A Review on the Medication Adherence in Obstructive Airway Disease Patients: A Focus on Inhaler Use

Reshma Babu, Angitha Binu, Jeffnisha J., Mathan S., Shaiju S. Dharan,

doi:10.5281/zenodo.15728124

Review Paper | Open Access
Volume 03 | Issue 06 | Article Id IJPS/250306390

A Review on the Medication Adherence in Obstructive Airway Disease Patients: A Focus on Inhaler Use
Reshma Babu* Angitha Binu Jeffnisha J. Mathan S. Shaiju S. Dharan
Ezhuthachan College of Pharmaceutical Sciences, Marayamuttom, Thiruvananthapuram

Abstract

Obstructive Airway Disorders, which are a group of respiratory conditions that involve blockage or narrowing of the airways, leading to difficulty in breathing. These disorders are characterized by reductions in airflow that occur at any level of the bronchial tree and may be due to the intrinsic narrowing or extrinsic compression of the airway. Some common Obstructive Airway Disorders (OADs) include Chronic Obstructive Pulmonary Disease (Bronchitis, Emphysema), Asthma, Bronchiectasis, Cystic fibrosis. The global prevalence of COPD is estimated to be around 10-15% of the adult population. In India it’s about 4.2%. Asthma affects around 3-4% of the global population and 12.9% in India. Treatment options typically includes beta agonists (short acting & long acting), corticosteroids, leukotriene receptor antagonists, muscarinic antagonists (SAMAs & LAMAs), with inhaler therapy stands as a primary approach in the management of OAD. Nevertheless, poor patient adherence poses a major barrier or challenge to achieving optimal treatment outcomes. This review examines the multifaceted factors influencing patient adherence to inhaler therapy in OAD management, includings the impact of patient education, device usability, communication of health care provider, socioeconomic status and cultural believes on adherence levels. Additionally, various levels of interventions like treatment level, clinician level and patient level are evaluated for their efficacy in enhancing adherence. Understanding these factors are crucial for optimizing asthma outcomes.

Keywords

Adherence on ICS inhalers, Non-adherence, Interventions, Treatment outcomes

Introduction

Obstructive Airway Disease are conditions marked by airflow limitation and inflammation. They are among most prevalent chronic respiratory conditions worldwide. OAD includes COPD, asthma, bronchiectasis, cystic fibrosis. It can cause symptoms such as wheezing, breathlessness, chest tightness, coughing, etc. Some common OAD’s such as asthma and COPD requires lifelong & long term management involving inhaled medications such as corticosteroids, short acting and long acting beta agonists, anticholinergics, etc. They work directly at the site of inflammation in the airways, offering targeted, effective control with minimal side effects. They can cause metabolic disturbances such as hypertension, dyslipidemia, diabetes, weight gain and so on.^[1,2]Inhaler therapy is a critical component in the management of OAD conditions to deliver anti-inflammatory agents and bronchodilators directly to the lungs, with high therapeutic efficacy and minimal side effects. However the success of inhaler therapy depends highly on the patient’s ability and willingness to use the medication correctly and consistently as recommended by the healthcare professional. OAD remains under-controlled in a significant proportion of patients largely due to poor adherence to prescribed inhaler therapies.^[3-7]]Medication adherence is defined as the extent to which a patient’s behavior in taking medication corresponds with agreed recommendations from a healthcare provider. Non-adherence to inhaler therapy is a well-documented challenge and a major barrier to achieving optimal OAD control. It results in poor symptom management, frequent exacerbations, increased hospitalizations & unnecessary escalation of therapy. Several interrelated factors including treatment complexity, socio-economic barriers, poor health literacy, and inadequate provider-patient communication-contribute to this issue.^[8-10]Notably, studies have shown that adherence rates for ICS in OAD patients often falling below 50%. The problem of non-adherence is multifactorial and influenced by a complex interplay of treatment-related factors (complexity of the regimen, cost, side effects), clinician related factors (lack of communication, inadequate patients education) & patient-related factors (socioeconomic status, cultural beliefs, psychological health, forgetfulness) and additionally incorrect inhaler 0technique.^[9,10]

DIAGNOSIS

Asthma
Diagnosis of asthma involves a combination of clinical history, physical examination, and pulmonary function testing. Spirometry is the gold standard for assessing lung function, evaluating parameters such as Forced Expiratory Volume in 1 second (FEV1), Forced Vital Capacity (FVC), and the FEV1/FVC ratio. A positive bronchodilator reversibility test supports the diagnosis. Other diagnostic tools include Peak Expiratory Flow (PEF) monitoring and measurement of fractional exhaled nitric oxide (FeNO), which reflects eosinophilic airway inflammation ^[11].

