Inhaler regimen switches impact outcomes, doctor-patient relationships

When patients with asthma or chronic obstructive pulmonary disease switch their inhaler regimen, there can be consequences for clinical outcomes, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

These switches also can negatively affect the doctor-patient relationship, Omar S. Usmani, MB BS, PhD, FHEA, FRCP, FERS, professor of respiratory medicine at the National Heart and Lung Institute, Imperial College London, and colleagues wrote.

The researchers reviewed 21 studies, including four covering asthma, six on chronic obstructive pulmonary disease (COPD) and four examining both, with sample sizes ranging from 19 to 68,942, published through Nov. 21, 2020.

Study findings

Eight studies reported a switch in both device and drug, eight reported a switch in device and five reported a switch in just the inhaled drug. Nonclinical reasons for switching included costs in six studies, changes to internal or institutional guidelines in two studies and reasons that were not clearly reported in 13 studies.

Patients did not consent to the inhaler regimen switch in five studies, although they did consent in one study. Another study indicated partial consent, whereas 14 studies did not clearly indicate consent.

In six studies, approximately 65% of patients received training or education about inhaler technique before any switch. Two studies indicated formal support and education for all patients, two studies reported no support or training and 11 studies did not clearly indicate whether there was any support or training.

Twelve studies examined symptom control. Five datasets did not clearly define whether there was consent for switching, although disease control improved after the switch. But in one study where there was no consent, disease control significantly got worse.

In four studies with unclear consent for switching, switching had heterogenous effects on hospital admission or attendance, courses of oral corticosteroids and lower respiratory tract infections.

Five datasets in 11 studies with unclear consent for switching found significant reductions in short-acting beta agonist (SABA) use after switching, while two datasets with unclear or no consent found significant or numerical increases in SABA use after switching.

One study found a numerical improvement in long-acting beta agonist (LABA) prescription rates, and another found a significant improvement in LABA use after switching, although consent for switching was unclear in both studies.

In one study of 10 patients that examined exacerbations, those who switched experienced significant increases in exacerbation rates compared with patients who did not switch. Another study, however, showed a significant decrease in exacerbation rates with any type of switch or with switches from branded to generic inhalers, compared with patients who did not switch. Consent for these switches was unclear.

Meanwhile, in three more of these studies involving exacerbations, two datasets indicated no evidence of a difference in severe exacerbation rates with switching, and two datasets found a significant reduction in severe exacerbation rates.

Provider-patient relationships

Two thematic, narrative studies reported on relationships between patients and their health care providers, with patient responses ranging from “I am completely satisfied” to “I don’t think they know who I am.”

Nearly all participants who did not consent to a switch said this change impacted their relationship with their doctor regardless of whether their previous relationship had been positive. Patients further said that they were “angry,” “upset” or “shocked.”

Patients said the surreptitious nature of these switches harmed their relationships with their doctors. These patients also said they believed cost issues drove these switches, which were not in their best interests.

In one survey, 16% of patients who agreed to the switch still said they had a negative view of the change and were disappointed, although 64% said they trusted their general practitioner (GP). Every respondent except one said their GP had explained the switch well and did not rush the consultation.

When five GPs were asked about these relationships, four expressed concern that sending a letter to patients informing them of these changes was impersonal, although making these changes opportunistically when patients visited the office was also problematic.

These five GPs said patient pressure was a primary influence in their prescriptions. Although these GPs were first reluctant to make these changes, they did not want to upset their patients and risk losing them to another practice.

The GPs indicated that the positivity of the existing doctor-patient relationship was key in the decision to approach a patient with a change, noting that they did not approach patients in four cases due to previous negative or confrontational experiences.

Overall, the researchers said the study designs and outcomes were heterogenous, but they still indicated worse symptom control, SABA use, oral corticosteroid use, adherence and consultation rate outcomes when patients did not consent to the switch, in addition to negative effects on the patient-doctor relationship.

Best practices

The researchers recommended best practices including engaging patients in the switching process and obtaining patient consent before the switch. Also, the researchers wrote, there is a need to develop new strategies so patients do not feel that nonclinical reasons for switching outweigh their health and well-being. Further, patients should have mandatory formal training before and after any switching.

Finally, the researchers said their study highlights the often-forgotten complexity associated with inhaler use and how there is an urgent need to develop a robust framework for the personalized switching of inhalers and subsequent evaluation of outcomes. Large, high-quality standardized studies would inform policies and best practices.