Adherence: The Goal to Control Asthma

doi:10.1016/j.ccm.2012.06.002

Clinics in Chest Medicine

Volume 33, Issue 3, September 2012, Pages 405-417

https://doi.org/10.1016/j.ccm.2012.06.002 Get rights and content

Introduction

Asthma is a chronic condition that requires sufficient adherence to preventative and therapeutic interventions to achieve adequate control of the disease.¹ Control of asthma can be defined as minimal or no symptoms, optimal pulmonary function, few/no exacerbations, and the ability to enjoy normal activities.² Asthma control is the main goal of asthma therapy, but in order to achieve this it is crucial that the patient agrees with the diagnosis and is willing to follow the recommendations provided. This situation is particularly true for patients with severe asthma requiring polypharmacology, sometimes with potentially significant side effects.³

Optimal medication adherence (ie, taking medication as prescribed by the physician) is important to optimize the benefits of therapy. Timely modulation of dose strength by the physician according to the severity and variability of the disease is needed to ensure that asthma control is maintained. The treatment can be adjusted by the patient or caregiver with the guidance of an agreed written asthma action plan, but poor adherence can also apply to the use of written asthma action plans as well as environmental recommendations (eg, allergen avoidance) and follow-up visits. Poor inhaler technique is also a common form of unintentional poor adherence.⁴

This article focuses on medication adherence. The criteria proposed to define medication adherence and its various patterns are discussed, current research on adherence in asthma and its effects on asthma control is reviewed, and determinants and predictors of poor adherence are identified. Available methods of assessing adherence are reviewed, as well as interventions that could improve it. Future perspectives and research needs are discussed.

Section snippets

Definition of adherence to asthma therapy

Adherence, a term sometimes used interchangeably with compliance, observance, or concordance, describes the extent to which patients' medication-taking behavior is in keeping with the prescription provided.⁵ Adherence includes 3 specific components: (1) acceptance of the recommendation (the patient agrees to take the medication/follow the recommendation), (2) observance of the prescription (the patient uses the treatment as suggested by the physician), and (3) persistence (the extent to which

Studies of large asthmatic populations

Studies in large Health Maintenance Organization (HMO) populations confirm high rates of nonadherence in asthma, although the data are limited to dispensed prescriptions and do not take into account prescribing that deviates from current guidelines. Williams and colleagues¹³ studied 405 adults aged 18 to 50 years, in an HMO in Michigan over a period of 3 years. Adherence to ICS, calculated as a percentage of days covered between 2 prescription refills, was approximately 50%. Poor adherence was

Poor adherence in childhood asthma

A review of 10 studies in pediatric asthma reported a mean adherence rate of 48% for controller medication,¹⁹ and more recently, a survey study²⁰ found that only 55% of children with persistent asthma reported using daily preventative medication. In a cohort study involving 42 primary care practices in 3 regions of the United States and 638 children (mean age 9.4 years), one-third of children prescribed daily controllers used them 4 days or fewer per week.²¹ Children with suboptimally

Poor adherence with oral corticosteroids

Adherence with oral corticosteroids is also suboptimal. Cooper and Hickson²⁵ found that of 6035 children under the care of Medicaid, who attended the emergency department or were hospitalized for an exacerbation of asthma, only about half were supplied with oral corticosteroids in the days after the event, and this was even lower in black children (47%) compared with 64% in other populations.

Poor adherence in difficult-to-control asthma and after acute asthma

Poor adherence to oral and inhaled corticosteroid therapy seems to be a common reason for poor asthma control in difficult asthma, although patients may be reluctant to admit it. Gamble and colleagues²⁶ found that despite initial denial, 35% of patients with difficult asthma (63 of 188) filled 50% or fewer prescriptions of controller medication. Patients who filled 50% or fewer prescriptions had significantly lower asthma quality-of-life (QoL) scores and 25% of these patients had 3 or more

Education

Providing the patient and family with a rationale for treatment recommendations, benefits versus potential side effects, and side effect management tools can promote adherence. Asthma education can include53, 54, 55, 56, 57 the delivery of written materials by a health care professional, teaching self-management skills, telephone follow-up, individual versus educational group sessions, involvement of support groups, medication adherence monitoring and feedback, counseling, and inhaler technique