COPD

The diagnosis of COPD is primarily based on spirometry, with a post-bronchodilator FEV1/FVC ratio of less than 0.70 confirming persistent airflow limitation. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend assessment of symptoms using tools such as the Modified Medical Research Council (mMRC) dyspnea scale and COPD Assessment Test (CAT) in combination with spirometric classification. Other tests include physical examination, clinical history, social history. ^[12]

PREVALENCE

Worldwide prevalence of COPD: According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the global prevalence of COPD is estimated to be around 10-15% of the adult population. This varies based on region and the methods used for diagnosis. The estimated global prevalence of COPD is 9-10% in 40 years aged adults.^[13,14]Worldwide prevalence of Asthma: Asthma affects around 3-4% of the global population, with estimates varying based on age group, region, and diagnostic criteria. The Global Asthma Report 2018 suggests that more than 300 million people worldwide have asthma. Asthma affected an estimated 262 million people in 2019.^[13,14]

MANAGEMENT

Asthma
Asthma management is tailored based on symptom severity and control, following a stepwise approach as recommended by the Global Initiative for Asthma (GINA) guidelines. First-line therapy includes daily inhaled corticosteroids (ICS), with the addition of long-acting beta-agonists (LABA) in moderate to severe cases. Additional therapies may include leukotriene receptor antagonists, biologics (e.g., omalizumab, mepolizumab), and short-acting beta-agonists (SABA) for relief. ^[11,15]
COPD
Management of COPD focuses on symptom control, reduction of exacerbation frequency, and improvement of exercise tolerance. Treatment typically includes bronchodilators such as long-acting muscarinic antagonists (LAMA) and LABAs. In patients with frequent exacerbations, inhaled corticosteroids may be added. Non-pharmacological interventions include smoking cessation, pulmonary rehabilitation, vaccination, and oxygen therapy for advanced disease. ^[11,15]

Inhalers IN OAD

Inhalers are the mainstay in OAD treatment. They are easily handheld, small devices which used to deliver medication directly to lungs and include major types such as metered-dose, dry powder and soft mist inhalers.^[16]

- Inhaled Corticosteroids (ICS): Fluticasone, Budesonide, Beclometasone, Mometasone, Ciclesonide, Triamcinolone, Flunisolide.^[19]
Inhaled beta agonists: Salbutamol, Terbutaline, Salmeterol, Formoterol.^[16-19]

MECHANISM OF ACTION:

ICS directly target the lungs, allowing for a high local concentration with minimal systemic absorption. This minimizes side effects while effectively reducing airway inflammation.

Common side effects: Sore throat, oral thrush, hoarseness, cough, headache, etc.^[20,2]

Medication Adherence

Medication adherence is defined as the extent to which a patient adheres to the prescribed dose and interval of the medication regimen by the health care professional for achieveing the optimal therapeutic outcomes.^[21-23]Measuring adherence is a challenge due to the absence of a univesely accepted standard. Inhalers are the cornerstone in the treatment of obstructive airway disease, yet suboptimal patient adherence poses a significant challenge to achieving treatment goals. A proactive, multidisciplinary approach can enhance inhaler use, reduce disease burden, and improve patient outcomes.^[24,25]

Understanding The Causes Of Medication Non-Adherence

Medication non-adherence can be generally classified into two main types, that is intentional and unintentional. ^[26]

Intentional non-adherence involves a conscious decision by the patient to stop or reduce therapy, often during periods of symptom relief. This behavior is commonly liked to misunderstandings about the disease progression and the treatment objective.^[21-26]
Unintentional non-adherence happens when patients fail to follow treatment recommendations due to factors beyond their control, such as cognitive impairments, language difficulties or physical disabilities.^[21-26]

Complex medication regimens and polypharmacy are among the leading causes of unintentional non-adherence. Additionally, the use of multiple devices, limited understanding of the disease, confusion regarding prescribed medications, depression, have impact on medication non-adherence.^[22,23]Adherence in OAD patients are affected by variety of factors that can be associated with patient, physician, treatment, or society.Patient related factors include cognitive ability, health beliefs, self-efficiency, comorbid conditions, psychological profile, etc.^[23]Treatment & physician related factors are polypharmacy, lack of counseling, patient-prescriber relationship, side effects of drug, method of administration, etc.^[28,30]Society related factors include lack of social support, cultural and societal misbeliefs, access to medication device training follow up, etc.^[23-27]

