Maintenance therapy appears underused prior to asthma exacerbations

Christopher D. Theroux, MD

Patients with moderate to severe persistent asthma are recommended to be on daily maintenance inhalers with an as-needed “rescue” inhaler. This study highlights that a significant number of patients in this cohort are not filling their prescribed inhalers, both rescue and maintenance, until the onset of worsening asthma symptoms.

The most updated Global Initiative for Asthma (GINA) guidelines that recommend ICS/formoterol over short-acting bronchodilators as the preferred as-needed inhaler was a massive shift in the long-standing dogma of asthma care over the last several decades. Since the most recent guideline update, there has been a distinct challenge in following these recommendations based on the currently available inhaler regimen.

The vast majority of ICS/LABA inhalers come in fixed-quantity blister pack devices, with few exceptions, that are geared mostly toward once- or twice-daily maintenance use, not as-needed use. These inhalers are expensive, even with insurance, and can be cumbersome for adults — let alone children — to use properly. 

Most insurances have preferred formulary agents that limit a clinician’s choice in choosing specific inhalers that would be most appropriate for the individual patient. Beyond that, some patients may not see the immediate benefit with the daily use of maintenance inhalers, so they may end up stopping using them on their own.

Although the sheer number of patients in this study cohort who are not consistently adherent with maintenance medications is shocking, I am frankly not surprised. These results are also based off a patient cohort with access to insurance. Patients with limited insurance are more likely to lack access to the recommended daily and as-needed inhalers with increased morbidity, unfortunately, as a result.
As a pulmonary critical care physician who treats asthma in both the outpatient and inpatient settings, these findings also mirror my own personal experiences. Asthma is a disease where improved control often results in worse adherence with therapy.

Each exacerbation requiring presentation to medical care is a point where both patients and clinicians need to reflect on the effectiveness of the asthma care plan in place and make adjustments as needed. More often than not, access and adherence to inhaler therapies are significant contributors to worsening asthma control and exacerbations.
These findings should be a wake-up call to physicians treating asthma in the outpatient setting. They highlight the true challenges with adherence to recommended inhaler therapies and the potential for increased exacerbations as a result.

Physicians need to fully assess all aspects of their patients’ inhaler regimens, whether they be medication affordability, ease of use and proper technique, patient adherence and use patterns, or clinical response to the inhaler regimen. Pharmacy fill patterns also may be a useful aid in providing objective measures of patient adherence with care.

Improving inhaler access and patient adherence should be a constant goal of treating clinicians, as they have clear benefits such as improving patient quality of life and reducing the number of exacerbations, as well as relieving the burden on acute care in the U.S. health care system.
This study is industry funded, and the supporting pharmaceutical company has a recently approved as-needed short-acting bronchodilator/inhaled corticosteroid inhaler that appropriately fills the gap that the authors outline in asthma care.

As these types of inhaler therapies come to market, continued investigation is needed into the impact that they have in comparison to current regimens. Specifically, the GINA guidelines were shaped around ICS/formoterol use with its longer-acting beta-agonist. Clear benefit from an ICS/short-acting bronchodilator over the longer-acting form needs to be established. 

Heather De Keyser, MD, MS

These results are not particularly surprising. It is well known that medication adherence in those with asthma (or any chronic disease, for that matter) is quite poor.

So, it makes sense that prescription refills for controller medications prior to an exacerbation would be low until a patient has an exacerbation and then is reminded of the importance of their inhaled steroids so they start taking them again.

Also, this study only shows that a patient may not be “filling” a maintenance medication during this “window of opportunity.” It does not mean that they are not using a previously filled medication during that time. This is a limitation of this type of analysis.

In my practice, we have found that adherence to daily dosing of inhaled corticosteroids is low, so finding that only about 50% of patients fill their controller medications in the month prior to an exacerbation is consistent with that. Additionally, it is consistent that after an exacerbation, there is a significant uptick in controller medication use.

Patients may remember feeling poorly, missing work or school, and may be much more likely to adhere to therapy after an exacerbation like this. However, we have unfortunately seen that this effect is not sustained and that medication adherence generally drops off significantly again over time until another exacerbation and the cycle repeats itself.

Another important thing to point out is that children have higher rates of exacerbations in this data set, which is something that we are very aware of in pediatrics, but I think gets lost sometimes in the conversation regarding asthma therapies.

If health care providers know more about the medication use patterns of their patients, it becomes easier to care for them. If I find out that my patients with frequent exacerbations are simply not filling their medications, it leads to a very different conversation than if I know they are taking the medications and still having difficulties. Additionally, it presents a good opportunity for continued education about the role of inhaled steroids in the prevention of asthma exacerbations.

A real-world study using objective measures of actual medication use such as electronic monitoring in this window of opportunity would be key to better understanding the true underlying patient behavior.