Non-adherence may cause 80% of asthmatics receiving unnecessarily heavy medication
Published online: December 17, 2019
In their treatment of people with asthma, most clinicians follow a step-wise approach, as recommended in national and international guidelines. In doing so, most people can control their asthma using a prescribed combination of an inhaled preventer (inhaled corticosteroid [ICS]) and a reliever (a long-acting beta-agonist [LABA]). However, a minority remains suffering from uncontrolled asthma despite the ICS/LABA. For these people, a physician can consider additional medication including oral corticosteroids and injectable biologics. As these additional treatments are often either more prone to severe side effects (OCS) or significantly more expensive (biologics), the physician should make a careful evaluation whether these additional treatments are really necessary. An important aspect is assessment of patient adherence to initial ICS/LABA therapy, i.e. are these treatment taken as prescribed or should this be optimized first.
In this study published in The Journal of Allergy and Clinical Immunology: In Practice, Van Boven et al. used the national Australian Pharmaceutical Benefits Scheme database to identify over 3,000 people that initiated ICS/LABA therapy and followed them for up to 3 years. At the end of follow-up, they assessed how many people had received additional medication including OCS, biologics and long-acting muscarinic antagonists (LAMA). Subsequently, they divided the total cohort in different groups based on their pattern of medication adherence to ICS/LABA since the start of therapy and analyzed how many people in each group received additional asthma medication. The study team was mainly interested in (1) how many people receive additional asthma medication in general and (2) whether patients non-adherent to ICS/LABA were receiving additional asthma treatments and (3) if yes, whether this was more often than patients that were adherent to ICS/LABA.
The study showed that within three years after ICS/LABA initiation, almost one in 20 people (3.9%) with asthma were prescribed additional asthma therapy (OCS:89; LAMA:39; biologics: <3). The authors identified four different adherence trajectories related to ICS/LABA use. These adherence trajectories were: non-persistent use, i.e. people stopping therapy (20%), seasonal use (8%), poor adherence (58%), and good adherence (13%). Of all people receiving additional medication, 80% was commenced in poorly-adherent patients. The authors further found that people with poor adherence did not have a higher probability of receiving additional asthma therapy than people who were adherent. The authors concluded that the majority of patients seem to be stepped-up to high risk OCS therapy without adequate assessment of medication adherence. Therefore, they stress the need for objective adherence assessment (e.g. by “smart” inhalers) and the provision of interventions to enhance 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.