Prevent Treatment Nonadherence in Asthma, COPD: Build Strong Patient Relationships

The authors noted that several promising approaches for increasing adherence warrant further investigation. These include patient empowerment strategies such as motivational interviewing, patient education, training of healthcare providers, and electronic and digital tools.

To learn more about the reasons for nonadherence, related consequences, and potential solutions, Pulmonology Advisor interviewed Marc C. Gauthier, MD, a clinical and research instructor associate in the Division of Pulmonary, Allergy and Critical Care Medicine at the University of Pittsburgh in Pennsylvania.

Pulmonology Advisor: What are some of the problems associated with nonadherence to medication regimens in asthma and COPD?

Dr Gauthier: There are several. One of the most common is cost — these are often medications with significant costs for the patient in terms of high copays. As such, patients are often eager to stop using these medications, or may try to stretch an inhaler’s life by using it less frequently to minimize their out-of-pocket expenses.

A second problem regarding adherence is lack of perceived benefit. While patients often get quick relief of symptoms with rescue inhalers, controller inhalers are longer acting with slower onset of action. These inhalers provide good results over time but may not provide effective short-term relief. Patients may misconstrue the lack of immediate relief with lack of efficacy, making them less likely to use the medication, particularly in the setting of the high costs of these medications.

Furthermore, side effects from these medications, such as thrush and hoarseness, may affect the patient significantly and need to be monitored. Finally, inhaler technique is a common form of nonadherence. While patients may use their medications as indicated, poor technique can drop the effective dose significantly, even in patients who take their medications exactly when they are supposed to. This can lead to effective noncompliance despite a patient using the medication as directed.

Pulmonology Advisor: What are potential solutions that may help improve adherence?

Dr Gauthier: There is not much one can do about the cost of these medications, but we try to use inhalers that are the lowest cost to the patient to minimize this issue. Unless we have a reason to use a particular inhaler, we prefer to use whichever option has the best coverage for that patient’s insurance. For patients who struggle with twice-daily dosing, once-daily dosed inhalers may be a better option.

It is important to establish a relationship with patients to improve their understanding of the disease and the goals and expectations of treatment. We emphasize that controller inhaler medications work over time, and the benefits are seen only with continued use. We try to set reasonable expectations for the effects of these medications and explain that benefit may be seen in decreased exacerbations and rescue medication need even if it may not be appreciated in day-to-day symptoms. 

Finally, we emphasize inhaler teaching in every new patient we see in our practice and every time we switch inhalers to make sure patients have optimal technique when they leave the clinic. This routine approach to inhaler teaching helps to ensure proper inhaler use without making patients feel singled out for being unable to correctly use their inhalers, which are often difficult devices to master without good teaching.

Pulmonology Advisor: What should be next steps in this area in terms of research or otherwise?

Dr Gauthier: New devices are being launched to assist patients with medication adherence. There are emerging tools for patients to track inhaler use and to set up reminders on a computer or smartphone to take their inhalers. Unfortunately, there is still a segment of patients with severe asthma who continue to lack effective therapies, and ongoing research on their underlying pathology will hopefully identify new targets for future drug therapies.

Pulmonology Advisor: Are there any additional key takeaways that you would like to note for clinicians?

Dr Gauthier: We always emphasize with our patients that asthma is a chronic disease, and management takes time and patience. Building a strong relationship with patients is key to getting patient buy-in to treatment and ensuring that patients will call into the office with issues rather than self-discontinuing medications when problems arise. Finally, this relationship is important in setting and achieving treatment goals with the patient.

References

1. World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003.
2. Belleudi V, Di Martino M, Cascini S, et al. The impact of adherence to inhaled drugs on 5-year survival in COPD patients: a time dependent approach. Pharmacoepidemiol Drug Saf. 2016;25(11):1295-1304.
3. Dekhuijzen R, Lavorini F, Usmani OS, van Boven JFM. Addressing the impact and unmet needs of nonadherence in asthma and chronic obstructive pulmonary disease: where do we go from here? [published online January 12, 2018]. J Allergy Clin Immunol Pract. doi:10.1016/j.jaip.2017.11.027
4. Horne R. Compliance, adherence, and concordance: implications for asthma treatment. Chest. 2006;130(1 Suppl):65S-72S.
5. Costello RW, Foster JM, Grigg J, et al. The seven stages of man: the role of developmental stage on medication adherence in respiratory diseases. J Allergy Clin Immunol Pract. 2016;4(5):813-820.
6. Levy ML, Hardwell A, McKnight E, Holmes J. Asthma patients’ inability to use a pressurised metered-dose inhaler (pMDI) correctly correlates with poor asthma control as defined by the Global Initiative for Asthma (GINA) strategy: a retrospective analysis. Prim Care Respir J. 2013;22(4):406-411.
7. Williams LK, Peterson EL, Wells K, et al. Quantifying the proportion of severe asthma exacerbations attributable to inhaled corticosteroid nonadherence. J Allergy Clin Immunol. 2011;128(6):1185-1191.e2.
8. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011;105(6):930-938.
9. Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respir Care. 2005;50(10):1360-1375.