GINA 2022 – What you need to know about Asthma Inhaler Adherence
The global initiative for asthma (GINA) is an organisation which works with public health officials and healthcare professionals to reduce asthma prevalence, morbidity, and mortality. Each year GINA produce a report on various aspects of asthma treatment and management, the most current report from GINA was produced in 2022.
Asthma is a common obstructive lung disease characterized by chronic airflow limitation due to hyperreactive airways. The disease affects people all of ages every day, asthma affected an estimated 262 million people in 2019 and caused 455,00 deaths according to the world health organization (WHO)1. The common treatment for asthma is inhaled medication which controls asthma symptoms and allows those with asthma to lead a normal, active life.
[vital_featured_image]
The 2022 GINA report offers guidance on asthma control and asthma severity which are key points in overall asthma management. The two main features of Asthma control are symptom control, and risk assessment of adverse outcomes such as severe exacerbations requiring admission. Poor symptom control can be a burden to patients and increase the risk of exacerbations, although it is important to note patients with good symptom control can still have severe exacerbations due to the high variability in asthma symptoms.
Asthma Assessment
In a patient asthma assessment, GINA recommends initially assessing symptom control and then administering Inhaled corticosteroids (ICS) along with short-acting beta-2-agnoists (SABA) or long-acting beta-2-agnoists (LABA) and/or anticholinergic agents if required. For safety, GINA no longer recommends treatment of asthma in adults with SABA alone, all adults and adolescents with asthma should receive ICS-containing controller treatment to reduce their risk of serious exacerbations.
When assessing the patient’s future risk for exacerbations alongside various risk factors, GINA highlight incorrect inhaler technique and poor inhaler adherence as issues to be addressed. It is important that asthma that is exacerbated due to modifiable factors such as incorrect inhaler technique and/or poor adherence is distinguished from severe asthma to avoid over-treatment.
Inhaler Adherence
Inhaler adherence is defined as the likelihood to which a patient will voluntarily implement instructions from a healthcare professional regarding dosage, timing and frequency of medication and continues to re-order prescriptions whenever needed leading to a better therapeutic outcome2. Or to put it more simply, adherence is how well a patient follows the medical prescription. Different types of inhaled medication can also influence adherence, such as frequency of medication and the type of device used to administer medication. There is increased awareness of poor adherence in chronic diseases and the importance of interventions to improve adherence. Approximately 50% of adults and children on long-term therapy for asthma fail to take medications as directed at least part of the time2.
In clinical practice, poor adherence may be identified by an empathic question that acknowledges the likelihood of incomplete adherence and encourages an open discussion. Checking the date of the last prescription, or the date on the inhaler, may assist in identifying poor adherence. In some health systems, pharmacists can assist in identifying poorly adherent patients by monitoring dispensing records. Electronic inhaler monitoring has been used in clinical practice to identify poor adherence in severe asthma or difficult to treat asthma.
Factors Contributing to Poor Adherence
It is important to confront patients’ beliefs and concerns about asthma and asthma medications to understand the reasons behind their medication-taking behaviour. Factors which influence poor adherence are highlighted in table 1 and include both intentional and unintentional factors. Issues such as ethnicity, health literacy and numeracy are often overlooked. Patients concerns about side effects may be either real or perceived.
In the GINA report, the most important considerations are reducing the risk of severe exacerbations and achieving good adherence with regularly prescribed ICS in patients with infrequent symptoms. Adherence with prescribed daily ICS is poor in patients with infrequent symptoms, exposing the patient to risks of SABA-only treatment if they are prescribed daily ICS plus as-needed. When prescribing ICS for a patient with mild asthma, clinicians should be aware that adherence with maintenance ICS in the community is very low. They should consider the likelihood that patient will be poorly adherent with daily ICS, exposing them to the risk of SABA-only treatment.
Table 1. Poor Medication Adherence - GINA 20221.
Factors Contributing to Poor Adherence | How to Identify Poor Adherence in Clinical Practice |
Medication/regimen factor · Difficulties using inhaler device (e.g., arthritis) · Burdensome regimen (e.g., multiple times per day) · Multiple different inhalers Unintentional poor adherence · Misunderstanding instructions · Forgetfulness · Absence of daily routine · Cost Intentional poor adherence · Perception that treatment is not necessary · Denial or anger about asthma or its treatment · Inappropriate expectations · Concerns about side-effects (real or perceived) · Dissatisfaction with healthcare providers · Stigmatization · Cultural or religious issues · Cost | · Ask an empathic question · Acknowledge the likelihood of incomplete adherence and encourage an open non-judgemental discussion Examples are: ‘Many patients don’t use their inhaler as prescribed in the last 4 weeks, how many days a week have you been taking it – not at all, 1,2,3 or more days a week?’ ‘Do you find it easier to remember your inhaler in the morning or the evening?’ Check medication usage: · Check the date of the last prescription · Check the date and dose counter on the inhaler · In some health systems, prescribing and dispensing frequency can be monitored electronically by clinicians and or pharmacists |
Examples of Successful Adherence Intervention | |
· Shared decision-making for medication/dose choice · Inhaler reminders, either proactively or missed doses · Prescribing low dose ICS once daily-versus twice daily · Home visits by an asthma nurse for a comprehensive asthma program |
How Often Should Inhaler Adherence be Checked?
