Adherence to Treament: How can it be improved ?

Fernán Caballero FonsecaCaracas, Venezuela

December 2011

• Adherence• Technique • Misdiagnosis• Location of inflammation• Lack of eosinophilic inflammation• Genetics

Potential reasons for not achieving control in asthma patients

Definitions of adherence / compliance

EffectiveEffectiveTherapiesTherapies

PatientPatientAdherenceAdherence

EffectiveEffectiveDiseaseDiseaseManagementManagement

• The extent to which the patient's actual practice corresponds to the prescribed regimen • For ambulatory patients ... the link between

medical process and treatment outcome

Urquhart. Eur Heart J. 1996;17:8

Months of Therapy

Vanelli MR et al. Moving beyond market share. In: In Vivo: The Business and Medicine Report. 2002:1-6.

Pat

ien

ts C

on

tin

uin

g T

her

apy

(%)

Patient persistence on medication in chronic diseases

CCB = calcium channel blocker; SERM = selective estrogen receptor modulator; SSRI = selective serotonin reuptake inhibitor.

Across classes, 20% - 35% loss in patient base after fill of initial prescription

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11

Multiple Sclerosis(Biologic)

High Cholesterol(Statin)

Hypertension(CCB)

Osteoporosis(SERM)

Depression(SSRI)

Asthma (InhaledSteroid)

Most adherence is thoughtful

Missed Work/SchoolLoss of sleep

Chronic SymptomsImpaired QOL

Uncertainty/FearAttacks

Having to take RxSide effects

CostInconvenienceAppointments

CommunicationAccess

Burden of Illness vs Burden of Therapy

Adherence and outcomes

• Adherence/persistence rates range from 5-50%1

• Use patterns tend to be sporadic2

• Non-adherence likely accounts for ~60%of hospitalizations3

1Luskin AT Bukstein DA. Ann Allergy 1999, 2001 2Bender B JACI 20033Williams LK JACI 2004;114:1288-1293

Types of nonadherence to medication

•Not filling prescriptions

• Not following directions

• Premature discontinuation

• Keeping the clinic visit schedule

• Contacting the clinic as directed

• Bringing medicines, diaries, or biological samples to clinic appointments

• Completing diaries

• Maintaining a diet, allergen avoidance, exercise program, or other aspects of the clinical regimen

Adherence also pertains to

Patient-related barriers

• Patient/family demonstrate psychological problems

• Patient doesn’t understand the treatment

• Condition is either mild or severe

• Patient has insufficient faith in physician or treatment

• Patient just isn’t motivated

Depression

Nonadherence Unhealthy Behavior

Bender BG AAAAI 2010

Depression is a risk factor for nonadherence

Depressed patients are 3 times more likely to be nonadherent with medical treatment recommendations than nondepressed patients.

DiMatteo MR. Arch Intern Med. 2000;160:2101-2107.

Anxiety and depression in adolescents with asthma

Is associated with

1. Increased risk of smoking

2. Decreased use of controller medication

Adolescents who smoked were 2.58 times more likely to demonstrate evidence of depression or anxiety

Bush T. J Adolescent Health 2007;40:425

0 10 20 30 40 50 60 70 80 90 100

I want immediate relief

I am confident to intervene early

I use my medication as and when necessary

I manage my asthma myself

I prefer to adjust ICS to changes of my asthma

Concern side effects of higher doses

Concern too much medication when well

Fear of having a serious asthma attack

No need to take my asthma medications every day

Prefer to take high dose of [ICS/combination]

Agree strongly Agree somewhat(n=3,415)

Patients attitudes towards asthma management

Patients (%)

Proportion of patients that agree with each statement

Partridge MR et al. BMC Pulmonary Medicine 2006:6:13

Treatment-related barriers

• Treatment is prolonged and/or prophylactic

• Consequences of therapy are delayed

• Medication is associated with adverse side effects

• Medication is expensive

• Therapeutic regimen is complex and difficult to administer ( multiples devices etc.)

Adherence to inhaled asthma therapy decreases over time

• Adults with moderate-to-severe asthma (N=50)• Treated with ICS twice daily• Actuation of inhaler monitored electronically

Apter AJ, et al. Am J Respir Crit Care Med. 1998;157:1810-1817.

