Patient Adherence in Asthma: Effective Everyday Strategies

Transcription

1 Program Name: Patient Adherence in Asthma: Effective Everyday Strategies Kenneth Chapman, MD, FRCPC, FACP Planning Committee: Louis-Philippe Boulet, MD, FRCPC, FCCP Alan Kaplan, MD, CCFP(EM), FCFP Jacques Bouchard, MD,CCFP John Li, MD, CCFP Accrediation Information: This version of the program is unaccredited and intended for informational purposes only. An accredited version is available online at until February 26, Sponsor: This case study is supported by an educational grant from GlaxoSmithKline and Merck. 1

2 Learning Objectives By completion of the program, the participant should be able to: Identifying the goals of asthma management in primary care and the risks of suboptimal control Counsel patients for improved understanding of their therapy, the importance of adherence, and how best to communicate with their physicians and healthcare providers Effectively manage asthma in accordance with clinical practice guidelines Describe the therapeutic classes of medications used in the treatment of asthma Pre-course Survey 1) How would you rate your knowledge of asthma management goals? (1 = poor, 5 = excellent) 2) How would you rate your comfort level in promoting adherence to asthma therapy? (1 = poor, 5 = excellent) 3) How familiar are you with the factors that influence adherence in asthma management? (1 = not familiar, 5 = very familiar) 4) How familiar are you with the criteria for uncontrolled asthma? (1 = not familiar, 5 = very familiar) 5) How familiar are you with the link between asthma and allergic rhinitis? (1 = not familiar, 5 = very familiar) 6) How would you rate your comfort level in creating a patient action plan for asthma management? (1 = poor, 5 = excellent) 7) How confident are you that your asthma patients are well controlled and asthma is not affecting their quality of life? (1 = not at all confident, 5 = completely confident) 8) How would you rate your knowledge of the most current asthma treatments? (1 = poor, 5 = excellent) 2

3 Pre-Test 1) The Canadian Thoracic Society criteria for controlled asthma include the need for rescue medication: a) <4 times/week b) <5 times/week c) <6 times/week d) <7 times/week 2) Among the factors found to be associated with asthma exacerbation, risk of asthma exacerbation increases most with: (choose the best answer) a) allergic rhinitis, gastro-esophageal reflux disease, and psychological dysfunction b) psychological dysfunction, poor inhaler technique, and benign prostatic hyperplasia c) smoking, underweight, and gout d) diabetes, macular degeneration, and previous exacerbation 3) Despite serious and life-threatening consequences, studies show adherence rates in asthma are: a) <70% b) <60% c) <50% d) <40% 4) When asked directly, patients tend to accurately report their adherence. o True o False 5) A controller therapy available as combination with ICS for asthma is: a) Inhaled corticosteroid (ICS) b) Leukotriene receptor antagonist (LTRA) c) Long-acting beta2-agonist (LABA) d) Prednisone 3

4 Asthma Asthma is: a chronic, inflammatory disease of the airways 1 the most common chronic respiratory disease in Canada 2 dramatically increasing in global incidence 1 associated with significant comorbidity from wide ranging conditions including allergic rhinitis, chronic infections, gastro-esophageal reflux disease, obesity, obstructive sleep apnea, and psychological disturbances 2-6 commonly triggered by agents in the environment that cause respiratory inflammation 2,3 Risks of Sub-Optimal Control Include: 1,7,8 risk of exacerbations risk of hospitalization or death reduced quality of life Exacerbation 9 An acute asthma exacerbation is characterized by a worsening of symptoms, requiring a short course of oral corticosteroids, emergency room visit, or hospitalization. Current asthma control is a predictor of future instability in asthma control and asthma exacerbations. 7 Once asthma control is established, it is more likely to be maintained when therapeutic adherence is adequate. 7 Risk of exacerbations increases with factors including: 9 previous exacerbations poor asthma control poor inhaler technique poor adherence allergic rhinitis and allergies gastro-esophageal reflux disease psychological dysfunction obesity smoking 4

5 Diagnosis Diagnosis 2 Asthma is diagnosed based on: clinical history (including family history) compatible with the definition of asthma objective measures of lung function (individuals >6 years of age) Pulmonary function criteria supportive of an asthma diagnosis include: spirometry showing reversible airway obstruction peak expiratory flow (PEF) variability a positive challenge test such as methacholine or exercise challenge Definition of Asthma: 2 Asthma is an inflammatory disorder of the airways characterized by paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production and cough, associated with variable airflow limitation and airway hyper-responsiveness to endogenous or exogenous stimuli. Inflammation and its resultant effects on airway structure and function are considered to be the main mechanisms leading to the development and maintenance of asthma. 5

