data coding of interview transcripts to identify major themes.

Results

A total of 274 participants responded to the survey, 29 participated in an interview (12 doctors, 9 nurses, and 8 pharmacists), working in GP practices from across the UK. Nearly half of the survey participants infrequently step down asthma medication (doctors=42.7%, nurses=46.3%). Four major themes related to barriers to stepping down were (i) lack of awareness of the need to step down, (ii) inertia to step down, driven by low confidence in ability, fear of consequences, and concern for who is responsible for stepping down, (iii) self-efficacy of ability to step down, influenced by lack of clear, applied guidance and limited training, and (iv) feasibility of step down, driven by a lack of systematic acceptance of stepping down and time. Strategies proposed to reduce overtreatment included education and training, improved gathering of evidence and guidance, and integrating step down into routine asthma care.

Conclusion

Failure to implement this guideline recommendation into everyday asthma management is influenced by several contributing factors. Future directions should include addressing evidence gaps, implementing clear and practical guidance, integration of step-down assessment into the asthma review, and education of professionals and patients.

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.