Perspectives and future research

The design and methodology of future studies can be improved, and the measurement of clinical outcomes and objective adherence rates should be included in all new research. The dichotomy of good adherence/poor adherence using arbitrary cut points may be insensitive to variations over time and proportionally large changes may be misinterpreted; for example, an intervention may be considered effective if a patient doubles adherence from 10% to 20%. Although short-term improvements are beneficial,

Summary

Poor adherence is a major problem and often results in inadequate use of treatments, insufficient control of the disease, and increased health care use and costs. It has many determinants, including suboptimal knowledge of the disease and its treatment, lack of self-management skills, and insufficient or ineffective interventions or communication. Despite extensive research on poor adherence, and many novel interventional approaches, a practical and definitive solution remains elusive and

First page preview

Click to open first page preview

View PDF

References (91)

P. Chanez et al.
Severe asthma in adults: what are the important questions?
J Allergy Clin Immunol
(2007)
H. Milgrom et al.
Noncompliance and treatment failure in children with asthma
J Allergy Clin Immunol
(1996)
C.R. Horn et al.
Compliance with inhaled therapy and morbidity from asthma
Respir Med
(1990)
S.L. Spector et al.
Compliance of patients with asthma with an experimental aerosolized medication: implications for controlled clinical trials
J Allergy Clin Immunol
(1986)
M.G. Cochrane et al.
Inhaled corticosteroids for asthma therapy: patient compliance, devices, and inhalation technique
Chest
(2000)
L.K. Williams et al.
Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma
J Allergy Clin Immunol
(2004)
L.K. Williams et al.
Patients with asthma who do not fill their inhaled corticosteroids: a study of primary nonadherence
J Allergy Clin Immunol
(2007)
B.G. Bender et al.
Adherence and persistence with fluticasone propionate/salmeterol combination therapy
J Allergy Clin Immunol
(2006)
G.B. Diette et al.
Consistency of care with national guidelines for children with asthma in managed care
J Pediatr
(2001)
N. Walders et al.
Patterns of quick-relief and long-term controller medication use in pediatric asthma
J Pediatr
(2005)

S.Z. Bosnic-Anticevich et al.

Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time

J Asthma

(2010)

B. Bender et al.

Asthma

J.M. Foster et al.

Treatment adherence and psychosocial factors

B. Bender et al.

Nonadherence in asthmatic patients: is there a solution to the problem?

Ann Allergy Asthma Immunol

(1997)

M.M. Sockrider et al.

Helping patients better adhere to treatment regimen

J Respir Dis

(1996)

R.W. Watts et al.

Do patients with asthma fill their prescriptions? A primary compliance study

Aust Fam Physician

(1997)

J.M. Bronstein et al.

The use of Medicaid claims as a supplementary source of information on quality of asthma care

J Healthc Qual

(2000)

R.K. Kandane-Rathnayake et al.

Adherence to asthma management guidelines by middle-aged adults with current asthma

Thorax

(2009)

T.L. Creer

Medication compliance and childhood asthma

P. Lozano et al.

Asthma medication use and disease burden in children in a primary care population

Arch Pediatr Adolesc Med

(2003)

S.C. Ranganathan et al.

Difficult asthma: defining the problems

Pediatr Pulmonol

(2001)

N.J. Spurrier et al.

Association between parental perception of children's vulnerability to illness and management of children's asthma

Pediatr Pulmonol

(2000)

W.O. Cooper et al.

Corticosteroid prescription filling for children covered by Medicaid following an emergency department visit or a hospitalization for asthma

Arch Pediatr Adolesc Med

(2001)

J. Gamble et al.

The prevalence of nonadherence in difficult asthma

Am J Respir Crit Care Med

(2009)

J.A. Krishnan et al.

Corticosteroid use after hospital discharge among high-risk adults with asthma

Am J Respir Crit Care Med

(2004)

B.A. Briesacher et al.

Comparison of drug adherence rates among patients with seven different medical conditions

Pharmacotherapy

(2008)

J.M. Foster et al.

Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma

Intern Med J

(2012)

Cited by (146)

The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today
2024, Journal of Allergy and Clinical Immunology: In Practice
The Global Initiative for Asthma (GINA) recommends that short-acting β₂-agonist (SABA) monotherapy should no longer be prescribed, and that as-needed combination inhaled corticosteroids (ICS)–formoterol is the preferred reliever therapy in adults and adolescents with mild asthma. These recommendations are based on the risks of SABA monotherapy, the evidence that ICS-formoterol reliever therapy markedly decreases the occurrence of severe asthma exacerbations compared with SABA reliever therapy alone, and because ICS-formoterol reliever therapy has a favorable risk/benefit profile compared with maintenance ICS plus SABA reliever therapy. Data supporting the use of combination ICS-albuterol reliever therapy in mild asthma are more limited, but there are studies that inform its use in this population. In this review, we compare, using a pros and cons format, the (1) long-term safety and efficacy of ICS-formoterol reliever therapy versus SABA reliever therapy alone, (2) long-term safety and efficacy of ICS-albuterol reliever therapy versus SABA reliever therapy alone, (3) immediate bronchodilator effects of ICS-formoterol versus SABA alone, and (4) clinical and regulatory factors that may inform reliever therapy prescription decisions. By presenting the evidence of these reliever inhaler options, we hope to inform the reader while also calling for necessary future effectiveness and implementation research.
GEMA 5.3. Spanish Guideline on the Management of Asthma
2023, Open Respiratory Archives
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide.
Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists.
Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
La Guía Española para el Manejo del Asma, mejor conocida por su acrónimo en español, GEMA, está a nuestra disposición desde hace más de veinte años. Veintiuna sociedades científicas o grupos relacionados, tanto de España como de otros países, han participado en la preparación y desarrollo de la edición actualizada de GEMA que, de hecho, se ha posicionado en la actualidad a nivel mundial como la guía de referencia sobre asma en lengua española.
Su objetivo es prevenir y mejorar la situación clínica de las personas con asma, aumentando el conocimiento de los profesionales sanitarios involucrados en su cuidado. Su propósito es convertir la evidencia científica en recomendaciones prácticas sencillas y fáciles de seguir. Por lo tanto, no se trata de una monografía que reúna todo el conocimiento científico sobre la enfermedad, sino más bien de un documento conciso con lo esencial, diseñado para ser aplicado rápidamente en la práctica clínica de rutina. Las recomendaciones son necesariamente multidisciplinares, están desarrolladas para ser útiles y una herramienta indispensable para médicos de diferentes especialidades, así como para profesionales de enfermería y farmacia.
Seguramente, los aspectos más destacados de la guía son las recomendaciones para: establecer el diagnóstico del asma utilizando un algoritmo secuencial basado en pruebas diagnósticas objetivas; el seguimiento de los pacientes, preferentemente basado en la estrategia de lograr y mantener el control de la enfermedad; el tratamiento según el nivel de gravedad del asma utilizando seis escalones, desde la menor hasta la mayor necesidad de medicamentos, y el algoritmo de tratamiento basado en fenotipos para la indicación de biológicos en pacientes con asma grave no controlada. A esto se suma ahora una novedad para su fácil uso y seguimiento a través de una aplicación informática basada en la inteligencia artificial conversacional de tipo chatbot (ia-GEMA).
Airway hyperresponsiveness reflects corticosteroid-sensitive mast cell involvement across asthma phenotypes
2023, Journal of Allergy and Clinical Immunology
Airway hyperresponsiveness is a hallmark of asthma across asthma phenotypes. Airway hyperresponsiveness to mannitol specifically relates to mast cell infiltration of the airways, suggesting inhaled corticosteroids to be effective in reducing the response to mannitol, despite low levels of type 2 inflammation.
We sought to investigate the relationship between airway hyperresponsiveness and infiltrating mast cells, and the response to inhaled corticosteroid treatment.
In 50 corticosteroid-free patients with airway hyperresponsiveness to mannitol, mucosal cryobiopsies were obtained before and after 6 weeks of daily treatment with 1600 μg of budesonide. Patients were stratified according to baseline fractional exhaled nitric oxide (Feno) with a cutoff of 25 parts per billion.
Airway hyperresponsiveness was comparable at baseline and improved equally with treatment in both patients with Feno-high and Feno-low asthma: doubling dose, 3.98 (95% CI, 2.49-6.38; P < .001) and 3.85 (95% CI, 2.51-5.91; P < .001), respectively. However, phenotypes and distribution of mast cells differed between the 2 groups. In patients with Feno-high asthma, airway hyperresponsiveness correlated with the density of chymase-high mast cells infiltrating the epithelial layer (ρ, −0.42; P = .04), and in those with Feno-low asthma, it correlated with the density in the airway smooth muscle (ρ, −0.51; P = .02). The improvement in airway hyperresponsiveness after inhaled corticosteroid treatment correlated with a reduction in mast cells, as well as in airway thymic stromal lymphopoietin and IL-33.
