Inhaled therapies are the backbone of asthma and chronic obstructive pulmonary disease management, helping to target therapy at the airways. Adherence to prescribed treatment is necessary to ensure achievement of the clinician’s desired therapeutic effect. In the case of inhaled therapies, this requires patients’ acceptance of their need for inhaled therapy together with successful mastery of the inhaler technique specific to their device(s). However, there are a number of challenges and barriers that the inhaled mode of delivery can pose to optimum adherence- to therapy initiation and, thereafter, to successful implementation and persistence. The potential effects on adherence of different categories of devices, their use in multiplicity, and the mixing of device categories are multifactorial. Furthermore, many common errors exist which contribute to substandard use of inhaler medication.
In the routine care management of asthma and COPD, treatment initiation can be affected by a range of psychological and practical barriers, among them denial of diagnosis, disease awareness, lack of trust in health care professionals, medication fears, cognitive ability, affordability, and access to therapy. In the context of asthma and COPD, mode of therapy delivery can introduce an additional obstacle. The recent REcognise Asthma and LInk to Symptoms and Experience (REALISE) Asia study, which assessed patients’ perception of asthma control and attitudes toward treatment in a multinational Asian population, found that approximately half of all patients agreed with statements that having inhalers was “embarrassing” or “a nuisance.” Patients with uncontrolled asthma, in particular, felt that it was an embarrassment (62.0%) or a nuisance (52.2%) to use or even carry (56.7%) an inhaler in public, representing real psychosocial barriers to initiation (and subsequent implementation and persistence) of inhaled therapy.
Although treatment implementation and persistence are 2 distinct concepts these are closely linked when considering the potential implications of therapeutic delivery approach in asthma and COPD. The more challenging the patients find the mode of delivery of their maintenance therapy, the greater their potential barriers to successful implementation (administration and successful delivery) and, in turn, the greater the potential for diminished treatment outcomes. The international Implementing “Helping Asthma in Real People” (iHARP) initiative is the largest evaluation of routine care inhaler technique conducted in asthma to date. Analysis of the data revealed a high prevalence (90%) of inhaler technique errors (≥1 error) across all devices: 84% for their Diskus, 91% for Turbohaler, 92% for pMDI, and 91% for the pMDI when used with a spacer. More than 20% of the patients demonstrated at least 4 errors when using their controller inhalers.
As inhaled therapies form the backbone of the therapeutic management of asthma and COPD, it is important to prescribe an inhaler that the patient can and will use. The identification of patients’ attitudes (and potential concerns) to inhalers should also be explored to ensure there are no obvious barriers to initiation and use of the prescribed therapy. Thereafter, it is crucial that patients are instructed as to the correct use of their inhalers and that their technique is regularly checked and corrected/retrained, as required. Failure to do so will result in suboptimal implementation (failure to receive the prescribed dose at the frequency intended), suboptimal treatment outcomes, and potential early discontinuation.
Journal of Allergy and Clinical Immunology: In Practice, 2016-09-01, Volume 4, Issue 5, Pages 823-832, Copyright © 2016 The Authors
