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Inhaled therapy characteristics and adherence pattern in patients with bronchial asthma .
Abdellah Hamed, Khaled Fawzy, Esraa Ameen, Kamal Atta.
Department of Respiratory medicine, Sohag faculty of medicine, Sohag university. Egypt.
Address correspondence: Abdellah Hamed Khalil Ali, Department of Respiratory Medicine, and Sohag Faculty of Medicine, Sohag University, and Sohag 82524, Egypt. Phone and Fax +2-0111428640; E-mail:[email protected]

Background:
Sub-optimal asthma management has been found largely due to patients’ medication non-adherence and incorrect inhaler technique. This study aimed to examine inhaler use technique and medication adherence among Egyptian asthma patients
Methods: A descriptive cross-sectional study was carried out among 110 clinically diagnosed asthma patients attending at a university hospital, Sohag, Egypt. Inhaler technique and adherence were evaluated by a standardized tool “Morisky Medication Adherence Scale, 2008.
Results: Findings of the study revealed that out of 110 patients 22.9% had medium level, 42.2% had a high level, and 34.9% had a low level of medication adherence. There was no relationship between demographic data and adherence in asthmatic patients. However, Good adherence was frequently encountered among asthmatic patients who used inhaler twice daily, who used drugs its onset of action 5- 20 minutes, who used aerolizer and turbohaler devices and who used budesonide and budesonide/formetrol.
Conclusion: Nonadherence is high among asthma patients attending sohag university hospital in Upper Egypt. There was strong relationship between inhaled drug criteria and degree of adherence in asthmatic patients.
Key Words: COPD, bronchial asthma, adherence, inhaled therapy.
Introduction:
Adherence to medication is a crucial part in the long term management of asthma. In chronic asthmatic patients, non-adherence or inhaler mishandling increases mortality, morbidity, and hospital admission [6, 7].
Factors related to adherence with inhaled therapy include complexity of the inhalation regimen, peculiarities of inhaler devices, type of inhaled agent, and a variety of patient beliefs and sociocultural and psychological factors.(7) Therefore, promoting optimal medication adherence is essential to optimize the benefits of treatment. Consequently, measurement of the degree of adherence to inhaled treatment in each individual patient becomes increasingly important in daily practice.
By opposition, non adherence leads to poor clinical outcomes, increase in morbidity and death rates, and unnecessary healthcare expenditure (Brown and Bussell, 2011). There are limited studies that have examined adherence to asthma therapy in Egypt. The aim of the study: was to assess adherence to inhaled therapy in patients with bronchial asthma and to to identify drug characteristics contributing to non-adherence.
Patients and Method:
Study subjects and design
A descriptive cross-sectional study design was used, and 110 clinically diagnosed asthma patients were selected from the in patient department and out patient clinic of chest diseases , Sohag university hospitals. Before the data collection, the study was approved by the local ethics committee of sohag university hospitals and a written informed consent was obtained from every patient included in the study.
After taking informed consent from the patients, the informations regarding age sex, literacy, residence, occupation, smoking habits, Socioeconomic status, co morbidities, date of diagnosis of asthma and pulmonary function tests were recorded.
Inhaler Use
Further questions related to the currently prescribed aerosol therapy for asthma like no of medications prescribed per day, type of device, type of drug, onset of action of inhaler and frequency of administration of inhaler. .
The current prescribed medications for asthma were identified for all included patients: long-acting ?2-agonists (LABA), inhaled corticosteroids, combined LABA/ inhaled corticosteroids, short-acting anticholinergics, short-acting ?2-agonists, long-acting anticholinergics. Most patients were on combination therapy.
Morisky medication adherence scale scores
Medication adherence was tested using the Arabic version of the validated eight-item Morisky Medication Adherence Scale (MMAS-8, UCLA, Los Anglos, USA) [8–11]. The Arabic version of MMAS-8 is an eight-item questionnaire with seven yes/no questions and the last question is a five-point scale. On the basis of the scoring system of MMAS-8, adherence was rated as follows: high adherence (score: 8), moderate adherence (score: 6 to <8), and low adherence (score: <6). Patients with low or moderate grades of adherence were considered nonadherent to their medications.
Statistical analysis:
The data collected by using structured questionnaire and reviewing medical record forms were entered in a separate spreadsheet using EXCEL (2010). The entered data was analyzed using Statistical package for social sciences (SPSS) software version 20. Quantitative data was represented as mean± standard deviation. Data was analyzed using ANOVA for comparison of the means of three groups. Qualitative data was presented as number and percentage and compared using either Chi square test. P-value < 0.05 was considered as statistically significant.
Results:
The demographic and medical characteristics of studied patients are shown in Table 1.A total of 110 took part in the study at Sohag university Hospitals and Clinics, Sohag, Egypt. The respondents had a mean age of 39.22±13.51 years. There were more females than males (69/ 41; 62.72%). 50% of patients are illiterate.
The most commonly used aerosol therapy in asthma patients is presented in Table (2). As regard frequency of administration of inhaler, it was found that asthma patients were frequently using the inhaler twice daily, also asthmatic patients used the on need more frequently. As regard onset of action of inhaler, it was found that the inhaler that of 5 minutes of onset of action was frequently used by asthma patients patients than other types of inhalers . As regard type of device, it was found that aerolizer , MDI, turbohaler and handihaler were frequently used by asthma in order than other types of devices. As regard type of drug, it was found that budesonide, formetrol, salbutamol and budesonide/ formetrol were frequently used by asthma in order than other types of drugs.