Airway hyperresponsiveness to mannitol is related to mast cell infiltration across asthma phenotypes, correlating with epithelial mast cells in patients with Feno-high asthma and with airway smooth muscle mast cells in patients with Feno-low asthma. Treatment with inhaled corticosteroids was effective in reducing airway hyperresponsiveness in both groups.
The ICS/Formoterol Reliever Therapy Regimen in Asthma: A Review
2023, Journal of Allergy and Clinical Immunology: In Practice
The Global Initiative for Asthma recommends that low-dose inhaled corticosteroid (ICS)/formoterol be preferred to short-acting beta₂-agonists as reliever therapy in adolescents and adults with asthma, across the range of asthma severity. This recommendation represents the most fundamental change in asthma management for many decades. In this commentary, we review the rationale for combination ICS/formoterol therapy, the evidence on which this recommendation has been made, the limitations in the evidence, the practical issues relevant to the implementation of ICS/formoterol reliever-based regimens in clinical practice, and the emerging evidence for the efficacy and safety of combination ICS/salbutamol reliever therapy regimens.
Guanosine and uridine alleviate airway inflammation via inhibition of the MAPK and NF-κB signals in OVA-induced asthmatic mice
2021, Pulmonary Pharmacology and Therapeutics
Citation Excerpt :
Apart from having devastating effects on select individual patients, asthma also causes enormous societal burdens [2,3]. Inhaled corticosteroids (ICS) are the mainstay maintenance treatment for most patients, but the compliance of ICS is somewhat poor in both children and adults [4] and a certain proportion of patients are glucocorticoid resistant [5]. In some patients’ minds, the short-acting β2 agonist (SABA) is safer and cheaper than ICS, and therefore more acceptable to them.
Asthma is one of the most common respiratory diseases. Lack of response or poor adherence to corticosteroids demands the development of new drug candidates for asthma. Endogenous nucleosides could be potential options since uridine has been reported to have an anti-inflammatory effect in asthma model. However, its molecular pathways and whether other nucleosides have similar therapeutic effects remain untouched. Thus, we herein report our investigation into the anti-inflammatory effects of guanosine and uridine, and the related inner signaling pathways in asthma model. Present study shows that administration of guanosine or uridine can reduce lung inflammation in OVA-challenged mice. Total cell counts in BALF, cytokines such as IL-4, IL-6, IL-13, OVA-specific IgE and mRNA level of Cxcl1, Cxlc3, IL-17 and Muc5ac were decreased in asthmatic mice after treatment. Besides, the production of IL-6 in LPS/IFN-γ induced THP-1 cells was also decreased by both nucleosides. In vivo and in vitro expressions of key molecules in the MAPK and NF-κB pathways were reduced after the treatment of both compounds. These findings suggest that guanosine has a similar potential therapeutic value in asthma as uridine and they exert anti-inflammatory effects through suppression of the MAPK and NF-κB pathways.
Predictors of Asthma Control and Exacerbations: A Real-World Study
2021, Journal of Allergy and Clinical Immunology: In Practice
Achieving optimal asthma control and minimizing the risk of exacerbation are the main goals of asthma treatment.
This study aimed to assess the predictors of poor asthma control and asthma exacerbations within a population of moderate to severe asthmatic patients treated in a tertiary-care center.
We conducted a cohort study assessing 738 patients enrolled in the Quebec registry in respiratory health (RESP) with a diagnosis of asthma confirmed by a respirologist and treated in a tertiary care center from April 2010 to March 2016. Sociodemographic and clinical data, including Asthma Control Questionnaire score, were collected at enrollment in the registry (ie, cohort entry) and patients were followed for a 2-year period thereafter. The information regarding exacerbations that occurred during follow-up was collected in administrative databases (Régie d l’assurance médicale du Québec [RAMQ], Maintenance et exploitation des données pour l‘étude de la clientèle hospitalière [MED-ECHO], and medication data registry [reMed]).
We assessed 738 subjects (64% women). Psychological distress (odds ratio [OR] 1.91; 95% confidence interval [95% CI] 1.21-3.02), smoking (OR 3.72; 95% CI 1.72-8.05]), and poor lung function, forced expiratory volume in 1 second less than 50% (OR 4.1; 95% CI 1.48-11.34]) appeared as significant factors associated with uncontrolled asthma. Occurrence of previous asthma exacerbations (hazard ratio [HR] 6.25; 95% CI 4.01-9.75]), poor asthma control (HR 1.60; 95% CI 1.07-2.38]), forced expiratory volume in 1 second between 50% and 80% (HR 2.25; 95% CI 1.58-3.34]), and older age (HR 2.26; 95% CI 1.37-3.74]) were associated with asthma exacerbations. Adherence to asthma treatment was very low in patients with (44.4% ± 34.4%) and without asthma exacerbations (37.5% ± 33.0%).
Psychological distress and current smoking are modifiable factors that need to be addressed in tailored behavioral interventions to improve asthma control. Asthma exacerbations are mostly associated with the intrinsic severity of the disease.