6 Asthma Control Asthma control should be regularly assessed, with appropriate modifications to management. Standard assessment now includes airway inflammation is a measure of asthma control, and may include the use of FeNO or sputum eosinophil count. 2 Asthma control criteria 2 Characteristic Frequency or value Daytime symptoms <4 days/week Night-time symptoms <1 night/week Physical activity Normal Exacerbations Mild, infrequent Absence from work or school due to asthma None Need for a FABA** <4 doses/week FEV 1 or PEF 90% personal best PEF diurnal variation* <10% 15% Sputum eosinophils <2% 3% *Diurnal variation is calculated as the highest PEF minus the lowest divided by the highest peak flow multiplied by 100 for morning and night (determined over a two-week period). **(SABAor use of ICS/LABA) fewer than 4 times per week Consider in adults with uncontrolled moderate to severe asthma who are assessed in specialist centres. Meet our Round Table Discussion Contributors Watch our discussion panel of experts throughout this program as they discuss key issues in the management of asthma. Their discussion aims to identify ways of enhancing patient adherence in the management of asthma, as well as ways of identifying non-adherence, understanding why it happens, and how healthcare professionals in their various roles can help support patient adherence for improved outcomes in the management of asthma. What are the defining criteria for controlled asthma? How can the goal of controlled asthma be integrated in day-to-day practice? Is there a quick and reliable way to assess control? Many patients believe that their asthma is controlled, even when they do not meet the criteria for controlled asthma. How can the pharmacist be essential to recognizing such patients? What is the role of the pharmacist in improving the management for these patients? 6

7 Management Asthma Management 2 The goal of asthma management is control of the disease to minimize risk of poor health outcomes, including complications, increased morbidity, and mortality. Asthma control should be regularly assessed, with appropriate modifications to management. Canadian Thoracic Society 2012 Asthma Management Continuum 2. 7

8 Suboptimal Control When patients believe their asthma is controlled... Is the perception the reality? Results of the TRAC Study: 10 Perceived asthma control: 97% Real asthma control: 47% The Reality of Asthma Control (TRAC) study, a major Canadian survey of physicians and patients, showed: 10 97% of the 893 patients believed their asthma was controlled 47% actually had controlled disease by guideline criteria 39% of 463 physicians followed Canadian asthma guidelines most or all of the time 11% of patients had written action plans One-half of patients with action plans did not use them regularly Almost three-quarters of patients expressed concerns about taking inhaled corticosteroids What are some of the red flags that can help us identify when patients are not administering their asthma medication correctly? 8

9 Manage & Monitor Monitoring adherence with guideline recommendations 2 The following parameters may be used to monitor or audit adherence with some of the key recommendations contained in the present clinical practice guidelines: asthma diagnosis is confirmed by an objective measure of lung function in individuals 6 years of age and over asthma control criteria are assessed at asthma follow-up visits (consider including sputum eosinophils in individuals 18 years of age and over with moderate asthma in tertiary care or specialized centres) patient has a reliever (SABA for any severity; or BUD/FORM for exacerbation-prone individuals 12 years of age and over with moderate asthma and poor control) patient is prescribed a controller (ICS or LTRA, or ICS/LABA, or prednisone) adjunct controller therapy (either a LABA or LTRA) is prescribed for children with asthma uncontrolled on a medium dose of ICS adjunct controller therapy (LABA as an ICS/LABA combination) is prescribed for adults with asthma uncontrolled on a low dose of ICS patient/parent/caregiver receives self-management education, including a written asthma action plan such these examples from the Asthma Society of Canada or Family Physician Airways Group of Canada. children with asthma uncontrolled on a medium dose of ICS are referred to an asthma specialist For full practice guidelines, please visit the Canadian Thoracic Society Are there gaps between the expectations set out in the guidelines and the realities of day to day primary care management of asthma? What can be done to close such gaps? 9

