Adherence: The Goal to Control Asthma
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
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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.