Ad

her

ence

(%

)

Week of Study

50

55

60

65

70

75

0 1 2 3 4 5 6

Inhalation technique: At least one critical error

40

35

0

30252015

10

5

%

Molinard M., J Aerosol Med 2003;16:249-254

Aeroliz. Autohaler Diskus pMDI Turbuhaler

Below 30 years

From 31 to 64 years65 years and over

Caballero F, Sánchez-Borges M, J Allergy Clin Immunol 2002; 109:S 242

Number (%) of patients performing the different inhalations maneuvers correctly

  MDI  TH  CI 

Remove the cap 73 (100)  NA  NA 

Shake the inhaler 47 (64.3)  NA  NA 

Keeping the inhaler upright 64 (87.7)  NA  NA 

Exhale to residual volumen 30 (41.1)  16 (57.1)  11 (57.8) 

Keeping head upright  71 (97.3)  NA  NA 

Place mouthpiece correctely 65 (89.0)  26 (92.9)  18 (94.7) 

Inhaling slowly presing the inhaler 39 (53.4)  NA  NA 

Deep and powerful inspiration 50 (68.5)  25 (89.3)  18 (94.7) 

Breath holding for 5 sec.  47 (64.4)  22 (78.6)  14 (73.7) 

Exhale away from mouthpiece 55 (75.3)  NA  NA IDM: Inhalador de dosis medida; TH: Turbohaler(R); CI: Aerolizer (R)

Improved adherence through monitoring and feedback

• Nides Chest. 1993;104:501

• Yeung Respir Med. 1994;88:31

• Matsuymara Ann Pharmacother. 1993;27:851

• Onyirimba Ann Allergy. 2003;90:411

Weinstein. Ann Allergy Asthma Immunol, 2005;94:251

An adherence intervention

• standard asthma care•monitoring by MDI Chronologs• direct clinician-to-patient feedback for treatment group

Week of study

1 2 3 4 5 6 7 8 9 10

Mea

n D

aily

Adh

eren

ce

20

30

40

50

60

70

80

90

Treatment Control

Onyirimba. Ann Allergy Clin Immunol 2003;90:411

• Establish a therapeutic goal with the patient

• Assess progress

• Maintain a positive relationship

• Provide positive feedback

• Avoid criticism

Improving adherence

Listen to the patient

Doctors interrupt the patient in less than 18 seconds after he starts to talk

Beckman HB and Frankel RM Ann Intern Med 1984

Improving adherence

• Simplify therapeutic regimen

• Allow flexible dosing

• Provide adequate information

• Minimize painful tests

• Maintain frequent contact

• Issue appointment reminders

Patient education

Patient education and self-management. Thorax 2003;58(Suppl I):i1

• Every office visit is an opportunity to reinforce self-management skills

• Use hospital admission to review self-management skills

• No patient should leave hospital without a written asthma action plan

• At routine visits review self-management in case asthma deteriorates

• Brief simple education linked to patient goals is most likely to be acceptable to patients

Components of an asthma management plan

• Triggers• Personal best peak flow• Routine medications• Signs and symptoms of worsening

asthma• Medications required for emergencies

and how to monitor response to them• Emergency contacts

Knowledge self-efficacy, effective self-treatment andself-management in asthma patients

Van Der Palen J, et al. (1997) Patient Education and Counseling, 32:S35-S41

Effects of a self-management educational program for the control of childhood asthma.

• Objetive:Evaluation of the effect of a self-management educational program in 29 children 6 to 14 y/o and their parents

• Randomized, prospective and single blind.• Results : The experimenltal group experienced a

estadistical significant effect on children´s asthma knowledge ( P < 0.001), self-management abilities

( P < 0.0001) and in parents knowlege ( P < 0.008)• A significant impact on the Morbility Index of the

study group at post-test ( P < 0.05) • Younger children benefited more than older ones ( P < 0.009)

MA Gabriela Pérez, Lya Felman, Fernán CaballeroPatient Education & Counseling, 36 (‘99) 47-55

Effect of self-management on hospitalization for asthma

Action plan + self-managemant

Cote J et al AJRCCM, 1997;155: 1509-14

Crowie L. et al Chest 1997; 112:1134-8

Ignacio-García JM et al AJRCCM 1995;151:353-9 Lahdensuo A et al

BMJ 1990;312:748-52 Yoon R et al

Thorax 1993;48: 1110-6Zeiger RS et al

JACI 1991;87:1160-8 Total

0.1 0.2 1 5 10Prefer Treatment Prefer control

Relative risk(IC 95 % Fijo)

Gibson PG J Allergy Clin Immunol 2000; 106:17-26

• Doctor-patient communication

• Parent/child education about therapies and disease management

• Identifying relevant patient goals for therapy and directly linking them to adherence

• Tailoring of therapies and management regimens to match patients’ preferences, lifestyles and abilities

Pediatric adherence is enhanced through the effective use of:

Weinstein AG. Ann Allergy Asthma Immunol 2011; 106; (4): 283-291

The potencial of asthma adherence management to enhance asthma guidelines

Final coments :

• It is easier to change patient therapy than to change patient behavior

• Patient reports of non-adherence are virtually always accurate, while patient report of good adherence are frequently exaggerated

• Non-adherence with therapy has different causes: adherence promotion strategies should be tailored to the cause

Henry Milgrom and Fernan Caballero

VENEZUELA

Golfo de Cariaco Edo Sucre - Youenn Jacquin

Isla Blanquilla - Youenn Jacquin

Isla Las Aves - Youenn Jacquin

Plaza Venezuela - Orlando Acosta

Los Nevados Edo Merida - Youenn Jacquin