Poor adherence with inhaled corticosteroids for asthma: Can using a single inhaler containing budesonide and formoterol help?

Division of Respiratory Medicine, University of Nottingham, Nottingham City Hospital.
British Journal of General Practice (Impact Factor: 2.29). 01/2008; 58(546):37-43. DOI: 10.3399/bjgp08X263802
Source: PubMed

ABSTRACT Poor adherence with inhaled corticosteroids is an important problem in asthma management. Previous approaches to improving adherence have had limited success.
To determine whether treatment with a single inhaler containing a long-acting beta(2)-agonist and a corticosteroid for maintenance treatment and symptom relief can overcome the problem of poor adherence with inhaled corticosteroids.
Randomised, parallel group, open-label trial.
Forty-four general practices in Nottinghamshire.
Participants who used less than 70% of their prescribed dose of inhaled corticosteroid and had poorly controlled asthma were randomised to budesonide 200 microg one puff twice daily plus their own short-acting beta(2)-agonist as required (control group), or budesonide/formoterol 200/6 microg one puff once daily and as required (active group) for 6 months. The primary outcome was inhaled corticosteroid dose.
Seventy-one participants (35 control, 36 active group) were randomised. Adherence with budesonide in the control group was approximately 60% of the prescribed dose. Participants in the active group used approximately 80% more budesonide than participants in the control group (448 versus 252 microg/day, mean difference 196 mug, 95% confidence interval 113 to 279; P<0.001) and were less likely to withdraw from the study (3 versus 13; P<0.01). No safety issues were identified.
Using a single inhaler for both maintenance treatment and symptom relief approximately doubled the dose of inhaled corticosteroid taken, suggesting this could be a useful strategy to overcome the problems related to poor adherence with inhaled corticosteroids.

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Available from: Kevin Mortimer, May 19, 2014
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    • "Preventer (or controller) medication is re commended for adults who report asthma symptoms twice or more during the past month, waking due to asthma symptoms once or more during the past month, or an asthma flare-up in the previous 12 months.116 A single fixed dose combination inhaler may enhance adherence to inhaled corticosteroids in asthma,120 and several randomized controlled trials suggest that single inhaler therapy reduces asthma exacerbations requiring oral corticosteroids, hospitalization, or emergency visits.121 The TOwards a Revolution in COPD Health (TORCH) trial found a modest reduction in mortality among COPD patients who were randomized to the combination of salmeterol and fluticasone compared to placebo.122 "
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    ABSTRACT: Adult-onset asthma and chronic obstructive pulmonary disease (COPD) are major public health burdens. This review presents a comprehensive synopsis of their epidemiology, pathophysiology, and clinical presentations; describes how they can be distinguished; and considers both established and proposed new approaches to their management. Both adult-onset asthma and COPD are complex diseases arising from gene-environment interactions. Early life exposures such as childhood infections, smoke, obesity, and allergy influence adult-onset asthma. While the established environmental risk factors for COPD are adult tobacco and biomass smoke, there is emerging evidence that some childhood exposures such as maternal smoking and infections may cause COPD. Asthma has been characterized predominantly by Type 2 helper T cell (Th2) cytokine-mediated eosinophilic airway inflammation associated with airway hyperresponsiveness. In established COPD, the inflammatory cell infiltrate in small airways comprises predominantly neutrophils and cytotoxic T cells (CD8 positive lymphocytes). Parenchymal destruction (emphysema) in COPD is associated with loss of lung tissue elasticity, and small airways collapse during exhalation. The precise definition of chronic airflow limitation is affected by age; a fixed cut-off of forced expiratory volume in 1 second/forced vital capacity leads to overdiagnosis of COPD in the elderly. Traditional approaches to distinguishing between asthma and COPD have highlighted age of onset, variability of symptoms, reversibility of airflow limitation, and atopy. Each of these is associated with error due to overlap and convergence of clinical characteristics. The management of chronic stable asthma and COPD is similarly convergent. New approaches to the management of obstructive airway diseases in adults have been proposed based on inflammometry and also multidimensional assessment, which focuses on the four domains of the airways, comorbidity, self-management, and risk factors. Short-acting beta-agonists provide effective symptom relief in airway diseases. Inhalers combining a long-acting beta-agonist and corticosteroid are now widely used for both asthma and COPD. Written action plans are a cornerstone of asthma management although evidence for self-management in COPD is less compelling. The current management of chronic asthma in adults is based on achieving and maintaining control through step-up and step-down approaches, but further trials of back-titration in COPD are required before a similar approach can be endorsed. Long-acting inhaled anticholinergic medications are particularly useful in COPD. Other distinctive features of management include pulmonary rehabilitation, home oxygen, and end of life care.
    International Journal of COPD 09/2014; 9:945-962. DOI:10.2147/COPD.S46761 · 3.14 Impact Factor
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    • "Adherence appears to be higher with a once daily oral nonsteroidal asthma medication compared with an inhaled corticosteroid taken twice daily [72, 73]. The combination of an ICS and long-acting beta-agonist also appears to be associated with superior adherence compared with ICS alone or both medications in separate inhalers [74–76]. However, data on combined medications are not based on studies using EMDs. "
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    ABSTRACT: Suboptimal adherence with preventive medication is common and often unrecognised as a cause of poor asthma control. A number of risk factors for nonadherence have emerged from well-conducted studies. Unfortunately, patient report a physician's estimation of adherence and knowledge of these risk factors may not assist in determining whether non-adherence is a significant factor. Electronic monitoring devices are likely to be more frequently used to remind patients to take medication, as a strategy to motivate patients to maintain adherence, and a tool to evaluate adherence in subjects with poor disease control. The aim of this paper is to review non-adherence with preventive medication in childhood asthma, its impact on asthma control, methods of evaluating non-adherence, risk factors for suboptimal adherence, and strategies to enhance adherence.
    Pulmonary Medicine 04/2011; 2011(2090-1836):973849. DOI:10.1155/2011/973849
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    • "A study of preferences among patients with mild asthma found that the percentage of patients preferring to use beclomethasone and formoterol inhalers on an as needed basis was similar to those preferring once-daily ICS/LABA in a single inhaler; also, more patients preferred either option than the regular use of a leukotriene receptor agonist with albuterol rescue[30]. Data from a small, open-label study across 44 primary care practices also suggested that adherence increases with a single-inhaler approach[33]. Additionally, the costs for single-inhaler therapy are likely to be lower, because patients use less drug overall [34]. "
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    ABSTRACT: Despite positive clinical experience and the published clinical benefits of monotherapy with low-or medium-dose inhaled corticosteroids or combination therapy with ICS + long-acting beta-agonist to treat asthma, many patients remain suboptimally controlled. Alternative approaches are needed, and 3 options that have had some success are: 1) using the patient's level of inflammation by established biomarkers to set treatment; 2) self-management incorporating flexible dosing; and 3) using a single inhaler for rescue and maintenance therapy. Which strategy for which patient depends ultimately on the individual patient's disease burden, life-style, comorbidities, preferences, and his or her ability to self-manage the disease, including assessing symptoms and adhering with therapy.
    World Allergy Organization Journal 02/2010; 3(2):31-37. DOI:10.1097/WOX.0b013e3181d27cd8
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