Inhaled corticosteroids usage: the behaviors behind the estimates

Published Online: November 1, 2016

Long-term inhaled corticosteroids (ICS) are often prescribed to help achieve asthma control. Their regular use, as prescribed by physicians, is important in achieving optimal clinical outcomes. In real-life, however, patients do not always take their ICS in exactly the manner recommended by their physician. Understanding patients’ ICS usage helps clinicians understanding whether persistent symptoms may be the result of more severe asthma or the result of low/suboptimal use of prescribed therapy. This knowledge can assist in shared decision making, where clinicians work with patients to understand their attitudes to treatment and reach joint agreement on the most acceptable, efficacious therapy available.

Electronic healthcare records (EHR) can be used to find out how patients use their ICS and whether they adhere to the recommended medication plan. EHR-based adherence studies, however, seldom differentiate between two distinct aspects of usage—less frequent use than recommended (“implementation”) and cessation of use (“discontinuation”)— and their associated determinants and clinical outcomes.

In a recent article by Souverein and colleagues  in The Journal of Allergy and Clinical Immunology: In Practice, United Kingdom electronic prescription records from almost 14,000 patients with asthma were used to compare different measures of ICS adherence and what these offer in terms of differentiating between suboptimal implementation and discontinuation. The authors found that patients often alternate between regular and variable ICS implementation, and, perhaps reflecting the variable nature of asthma, can even discontinue completely for several months. When the authors considered only episodes of active use (frequent or variable), ICS implementation estimates were relatively high  (~90%). Yet these estimates were much lower (~60%), more closely reflecting those in the published literature, when averaged over periods including episodes of discontinuation. The results indicate that published adherence estimates may mask distinct and different adherence behaviors. Discontinuation and implementation need to be disentangled and addressed separately by clinicians to understand better their patients’ adherence behaviors and work with them to optimize treatment choice and usage, and by researchers to improve understanding of the different causes and consequences of these two patterns of non-adherence.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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