10 Case Study: Meet Anna Anna is a non-smoking 48-year old mother of two, working full-time as a university administrator. She walks the 5km to and from work for exercise. With the arrival of the spring season, Anna has developed a red, runny nose an annual case of allergic rhinitis -- and reports having some mild wheezing and chest tightness during the morning on most weekdays while on her way to work. She is treating these symptoms with her fast-acting beta2-agonist inhaler. She has not noticed any nighttime difficulty breathing. She tells you her asthma is under control since she has not had a full-blown asthma attack since last visit and she has not needed any time off of work. Anna decided to book this appointment with you after attempting to refill her prescription for her relief medication, and being told that there were no more refills available on the prescription. When you ask Anna to demonstrate her inhaler technique, she does so accurately and efficiently. Labs and history: Diagnosis: asthma (confirmed), seasonal allergy Age: 48 Smoking years: 0 Height: 162cm Weight: 72.5kg BMI: 27.6 kg/m 2 HR: 82 bpm BP: 129/84 Forced expiratory volume (FEV 1 ) (personal best): 2.2 litres Current FEV 1 : 1.8 litres Peak expiratory flow (PEF) diurnal variation: 18% Sputum eosinophils: 5% Current medications: short-acting beta2-agonist (SABA) inhaler on demand Case Challenge 1: You determine that Anna s asthma is currently uncontrolled. Anna s information seems to indicate she is properly adherent to her SABA therapy (she has demonstrated she understands and follows her regimen). According to Canadian Thoracic Society guidelines, what therapeutic adjustment is the next appropriate choice to help better-control Anna s asthma? a. ICS b. LTRA Leukotriene receptor antagonist c. Prednisone d. ICS or ICS/LABA on demand 10

11 The Asthma-Allergic Rhinitis Link 9 Rhinitis is a strong independent risk factor for the incidence and development of asthma 12,13 60% of asthmatics have concomitant allergic rhinitis 14, % of people with rhinitis have concomitant asthma 14,15 Studies have found treatment of allergic rhinitis in patients with concomitant asthma improves both conditions. 16 Untreated rhinitis is associated with poor asthma control. 17 This association was absent when allergic rhinitis was treated with nasal preparations (corticosteroids or anti-allergic compounds). 18 Association of rhinitis with onset and incidence of asthma: 13 The nose knows... Rhinitis is a strong independent risk factor for the incidence and development of asthma

12 Assessment Thorough assessment at diagnosis and at regular follow-up is important to maintain asthma control. Regularly reassess: 2 Control Spirometry or PEF Inhaler technique Adherence Triggers Comorbidities (Possibly) sputum eosinophils Comorbidity 6 Assessment at diagnosis and follow-up should include assessment for comorbidity. In an Ontario study, asthma, together with its comorbidity (conditions found in individuals with asthma versus those without asthma), were associated with: 6% of all hospitalizations 9% of all emergency room visits 6% of all ambulatory care visits When the response to treatment is suboptimal: 2 Reaffirm the diagnosis Check for poor inhaler / device / administration technique Assess for poor adherence to maintenance therapy Ask about possible ongoing exposure to environmental triggers Assess for ongoing comorbidities (e.g., allergy, obesity, depression, diabetes, GERDD) 12

13 Case Challenge 2 Anna Revisited Case challenge 2: What about Anna s allergic rhinitis? You know that untreated rhinitis is associated with poor asthma control. Options include antihistamine or nasal corticosteroid nasal spray. But is it favourable to add an additional medication in the presence of the prescribed ICS or ICS/LABA? a. Yes; it is favourable to add a nasal corticosteroid or anti-allergic compound, with consideration given to total body load of steroid. b. No; it is better not to address the allergic rhinitis independently The Asthma-Allergic Rhinitis Link 9 60% of asthmatics have concomitant allergic rhinitis 14, % of people with rhinitis have concomitant asthma 14,15 Studies have found treatment of allergic rhinitis in patients with concomitant asthma improves both conditions. 16 Untreated rhinitis is associated with poor asthma control. This association was absent when allergic rhinitis was treated with nasal preparations (corticosteroids or anti-allergic compounds). 18 We know very well that asthma and allergic rhinitis often coincide and current thinking evaluates these as two different manifestations of a common underlying pathophysiology. How much importance should be placed on screening for allergic rhinitis in the presence of asthma and vice versa? When treating the coinciding conditions of asthma and allergic rhinitis, what is appropriate in overlap of corticosteroid-based medications? What other drug-drug-interactions should we be alert for? 13

14 Management of Asthma with Allergic Rhinitis What is the recommended management of concomitant asthma and allergic rhinitis? a combined treatment strategy is recommended 12,14 pharmacological agents for rhinitis treatment may reduce asthma morbidity 12,14 a 2009 review of studies with these rhinitis treatments indicates intranasal glucocorticosteroids, antihistamines, anti-leukotrienes and immunotherapy all have the potential to improve both rhinitis and asthma outcomes in patients with both conditions 12,19 antihistamines and intranasal corticosteroids are respectively indicated first-line for treatment of for allergic rhinitis 12,14 The therapeutic options for asthma treatment are becoming more numerous, and management choices are becoming more complex. Where do the newer therapies fit into treatment and what advantages can they offer? (Inhaled corticosteroids, Combination, other classes) 14

