Integrated Adherence Monitoring for Inhaler Medications

Abstract

Many adults, particularly those with chronic diseases, do not take the medications they are prescribed.1 Poor adherence to inhaled controller medications is particularly common among patients with asthma and chronic obstructive pulmonary disease (COPD). Twenty five percent of first prescriptions are not dispensed,2 and for ongoing treatment, adherence, when inhaler use is monitored, averages only between 25% and 50% of the prescribed dose.3,4 Poor inhaler adherence is associated with ineffective symptom control, increased exacerbations, and risk of death. Poor adherence may be intentional, unintentional, or a combination of both; each has different determinants.2 Detecting inadequate adherence is therefore only a starting point, but an indispensable one. Consider the following scenarios. A patient with obstructive sleep apnea reports worsening sleepiness. Data downloaded from the continuous positive airway pressure (CPAP) device show that use of CPAP has diminished. The patient explains that nasal obstruction from hay fever has prevented regular CPAP use. The physician prescribes nasal corticosteroids with antihistamines and arranges treatment review. Another patient has symptomatic asthma despite reporting regular use of a high-dose inhaled corticosteroid-based controller. The physician considers escalation of therapy to injectable biologics. These 2 examples reveal an important cognitive paradox. On one hand, it would be unusual for the patient with sleep apnea to receive a CPAP device without fully integrated (ie, built-in) adherence monitoring. Usage data downloads are essential for clinical management and used by some payers to decide eligibility for ongoing treatment. On the other hand, the common approach for the patient with asthma and COPD is use of inhaler devices without any adherence monitoring other than a dose-counter, forcing clinicians to rely on patient reports, which may be unreliable.Thisoutdatedapproachshouldbereconsidered becauseintegratedadherencemonitoringisdesirable,feasible, and achievable for inhaler medications. For clinicians, identification of poor adherence provides an opportunity to elicit underlying barriers to adherence, collaborate with patients to develop potential solutions, and interrupt the otherwise common escalation of treatment. For the patient, controller inhaler adherence monitoring with feedback increases adherence and reduces exacerbations in adults3 and children4 with asthma. Ideally, monitoring should also show patients when they took their last dose and how many doses remain in the inhaler. It is also useful to monitor use of inhaled reliever medications. Timely detection of increasing requirements for reliever medications may signal impending exacerbations and prompt activation of an action plan. As-needed corticosteroid and fast-acting β2-agonist in a single inhaler for mild asthma protects patients from exacerbations and reduces β2-agonist overuse 5; ideally, medication usage with such adjustable regimens should also be monitored.