Discussion
With the introduction of therapeutic aerosols in 1956 in the treatment of respiratory diseases, problems related to treatment began to occur within a few months [11]. International asthma and COPD guidelines strongly recommend evaluating the inhaler technique and adherence to the prescribed dosage regimen before concluding that current therapy is inadequate [1,2]. Inadequate medication adherence is common and associated with poor disease control and outcomes. Real-life data in asthma show that treatment adherence is in the range of 8-70%. Low inhaler adherence has also been associated with frequent asthma exacerbations [12-17]. In COPD, adherence with medical treatment is between 20-60%, and low treatment adherence is associated with increased disease mortality [18,19]. Similar to other countries, also in Turkey, level of adherence is not at desired levels in asthma and COPD patients and is associated with uncontrolled disease [20,21].
Currently, there is no perfect method for determining adherence to inhaler treatments in patients with obstructive lung diseases. Methods recommended for the follow-up of adherence in the management of asthmatic patients are direct biochemical measurement of the drug in blood or other body fluids, clinician judgment, patient self-report, prescription refill data, and electronic monitoring devices. Direct biochemical measurement can evaluate actual uptake, but it is costly, invasive, and only provides a point estimate of compliance. Clinician judgment and patient self-report can provide actual insight into non-adherent behavior, if regular face-to-face meetings and effective patient–clinician communication takes ongoing action. Longitudinal adherence measurement with prescription refills provides a continuous and remotely accessible alternative. Electronic monitors are objective, but widespread use has been limited by different monitors being needed for each device type. Each of the available methods has its own strengths, but none of the methods are specifically designed for the management of asthma non-adherence [6].
With this study it was seen that adherence assessment based only on the patient statements is a troublesome method. According to the study results, 89.4% of patients with obstructive lung disease participating in the study stated that they are adherent to the prescribed inhaler therapy. However, 28.8% of the patients who stated that they used the prescribed inhaler treatment regularly were using it irregularly according to the statements of their relatives. It was also observed in the study that, relatives of some of the patients who stated that they did not use the drug regularly reported that the patient is adherent to inhaler therapy. Therefore, the discrepancy between the statements given by the patients and their relatives in our study revealed a serious problem in assessment of adherence based solely on the patient’s statement. In this context, we think that patient relatives may be involved in the clinical judgment of adherence. This approach may help us both to evaluate adherence more accurately and to increase patient adherence. In this context, our study offers a different perspective.
Bender et al. investigated adherence and persistence for 12 months from the date of the first fluticasone propionate / salmeterol combination prescription in 5504 patients with COPD. Adherence to inhaler treatment was determined as 22.2% in that study. This pharmacy database study showed that drug adherence level was at a significantly low level [22]. Smart inhaler devices, also known as e-inhalers, containing sensors in an e-module, can help us in the following years [7]. However, it is a reality that they cannot be equally helpful for every type of adherence, especially the intelligent non-adherence type [6]. Therefore, regular and high quality communication between the patient and the physician is very important. In this regard involving the family members living in the same house may be beneficial. Our results emphasize that when the relatives of patients who report being adherent are questioned, it may turn out that patients are adherent.
Sulaiman et al. conducted an actual adherence study in patients with COPD in 2017, evaluating both intentional and unintentional non-adherence. Among 244 COPD patients discharged from the hospital with predicted FEV1 values below 80%, 179 patients with available data were evaluated within 30 days of discharge. The mean adherence was found to be 59.8%. The major factors determining adherence were poor lung function and impairment in cognitive function [23]. In a prospective, observational cohort study conducted by Cushen et al in 2018, discharged COPD patients were followed with a smart inhaler for adherence. In this study, four different clusters of adherence behaviour were defined. In that study, it was observed that patients with irregular use and poor inhaler technique had the highest mortality rate, and patients with good inhaler technique but who used their treatment irregularly had the highest general healthcare use. The study of Cushen et al. emphasizes the importance of detailed assessment of medication adherence in COPD [24]. In 2020, O’Dwyer et al. reported that digital technologies are valuable to quantify adherence and have clinical value in promoting adherence through biofeedback in patients with obstructive lung diseases [25]. However, there are relatively few digital technologies and smart inhalers in use all over the world. Therefore, the best way to evaluate adherence is to have good communication with the patient and to check drug records in the pharmacy system. By referring to the information of family members living in the same house, success in objectively evaluating adherence will be increased.
One of the important limitations of our study is the small number of patients. However, the number of patients who applied to the outpatient visit with a relative living in the same house is very low. The second limitation of our study is that the relationship between adherence and disease control was not evaluated because it was not included in the design of the study.
As a conclusion, it is a fact that rate of adherence to inhalers is low in real life. Attempts are being made to improve adherence rates, but there is still a long way to go. For the follow-up of adherence clinician judgment and patient self-reports. Adding the information of patients’ relatives to the use of patient self-reports can increase the power of clinician’s judgment in the follow-up of medication adherence.
Acknowledgements: FA and KA had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. FA and KA constructed hypothesis for research, FA, KA, TT and AF contributed substantially to the study design, TT, and AF contributed substantially to data collection, FA, and KA performed data analysis and interpretation. FA, KA, TT, and AF substantially contributed to the writing of the manuscript. FA, KA, TT and AF approved final manuscript.
Conflict of Interest: Authors have no conflicts of interest regarding the submitted work.
Funding information: No funding was received for the study.
Dr. Kurtuluş Aksu reports personal fees from Novartis, personal fees from Astra Zeneca, personal fees from Chiesi, personal fees from Sandoz, personal fees from GlaxoSmithKline, personal fees from İbrahim Etem, personal fees from Abdi İbrahim, outside the submitted work.
Dr. Funda Aksu, Dr. Tuğba Tezvergil and Dr. Ali Fırıncıoğluları has nothing to disclose for three-year period prior to the date of submission.