15 Adherence Adherence in Asthma Patient adherence to therapy is a requirement for asthma control. 1,7,20 Non-adherence to asthma therapy is widespread. 1 Studies show adherence rates of less than 50% Patients do not accurately report adherence. Conservative estimates suggest almost half of medications dispensed are not taken as prescribed. 1 Non-adherence increases risk of morbidity and mortality. 1 We often educate patients with asthma about adherence to maintenance medications by helping patients better understand their therapy. What are some of the common fears, myths, or misconceptions that can lead patients to skip medication or take it incorrectly? Forms of non-adherence: 1 failure to fill prescription (studies show 6-44% ) chronic under-use (leads to poor control and increased use of reliever medication) erratic use (usually with under-use associated with asymptomatic phases) variable adherence per medication type (e.g., under-use of controller medication and over-use of reliever medication) premature discontinuation Is it deliberate? 1 Adherence may be deliberate or non-deliberate. Some patients have poor adherence patterns because of misunderstanding, forgetfulness, or lifestyle, for example. Deliberate adherence happens when patients make a reasoned choice against taking their medication as prescribed. 15

16 Factors Affecting Adherence 1 Disease severity the immediacy of severe symptoms increases use of relief medications; patients may be non-adherent to controller medications however in when disease is severe Patient beliefs myths and misunderstandings contribute to non-adherence (e.g., patients may fear medication side effects, or patients may believe their controller medication doesn t work because they use it as a relief medication without the desired effect) Regimen factors patients are less likely to adhere to more demanding regimens, including: long duration of therapy, more frequent dosing, more complexity (multiple drugs, devices, or tasks) Milgrom et al found that prednisone bursts were common in patients who were non-adherent to their inhaled anti-inflammatory medication. 31 Detecting & Improving Adherence: Methods that can help detect poor adherence: Ask patient about regimen (when, where, why, how, with who?) Ask patient to demonstrate how they administer their medication Ask patient about their feelings and beliefs toward the medication and any perceived side effects Ask the patient if they experience any difficulties with the demands of their regimen Assess prescription fulfillment, possibly in consultation with pharmacist Limit prescription refills, to correspond to appointment schedule, to help ensure regular followup for reassessment Novel biomarkers of medication exposure may become a future tool for assessing adherence in asthma

17 Interventions to Improve Adherence: 20 Education: clear instructions about treatment and disease management Multidisciplinary care with common message Monitoring adherence Closer follow-up Simplification of regimens Adaptation of treatment to patient s characteristics Shared decision process Self-management programs with educational and behavioural components Memory aids and reminders Incentives; reinforcements Multifaceted interventions Asthma is a chronic disease that must be progressively assessed How can healthcare professionals collaborate to achieve optimal patient management? 17

18 Case Study: Meet Bill Bill Bill is a 22-year old self-employed carpenter, diagnosed with asthma 7 years ago at age 15. Bill was initiated 2 months ago onto an ICS inhaler. Bill s prescription was continued for his short-acting beta2- agonist (SABA) reliever inhaler. Bill is complaining that the new medication doesn t work and his asthma is bothering him almost daily. When you ask Bill if he has been using the new inhaler, he says yes. When you ask him to show you the technique he uses, he demonstrates it accurately. Labs and history: Diagnosis: asthma (confirmed) Age: 22 Smoking years: 3; not currently smoking Height: 180 cm Weight: 68 kg BMI: 21 kg/m 2 HR: 80 bpm BP: 121/80 Forced expiratory volume (FEV 1 ) (personal best): 2.2 litres Current FEV 1 : 1.7 litres Peak expiratory flow (PEF) diurnal variation: 19% Sputum eosinophils: 7% Current medications: ICS inhaler, short-acting beta2-agonist (SABA) reliever inhaler Case Challenge 3: What reasons might you still have to suspect adherence could be playing a role in Bill s current condition? a. uncontrolled asthma b. symptoms are worsening despite increased therapy c. a new medication was introduced d. patients do not accurately report adherence e. all of the above 18