The proportion of patients in the different categories of adherence according to MMAS-8 questionnaire is shown in Fig 1. Based on the MMAS-8 questionnaire, 42.2% of patients had good adherence, 22.9% intermediate adherence, and 34.9% poor adherence.
Table (3) shows relation between demographic data and adherence in asthmatic patients already on inhaler therapy. there was no statistically significant relationship between demographic data and adherence in asthmatic patients (p>0.05).
The relation between drug characteristics and adherence pattern in asthma patients already on therapy is shown in Table (4)(Fig 2 A,B,C,D). It was found that there was statistically significant relationship between adherence pattern and frequency of administration, onset of action, type of device, type of drug with P=(0.001, 0.002, 0.001, 0.001) respectively. It was found that good adherence frequently encountered among patients who used inhaler twice daily ,who used drugs its onset of action <5-20 minutes, who used Aerolizer and turbohaler, who used budesonide/ formetrol and budesonide only.
Discussion
Medication adherence is important for asthma patients for the effectiveness of the therapy. Adherence measured using the MMAS-8 – a scale that has been used widely to investigate adherence to medication in many disease areas including asthma 27–29 and COPD,30–32 where it has been used to investigate adherence to inhaled medications.
Analysis of the demographics of the study population revealed the majority of asthma patients to be female( 62.72%). The study was conducted in 110 asthma patients among which 69 were female and other 41 were male. The mean age was of 39.22±13.51 years. 52.72% came from urban area, 86.36 % had middle socioeconomic class,.50% were illiterate. The mean duration of asthma was 11.21±8.91 years. Likewise, more than half (75.45%) of the patients had one comorbidity.
In our study we found that, among the studied population poor adherence was observed in 34.9%, 22.9% intermediate adherence, and 42.2% of patients had good adherence. This result matches with the results of the study of (Rifaat et al., 2013and Ayele et al 2017 ) who found that adherence among asthmatic patients was 49%. This percentage shows that still many asthmatic patients are not adherent to their inhalational medications. Previously done research shows that, adherence to inhaled therapies is worse than that seen with oral or injected therapies in patients with asthma in different age groups [18–21]. Whereas in previous studies, among asthma patients, medication adherence rates have consistently been shown to be 30–40% and may increase as high as 70% [15–19]. This discrepancy in findings may be due to the difference in knowledge regarding asthma among participants, use of different measurement tool and inclusion of different groups of the sample population in the study.
In this study, none of the variables related to sociodemographic information (such as age, gender, place of residence, educational status, comorbidity, severity of symptoms and smoking habit), were associated with patients’ level of medication adherence. Consistent to these findings, Senior et al., 2004 showed that there was no association between level of adherence with sociodemographic and clinical variables (age, gender, marital status, place of residence, education, type of occupation and current smoking status, and severity of COPD). However, these findings are contradictory with other studies in which medication adherence was associated with age,[21] current smoking status,[21,27] comorbidity, number of medications consumed,[19] severity of symptoms,[16,18,27] and frequencyof daily dosing frequency,[26] and daily drug dosages.[18] The difference in findings might be due to the inclusion of a sample of different duration of disease, different study settings and use of different validated instruments in the studies.
As regard frequency of administration of inhaler in our study we found that 75.5% preferred twice daily therapy, 2.7% preferred once daily and 21.8% used inhaler on need . There was statistically significant relationship between good adherence and the use of inhaler twice daily in asthmatic patients in comparison with the use of on need inhaler However, this result is not comparable with that of the result of (Venables et al., 1996) which showed that 61% of patients expressed a preference for once-daily treatment, 12% preferred twice-daily treatment and 27% expressed no preference. Other studies found that adherence in asthmatic patients was unrelated to the number of daily doses of inhaler therapy (van et al., 2002 – Laforest et al., 2009 – Wells et al., 2013). Others observed that reliever inhalers were frequently used in asthmatic patients (Bender et al., 2006 – Apter et al., 1998).
As regard onset of action of inhaler, we found in our study that the inhaler of 5- 20 minutes of onset of action was frequently used by patients than other types of inhalers and this was statistically significant, this result due to asthma patients almost always complaining and need rescue bronchodilators medications which rapidly acting , also it is believed that the perception of the product delivering its action rapidly may lead the patient to continue taking the therapy on a daily basis (Sanduzzi et al., 2014).
In our study there was statistically significant relationship between good adherence and the use of turbohaler and aerolizer in asthmatic patients in comparison with the use of MDI. Our study result agrees with a previous study of (Friedman et al., 2010) which found that using dry-powder inhalers (DPIs) versus metered-dose inhalers (MDIs) was linked to adherence in this study results.
Moreover, we found that there was statistically significant relationship between good adherence and the use of budesonide/ formetrol and budesonide in asthmatic patients in comparison with the use of salbutamol . This observation agrees with that of Axelsson et al. who found better adherence to ICS/LABA compared to ICS and/or LABA and/or SABA) (Axelsson et al., 2009) and compared with ICS in monotherapy or in combination with LABA or montelukast in the study of (Stempel et al., 2005)
Conclusion: Non-adherence to medication is common problem in asthma and possess significant barrier to optimum management of asthma. It was found that good adherence frequently encountered among asthmatic patients who used inhaler twice daily ,who used drugs its onset of action 5 – 20 minutes, who used Aerolizer and turbohaler and who used budesonide and budesonide formetrol and it was statistically significant. These factors should be considered to improve asthma control.
Conflict of Interests: The authors declare that there is no conflict of interests regarding the publication of this paper .
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