All healthcare providers are encouraged to assess inhaler technique and adherence at every visit, not just when the patient presents to clinic because of their symptoms. Frequency of visits depends upon the patient’s initial level of control, their response to treatment and their level of engagement in self-management. Ideally, patients should be seen 1-3 months after starting treatment and every 3-12 months thereafter. A review visit should be scheduled within 1 week of an exacerbation.
Interventions Which Improve Adherence in Asthma
Inhaler adherence is viewed as an independent factor of poor asthma symptom control. GINA states that inhaler adherence can be detected early on in primary care. Good communication is important in asthma treatment, as good communication skills may result in increased patient satisfaction, creating enhanced patient adherence. Table 2 highlights strategic interventions that can help improve adherence.
Table 2. Interventions Which Improve Adherence in Asthma - GINA 20221
Choose · Choose the most appropriate inhaler device for the patient before prescribing. Consider the medication options, the available devices, patient skills and cost. · If different options are available, encourage the patient to participate in the choice. · For pMDIs, use of a spacer improves delivery and (with ICS) reduces the potential for side-effects. · Ensure that there are no physical barriers, e.g., arthritis, that limit use of the inhaler. · Avoid use of multiple different inhaler types where possible, to avoid confusion. |
Check · Check inhaler technique at every opportunity. · Ask the patient to show you how they use the inhaler (don’t just ask if they know how to use it). · Identify any errors using a device-specific checklist. |
Correct · Show the patient how to use the device correctly with a physical demonstration e.g., using a placebo inhaler. · Check technique again, paying attention to problematic steps. You may need to repeat this process 2-3 times. · Only consider an alternative device if the patient cannot use the inhaler correctly after several repeats of training. · Re-check inhaler technique frequently. After initial training, errors often recur within 4-6 weeks. |
Confirm · Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe. · Pharmacists and nurses can provide highly effective inhaler skills training. |
GINA recommends inhaler adherence should be encouraged with controller medication, even when symptoms are infrequent. ICS-containing controller treatment should be initiated as soon as possible after diagnosis is made, initiating the treatment early on allows the patient to see the SABA less as the main medication for asthma treatment and reduces the risk of poor adherence when a daily ICS is prescribed.
Successful interventions noted by GINA include:
- Shared decision making for medications/choice improved adherence and asthma outcomes.
- Electronic inhaler reminders, provocatively or for missed doses, improved adherence and reduced exacerbations and oral corticosteroid use.
- In a difficult inner-city environment, home visits for a comprehensive asthma program by an asthma nurse led to improved adherence and reduced prednisone courses over several months.
- In a health maintenance organization, an automated voice recognition programme with messages triggered when refills due or overdue led to improve ICS adherence relative to usual care, but no difference in urgent care visit.
- In a study, directly observed controller medication administration at school, combined with telemedicine oversight, was associated with more symptom-free days and fewer urgent visits than usual care.
It is important to note that improving adherence to controller medications may not necessarily translate to improved clinical outcomes. Further studies are needed of adherence strategies that are feasible for implementation in primary care. Overall prescribing medication and checking adherence is not all that is needed to achieve optimum asthma control.
In a patient-centred approach, the healthcare professional should discuss intervention in an empathic manner, allowing the patient to feel comfortable discussing worries and concerns regarding their treatment. GINA recommends a patient-caregiver partnership, alongside guided self-management and adequate treatment, to achieve long-term control and decrease the frequency of exacerbations of asthma.
References
- Global Initiative for Asthma - GINA. 2022. 2022 GINA Main Report - Global Initiative for Asthma - GINA.
- Murphy, J., McSharry, J., Hynes, L., et al. Prevalence and predictors of adherence to inhaled corticosteroids in young adults (15-30 years) with asthma: a systematic review and meta-analysis. J Asthma 2020: 1-23
- int. 2022. Asthma. [online] Available here.
- Jardim, J. and Nascimento, O., 2019. The Importance of Inhaler Adherence to Prevent COPD Exacerbations. Medical Sciences, 7(4), p.54.
- Rafi, M., Tahmin, C., Tashrik, S., Bonna, A., Jannat, F., Mily, S., Shrestha, A., Seemanta, S., Rashid, A., Mahjabeen, M., Nura, N., Shahriar, T., Mahadi, A., Ahmed, K., Hasan, M., Haque, M. and Hossain, M., 2022. Adherence to inhalers and associated factors among adult asthma patients: an outpatient-based study in a tertiary hospital of Rajshahi, Bangladesh. Asthma Research and Practice, 8(1).