Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children

Assessing Inhaled Corticosteroid Adherence and Responsiveness in Severe Asthma Using Beclometasone Dipropionate/Formoterol NEXThaler Dose-Counting and Nitric Oxide Monitoring

BACKGROUND

Sixty-five percent of people with severe asthma and a fractional exhaled nitric oxide (Feno) greater than or equal to 45 parts per billion (ppb) are nonadherent to inhaled corticosteroids (ICSs). Digital devices recording both time of use and inhaler technique identify nonadherence and ICS responsiveness but are not widely available. As the NEXThaler dose counter activates only at an inspiratory flow rate of 35 L/min, this may provide an alternative to identifying ICS responsiveness.

OBJECTIVE

To assess ICS adherence and responsiveness in severe asthma using beclometasone/formoterol (200/6 μg) NEXThaler (BFN) dose-counting.

METHODS

Patients with severe asthma with a Feno greater than or equal to 45 ppb were invited to use BFN in place of their usual ICS/long-acting β2-agonist. Feno, 6-item Asthma Control Questionnaire score, lung function, and blood eosinophil count were monitored for 3 months. A log10ΔFeno of greater than or equal to 0.24 was used to define Feno suppression as the primary marker of ICS responsiveness at day 28.

RESULTS

Twenty-seven of 48 (56%) patients demonstrated significant Feno suppression at month 1 (median pre-114, post-48 ppb, P < .001). A small but significant reduction occurred in Feno nonsuppressors. The 6-item Asthma Control Questionnaire score fell a median 1.2 units in Feno suppressors (P < .001) and 0.5 units in nonsuppressors (P = .025). These effects were sustained until month 3 in Feno suppressors, with a significant improvement in FEV1 and blood eosinophils. Sixty-seven percent (18 of 27) of those with baseline ICS/long-acting β2-agonist prescription refills of 80% or more were Feno suppressors, suggesting prior nonadherence despite adequate prescription collection. Seventy-nine percent of Feno suppressors did not require biologics within mean 11.4 months from initial dose counting.

CONCLUSIONS

BFN dose-counting identifies ICS responsiveness in severe asthma with the implication that these patients may not need to progress to biological therapies.

New Directions in Pediatric Asthma

Childhood asthma affects many children placing them at significant risk for health care utilization and school absences. Several new developments relevant to the field of pediatric asthma have occurred over the last 5 years; yet, there is much more to learn. It is poorly understood how to prevent the disease, optimally address environmental challenges, or effectively manage poor adherence. Moreover, it is not clear how to customize therapy by asthma phenotype, age group, high risk groups, or severity of disease. Highlights of advances in pediatric asthma are reviewed and multiple essential areas for further exploration and research are discussed.

Treatment Adherence in Young Children with Asthma

Treatment nonadherence in young children with asthma involves multiple factors and should be viewed within an ecological framework. Few interventions have targeted multiple bidirectional factors, however, and little research has examined which interventions may be most appropriate for young children. Additional research is needed to identify essential intervention components, and to determine how to sustain such interventions in at-risk communities. Pediatric psychologists, with training in psychosocial intervention, screening, and primary prevention models, may be uniquely equipped to partner with communities and medical settings to develop and sustain targeted interventions for young children with asthma.

Approaches to the assessment of severe asthma: barriers and strategies

Asthma is a chronic condition with great variability. It is characterized by intermittent episodes of wheeze, cough, chest tightness, dyspnea and backed by variable airflow limitation, airway inflammation and airway hyper-responsiveness. Asthma severity varies uniquely between individuals and may change over time. Stratification of asthma severity is an integral part of asthma management linking appropriate treatment to establish asthma control. Precision assessment of severe asthma is crucial for monitoring the health of people with this disease. The literature suggests multiple factors that impede the assessment of severe asthma, these can be grouped into health care professional, patient and organizational related barriers. These barriers do not exist in isolation but interact and influence one another. Recognition of these barriers is necessary to promote precision in the assessment and management of severe asthma in the era of targeted therapy. In this review, we discuss the current knowledge of the barriers that impede assessment in severe asthma and recommend potential strategies for overcoming these barriers. We highlight the relevance of multidimensional assessment as an ideal approach to the assessment and management of severe asthma.

Adherence to treatment in allergic respiratory diseases

Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice. Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence. Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.

Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children

Background: The metered-dose inhalers (MDIs) currently available for inhaled corticosteroid delivery do not offer an integrated dose counter; therefore, it is difficult to evaluate adherence of patients. The present authors developed a linear regression equation using canister weight to calculate the number of doses actuated from the MDIs. This study aimed to assess medical adherence after the integration of regular weighing of the canisters into the routine service.  Methods: A cohort study was carried out between May 2013 and April 2014. Children aged less than 8 years with a diagnosis of asthma were recruited. The duration of adherence assessment was 24 weeks. Participants had a regular schedule every 8 weeks to obtain a new FLIXOTIDE® 125 inhaler. Parents were asked to collect the discarded MDI canisters, which were then weighed by a laboratory scale. The weight of each canister was replaced in the regression equation to calculate the number of doses actuated from the MDIs.  Results: A total of 52 asthmatic children participated in the study. The median age was 52.7 months. At the end of 24 weeks, 44, 33, and 23 discarded MDI canisters were collected from visits 1, 2, and 3, respectively. The median percentages of adherence were 96.8%, 96.3%, and 96.3%, respectively. In 11 discarded canisters (11%), the remaining medication was more than 30% of the labeled doses. Approximately 90% of the participants had no asthma exacerbation during 24-week study period.  Conclusion: High adherence rates were achieved after integration of canister weighing into the asthma care service.