View all citing articles on Scopus

: Disclosure: LPB: Advisory Boards: AstraZeneca, GlaxoSmithKline, Merck, and Novartis. Lecture fees: 3M, AstraZeneca, GlaxoSmithKline, Merck, and Novartis. Sponsorship for investigator-generated research: AstraZeneca, GSK, Merck, and Schering. Research funding for participating in multicenter studies: Altair, Asmacure, AstraZeneca, Boehringer-Ingelheim, Genentech, GlaxoSmithKline, Pharmaxis, Schering, Wyeth. Support for the production of educational materials: AstraZeneca, GlaxoSmithKline, and Merck Frosst. Governmental: Adviser for the Quebec INNESS. Organizational: Chair of the Canadian Thoracic Society Respiratory Guideline Committee and chair of GINA Guidelines Dissemination and Implementation Committee. Laval University Chair on Knowledge Translation, Prevention and Education in Respiratory and Cardiovascular Health. Member Knowledge Translation Canada (Canadian Institutes of Health Research). DV: GlaxoSmithKline, AstraZeneca, Stallergenes, ALK, MundiPharma. YM: Lecture or training sessions fees: AstraZeneca, GlaxoSmithKline, MSD. JMF: Research funding: AstraZeneca and Nycomed. Lecture fees: AstraZeneca, Pharmaceutical Society of Australia and GlaxoSmithKline.

View full text

Adherence: The Goal to Control Asthma

Introduction

Section snippets

Definition of adherence to asthma therapy

Studies of large asthmatic populations

Poor adherence in childhood asthma

Poor adherence with oral corticosteroids

Poor adherence in difficult-to-control asthma and after acute asthma

Education

Perspectives and future research

Summary

First page preview

J Allergy Clin Immunol

J Allergy Clin Immunol

Respir Med

J Allergy Clin Immunol

Chest

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Pediatr

J Pediatr

Chest

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

Chest

Soc Sci Med

Respir Med

Lancet

J Allergy Clin Immunol

Chest

Patient Educ Couns

Chest

J Allergy Clin Immunol

Patient Educ Couns

J Allergy Clin Immunol

Chest

J Allergy Clin Immunol

Global strategy for asthma management and prevention: GINA executive summary

Eur Respir J

An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice

Am J Respir Crit Care Med

Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time

J Asthma

Asthma

Treatment adherence and psychosocial factors

Nonadherence in asthmatic patients: is there a solution to the problem?

Ann Allergy Asthma Immunol

Helping patients better adhere to treatment regimen

J Respir Dis

Do patients with asthma fill their prescriptions? A primary compliance study

Aust Fam Physician

The use of Medicaid claims as a supplementary source of information on quality of asthma care

J Healthc Qual

Adherence to asthma management guidelines by middle-aged adults with current asthma

Thorax

Medication compliance and childhood asthma

Asthma medication use and disease burden in children in a primary care population

Arch Pediatr Adolesc Med

Difficult asthma: defining the problems

Pediatr Pulmonol

Association between parental perception of children's vulnerability to illness and management of children's asthma

Pediatr Pulmonol

Corticosteroid prescription filling for children covered by Medicaid following an emergency department visit or a hospitalization for asthma

Arch Pediatr Adolesc Med

The prevalence of nonadherence in difficult asthma

Am J Respir Crit Care Med

Corticosteroid use after hospital discharge among high-risk adults with asthma

Am J Respir Crit Care Med

Comparison of drug adherence rates among patients with seven different medical conditions

Pharmacotherapy

Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma

Intern Med J