BACKGROUND: Accurate and reliable information about children's use of inhaled medications is needed because of the growing reliance on these drugs in the treatment of asthma and the excessive morbidity and mortality attributable to this disease. OBJECTIVE: This study was designed to evaluate the adherence of children with asthma to regimens of inhaled corticosteroids and β-agonists. METHODS: Data collected electronically by metered-dose inhaler monitors were compared with data recorded by patients on traditional diary cards. A volunteer sample of 24 children, between 8 and 12 years old, who had asthma for which they were receiving both inhaled corticosteroids and β-agonists, participated over a 13-week period. Each child was accompanied by a parent to all study visits. The main outcome measures were the use of medication as reported by diary card entries and recorded by electronic monitoring and disease exacerbation, as indicated by requirement for oral corticosteroids. RESULTS: The median use of inhaled corticosteroids reported by patients on their diaries was 95.4%, whereas the median actual use was 58.4%. More than 90% of patients exaggerated their use of inhaled steroids, and diary entries of even the least compliant subjects reflected a high level of adherence. The children who experienced exacerbation of disease sufficient to require a burst of oral corticosteroids differed markedly from the others in their adherence to prescribed therapy as recorded by the electronic monitors. The median compliance with inhaled corticosteroids was 13.7% for those who experienced exacerbations and 68.2% for those who did not. CONCLUSIONS: Electronic monitoring demonstrated much lower adherence to prescribed therapy than was reported by patients on diary cards. Low rates of compliance with prescribed inhaled corticosteroids were associated with exacerbation of disease. Poor control of asthma should alert the physician to the possibility of noncompliance. (J Allergy Clin Immunol 1996;98:1051-7.)

https://www.jacionline.org/article/S0091-6749(96)80190-4/pdf

Noncompliance and treatment failure in children with asthma

This article reviews recent literature in chronic illness or long-term health management including asthma, contraception, diabetes, HIV disease, and hypertension/cardiovascular disease, mental disorders, pain, and other diseases to determine the relationship between regimen factors and adherence to medications. The authors conducted an electronic literature search to detect articles published between 1998 and 2007. Articles were included if they pertained to a chronic illness or to contraception, included a clear definition of how adherence was measured, and included regimen factors as primary or secondary explanatory variables. Methodology of the studies varied greatly, as did methods of measuring adherence and regimen factors. Surprisingly few of these articles concerned (1) chronic treatment, (2) regimen factors such as dosing, pill burden, and regimen complexity, and (3) adherence measured in a clear manner. Most studies failed to use state-of-the-art methods of measuring adherence. Despite these flaws, a suggestive pattern of the importance of regimen factors, specifically dose frequency and regimen complexity, emerged from this review.

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The impact of medication regimen factors on adherence to chronic treatment: a review of literature

Inhaled corticosteroids for asthma therapy: patient compliance, devices, and inhalation technique.

Poor adherence to medication regimens may be contributing to the recent increase in asthma morbidity and mortality. We examined patient characteristics that may influence adherence to twice-daily inhaled steroid regimens. Fifty adults with moderate to severe asthma completed questionnaires examining sociodemographics, asthma severity, and health locus of control. Adherence was electronically monitored for 42 d. Following monitoring, patients' understanding of asthma pathophysiology and the function of inhaled corticosteroids were assessed. Patient beliefs about the effectiveness and convenience of these medications, and their perception of communications with their clinician were measured. Mean adherence was 63% ± 38%; 54% of subjects recorded at least 70% of the prescribed number of inhaled-steroid actuations. Factors associated with poor adherence were less than 12 yr of formal education (p < 0.001), poor patient–clinician communication (p < 0.001), household income less than $20,000 (p = 0.002), Spanis...

Adherence with twice-daily dosing of inhaled steroids. Socioeconomic and health-belief differences.

Background: Sociobehavioral factors influence adherence to inhaled corticosteroid (ICS) in adults with asthma and warrant exploration as explanations of apparent racial disparities in adherence. Objective: The purposes of this study were to identify barriers to adherence, potentially modifiable by healthcare providers, in a group of African Americans and non–African Americans and to test modifiable barriers as explanations of racial-ethnic differences in adherence. Methods: We conducted a cohort study of 85 adults (mean age, 47 ± 15 years; 61 [72%] female; 55 [65%] African American) with moderate or severe persistent asthma to determine modifiable sociobehavioral predictors of adherence. These were knowledge of the function of ICS, patient-perceived adequacy of communication with the provider, social support, attitude (perception of risks/benefits of ICS), depression, and self-efficacy. Adherence was calculated from electronic monitoring data as the mean of the number of doses recorded per 12 hours divided by the number prescribed, truncated at 100%. Past adherence, baseline severity of symptoms, and sociodemographics were treated as fixed confounders in ordinal logistic modeling. Results: Adherence was 60% ± 30%. In bivariate analyses, favorable attitude to ICS ( P = .01) was associated with better adherence. Of immutable predictors, African American race-ethnicity ( P = .001), lower educational achievement ( P = .01), lower household income ( P = .002), and more baseline symptoms ( P = .003) were associated with poorer adherence. In multivariable analysis, controlling for immutable predictors, favorable attitude was associated with adherence. Favorable attitude was associated with greater adherence in African Americans and non–African Americans. Controlling for immutable factors, the race-adherence relationship was not mediated by the mutable factors, but economic factors (income and insurance) were mediators. Conclusion: Attitude is strongly related to adherence but does not mediate the effect of race-ethnicity. (J Allergy Clin Immunol 2003;111:1219-26.)

https://www.jacionline.org/article/S0091-6749(03)01113-8/pdf

Modifiable barriers to adherence to inhaled steroids among adults with asthma: It's not just black and white

A Comparison of the Effects of bid and qid Dosing on Compliance with Inhaled Flunisolide

https://journal.chestnet.org/article/S0012-3692(16)59052-7/pdf

An evaluation of severity-modulated compliance with q.i.d. dosing of inhaled beclomethasone.

The Influence of Spring and Summer New England Meteorologic Conditions on the Respiratory Status of Patients With Chronic Lung Disease

Synchronous primary lung tumors are uncommon, and primary lung sarcomas are especially rare. We report an unusual case of a poorly differentiated carcinoma and a primary sarcoma of the lung. The surgical approach to patients with synchronous primary lung tumors should be aggressive. © 1992 Wiley-Liss, Inc.

Marianne Mann

Papers

A Comparison of the Effects of bid and qid Dosing on Compliance with Inhaled Flunisolide

An evaluation of severity-modulated compliance with q.i.d. dosing of inhaled beclomethasone.

The Influence of Spring and Summer New England Meteorologic Conditions on the Respiratory Status of Patients With Chronic Lung Disease

Simultaneous primary lung sarcoma and carcinoma.