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.