Enhancing Patient Outcomes: Interventions to Improve Medication Adherence In OAD Patients

Strategies to Improve Medication Adherence in COPD Patients

Patient Education Programs:

Focused education on the chronic and progressive nature of COPD helps patients understand the necessity of continuous medication use, even during asymptomatic periods.^[28-30]

Inhaler Technique Training:

Regular assessment and correction of inhaler techniques through pharmacist-led or nurse-led interventions significantly improve drug delivery and adherence.^[22-30]

Simplification of Treatment Regimens:

Reducing dosing frequency (e.g., using once-daily inhalers) and minimizing the number of inhaler devices can decrease complexity, psychological symptoms and improve adherence.^[22-25]

Use of Digital Reminders and Monitoring Tools:

Smartphone apps, automated calls, and electronic inhaler monitoring systems can provide medication reminders and track inhaler use.^[22-32]

Motivational Interviewing:

Counseling techniques that explore and resolve ambivalence can enhance a patient's intrinsic motivation to adhere to therapy.^[32-35]

Pulmonary Rehabilitation Programs:

Participation in structured rehabilitation programs improves patients understanding of disease management, leading to better adherence.^[35-40]

Addressing Psychological Comorbidities:

Screening and treating depression and anxiety (common in COPD) can indirectly boost adherence by improving patients overall mental health and engagement in self-care.^[40-45]

Strategies to Improve Medication Adherence in Asthma Patients

Asthma Action Plans:

Providing personalized written asthma action plans empowers patients to manage their condition independently, improving medication adherence.^[45-46]

Shared Decision-Making:

Involving patients in choosing their treatment regimens enhances their commitment and satisfaction, resulting in better adherence.^[46-48]

Inhaler Technique Reinforcement:

Similar to COPD, repeated training sessions to perfect inhaler use are critical, as incorrect technique leads to poor disease control.^[40-48]

Behavioral Interventions:

Incorporating behavior-change strategies (e.g., goal setting, self-monitoring) into asthma management programs shows a positive impact on adherence.^[30-46]

School and Workplace-Based Programs:

For children and working adults, targeted asthma management programs at schools or workplaces can maintain adherence in everyday environments.^[22-40]

Minimizing Medication Costs:

Financial assistance programs or prescribing cost-effective medications (such as generics) help remove economic barriers to adherence.^[22-50]

Use of Technology:

Mobile health interventions, such as digital asthma diaries and reminder systems, promote adherence and allow real-time symptom tracking.^[40-50]Bottom of Form

Intervention Category	COPD Patients	Asthma Patients
Patient Education	Structured programs on disease progression and medication importance	Education on asthma triggers, control, and medication use
Inhaler Technique Training	Regular assessment and correction of inhaler use	Ongoing technique checks during clinic visits and pharmacist support
Simplification of Regimens	Once-daily dosing, fewer devices, combination inhalers	Use of combination therapies and reducing daily doses
Behavioral & Motivational Support	Motivational interviewing, goal setting	Behavioral strategies (e.g., self-monitoring, habit-building apps)
Use of Technology	Digital reminders, smart inhalers, adherence-tracking apps	Mobile asthma apps, digital diaries, automated medication alerts
Psychological Support	Screening and management of depression/anxiety	Addressing stress and mental health affecting adherence
Action Plans / Self-Management	Pulmonary rehabilitation and COPD action plans	Personalized asthma action plans
Health System Support	Nurse/pharmacist follow-up, multidisciplinary care	Shared decision-making with patients, school-based or family interventions
Financial Accessibility	Use of generics, reimbursement programs	Reducing cost-related nonadherence

CONCLUSION

Inhalers are the cornerstone in the treatment of obstructive airway disease, yet suboptimal patient adherence poses a significant challenge to achieving treatment goals. Poor medication adherence and inhaler misuse remains significant barriers to optimal management of obstructive airway diseases. Multifactorial strategies addressing patient education, device selection, healthcare system engagement, and emerging technologies are essential for improving adherence rates. Overall, a proactive, multidisciplinary approach can enhance inhaler use, reduce disease burden, and improve patient outcomes.

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