Global burden of medication non-adherence in chronic obstructive pulmonary disease (COPD) and asthma: a narrative review of the clinical and economic case for smart inhalers

Abstract

Medication non-adherence to asthma and chronic obstructive pulmonary disease therapy poses a significant burden for patients and societies. Non-adherence encompasses poor initiation, implementation (including poor inhalation technique) and non-persistence. Globally, non-adherence is associated with poor clinical outcomes, reduced quality of life and high healthcare and societal costs. Costs are mainly caused by excess hospitalizations and impaired work productivity. Multiple intervention programs to increase adherence in patients with asthma and chronic obstructive pulmonary disease have been conducted. However, these intervention programs are generally not as effective as intended. Additionally, adherence outcomes are mostly examined with non-objective or non-granular measures (e.g., self-report, dose count, pharmacy records). Recently developed smart inhalers could be the key to objectively diagnose and manage non-adherence effectively in patients with asthma and chronic obstructive pulmonary disease. Smart inhalers register usage of the inhaler, record time and date, send reminders, give feedback about adherence and some are able to assess inhaler technique and predict exacerbations. Still, some limitations need to be overcome before smart inhalers can be incorporated in usual care. For example, their cost-effectiveness and budget impact need to be examined. It is likely that smart inhalers are particularly cost-effective in specific asthma and chronic obstructive pulmonary disease subgroups, including patients with asthma eligible for additional GINA-5 therapy (oral corticosteroids or biologics), patients with severe asthma in GINA-5, patients with asthma with shortacting beta2 agonists overuse, patients with asthma and chronic obstructive pulmonary disease with frequent exacerbations and patients with asthma and chronic obstructive pulmonary disease of working-age. While there is high potential and evidence is accumulating, a final push seems needed to cost-effectively integrate smart inhalers in the daily management of patients with asthma and chronic obstructive pulmonary disease.

Medication availability and economic barriers to adherence in asthma and COPD patients in low-resource settings

“…Several simple methods can be applied to address this problem: using simplified medication regimens, increasing the patient’s knowledge of self-management, and improving the skills of health care workers in patient education and adherence counseling 36 . Smart inhalers have already been created, which are not yet used in practice, but have already yielded good results regarding monitoring and managing medication adherence, however, more research is needed 37 . It is important to note that there is a large shortage of primary health care workers, especially in more remote Kyrgyz regions, and due to the heavy workload of physicians, they physically do not have time or forget to evaluate or support patients’ adherence.…”

Can electronic monitoring with a digital smart spacer support personalised medication adherence and inhaler technique education in patients with asthma?: Protocol of the randomised controlled OUTERSPACE trial

“…This can be measured using self-reported patient diaries, which are prone to reporting bias, or more accurately using electronic inhaler monitors. 13 Studies with these electronic devices show that persistence with treatment is relatively poor, but this may be improved by educational interventions. A recent UK study showed that average persistence for children with asthma was 49% for those who were monitored but received no reminders, and 70% for those who received reminders to take their treatment.…”

Dry Powder Inhalers in the Digitalization Era: Current Status and Future Perspectives

“…Unfortunately, approximately 22–78% of patients with asthma and COPD and 31–53% of CF patients are poorly adherent to their inhaled medications [ 36 , 37 ]. Errors in inhalation techniques occur in a percentage of 6.8–43.2%, and only 10–52% of physicians are adequately informed regarding proper device use [ 38 , 39 ].…”

“…Doser TM (Meditrack Inc., Hudson, MA, USA), Smart Mist ® (Aradigm Corporation, Hayward, CA, USA), MDILog TM (Westmed Technologies Inc., Englewood, USA), Smart Inhaler Tracker (Adherium Ltd., Auckland, New Zealand), and Smart Track TM (Adherium Ltd., Auckland, New Zealand) were some of the first digitalized pMDIs [ 36 , 107 ]. Except for the Doser, all of them provide records regarding date and time of actuation, as well as specific reminders through ringtones [ 107 ].…”

“…Although first conceived as pMDI sensors, the PP has recently received FDA clearance as add-on sensors for DPIs as well. Propeller ® sensors dedicated to Diskus ® (GlaxoSmithKline, Brentford, UK), Ellipta ® (GlaxoSmithKline, Brentford, UK), and Neohaler ® (Novartis, Basel, Switzerland) received FDA approval in 2015, 2016, and 2018, respectively [ 36 , 109 , 119 ]. In 2020, the European Commission (EC) announced Enerzair ® Breezhaler ® (Novartis, Basel, Switzerland) approval for all EU member states, as well as the UK, Iceland, Norway, and Liechtenstein [ 115 ].…”