19 Uncontrolled asthma can be an indicator of non-adherence. Patient adherence to therapy is a requirement for asthma control. 1,3,7,20 A new medication might mean that newly introduced factors such as patient beliefs or regimen factors might be causing non-adherence. 1 Non-adherence to asthma therapy is widespread. 1 Patients do not accurately report adherence. 21,24 Case Continued Back to Bill Conscious that adherence might still be playing a role in Bill s symptoms, you decide to ask him more about his medication regimen: When does he use his new inhaler? At this point it is revealed that Bill is using the new inhaler as a relief inhaler, and has thrown his relief inhaler out believing it to be replaced by the new inhaler. The reason for Bill s uncontrolled asthma is non-adherence due to patient beliefs. You reassure Bill that he did the right thing to book and an appointment, and that, together, you get his therapy on track and his asthma under control so he should be able to breathe easier. You review the education for selfmanagement and the action plan with Bill, paying particular attention to the difference between relief medication and controller medication. You write Bill a prescription to replace his discarded relief inhaler. Before Bill leaves your office, you ask him to explain his new regimen back to you to be sure he understands. Methods that can help detect poor adherence: Ask patient about regimen (when, where, why, how, with who?) Ask patient to demonstrate how they administer their medication Ask patient about their feelings and beliefs toward the medication and any perceived side effects Ask the patient if they experience any difficulties with the demands of their regimen Assess prescription fulfillment, possibly in consultation with pharmacist Limit prescription refills, to correspond to appointment schedule, to help ensure regular followup for reassessment 19

20 Key Points The goal of asthma management is control of the disease to minimize risk of poor health outcomes, including complications, increased morbidity, and mortality. Asthma control should be regularly assessed, with appropriate modifications to management. Poor asthma control increases risk of exacerbations, hospitalization, and death. Asthma is associated with significant comorbidity. Allergic rhinitis is highly associated with asthma, and is an independent risk factor for asthma. Treatment of allergic rhinitis can improve asthma morbidity. Consider scheduling a follow-up appointment in the spring and/or fall. Patient adherence is critical to effective asthma control and improved outcomes. Post test [see Pre-test] Discussion Forum 1. What techniques do you use to determine if non-adherence is playing a role in patients with poor asthma control? 2. What approaches do you feel are most promising for promoting adherence to treatment in asthma? 20

21 References 1. World Health Organization. Report: Adherence to long-term therapies: evidence for action. 2003; 211 pages. Available at: 2. Lougheed MD, Lemiere C, Ducharme FM, et al; Canadian Thoracic Society Asthma Clinical Assembly. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012;19(2): Available at: 3. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M, Gibson P, Ohta K, O'Byrne P, Pedersen SE, Pizzichini E, Sullivan SD, Wenzel SE, Zar HJ. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 2008;31(1): Boulet LP. Influence of comorbid conditions on asthma. Eur Respir J. 2009;33(4): Boulet LP. Asthma and obesity. Clin Exp Allergy. 2013;43(1): Gershon AS, Wang C, Guan J, To T. Burden of comorbidity in individuals with asthma. Thorax 2010;65: Bateman ED, Bousquet J, Busse WW, Clark TJ, Gul N, Gibbs M, Pedersen S. Stability of asthma control with regular treatment: an analysis of the Gaining Optimal Asthma control (GOAL) study. Allergy 2008;63: Guilbert TW, Garris C, Jhingran P, Bonafede M, Tomaszewski KJ, Bonus T, Hahn RM, Schatz M. Asthma that is not well-controlled is associated with increased healthcare utilization and decreased quality of life. J Asthma 2011;48: Sims EJ, Price D, Haughney J, Ryan D, Thomas M. Current control and future risk in asthma management. Allergy Asthma Immunol Res 2011;3(4): FitzGerald JM, Boulet LP, McIvor RA, Zimmerman S, Chapman KR. Asthma control in Canada remains suboptimal: the Reality of Asthma Control (TRAC) study. Can Respir J 2006;13(5): Ciavarella A, Kaplan A; Family Physician Airways Group of Canada. Asthma Action Plan. Available at: Accessed January Scadding G, Walker S. Poor asthma control? then look up the nose. The importance of comorbid rhinitis in patients with asthma. Prim Care Respir J 2012; 21(2): Shaaban R, Zureik M, Soussan D, et al. Rhinitis and onset of asthma: a longitudinal populationbased study. Lancet 2008;372: Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001;108:S Available at: Bousquet J. Allergic Rhinitis and its Impact on Asthma (ARIA). Clin Exp All Rev 2003;3: Price D, Kemp L, Sims E, von Ziegenweidt J, Navaratnam P, Lee AJ, Chisholm A, Hillyer EV, Gopalan G. Observational study comparing intranasal mometasone furoate with oral antihistamines for rhinitis and asthma. Prim Care Respir J 2010;19: Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy 2008;63 Suppl 86: Breekveldt-Postma NS, Erkens JA, Aalbers R, van de Ven MJ, Lammers JW, Herings RM. Extent of uncontrolled disease and associated medical costs in severe asthma--a PHARMO study. Curr Med Res Opin 2008;24: Nathan RA. Management of patients with AR and asthma: literature review. SouthMed J 2009;102:

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