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Review
. 2021 Jun;13(6):3846-3864.
doi: 10.21037/jtd-20-2360.

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

Evalyne M Jansen  1 , Susanne J van de Hei  2   3 , Boudewijn J H Dierick  1   3   4 , Huib A M Kerstjens  3   5   6 , Janwillem W H Kocks  3   6   7   8 , Job F M van Boven  1   3   6
Affiliations
Review

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

Evalyne M Jansen et al. J Thorac Dis. 2021 Jun.

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 short-acting 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.

Keywords: (non)-adherence; Asthma; chronic obstructive pulmonary disease (COPD); clinical outcomes; cost-effectiveness; smart inhaler.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-2360). Dr. HAMK reports research grants from GSK, Novartis, and Boehringer, and fees for consultancies in advisory boards from Chiesi, GSK, Novartis, and Boehringer, all paid to his institution. Dr. JWHK reports grants and non-financial support from AstraZeneca, grants and non-financial support from Boehringer Ingelheim, grants from Chiesi Pharmaceuticals, grants and non-financial support from GSK, grants from Novartis, grants from MundiPharma, grants from TEVA, from null, outside the submitted work; and Dr. JWHK holds 72.5% of shares in the General Practitioners Research Institute. Dr. JFMvB reports grants from AstraZeneca, grants and personal fees from Chiesi, personal fees from Teva, grants and personal fees from Trudell medical, personal fees from Novartis, personal fees from Boehringer Ingelheim, outside the submitted work and all paid to his institution. Dr. JFMvB receives funding from European Commission COST Action 19132 (European Network to Advance Best practices & technoLogy on medication adherence). The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Medication adherence rates across the globe for patients with asthma/COPD. The blue circles represent COPD adherence in the following countries: South Korea, China, Italy, Belgium, Spain, Nigeria, the US and Canada. The orange blocks represent asthma adherence in the following countries: New Zealand, Australia, China, Ethiopia, Saudi Arabia, Brazil, the United States, France and Italy. COPD, chronic obstructive pulmonary disease.
Figure 2
Figure 2
The evolution of smart inhalers over time. (A) Nebulizer Chronolog (68); (B) Aerosol Actuation Counter (MDI) (69); (C) Doser (MDI) (70,71); (D) Smart Mist (MDI) (69,72); (E) MDILog (MDI) (69,73); (F) SmartTouch for Symbicort (MDI) (69,70); (G) SmartInhaler Tracker (pMDI) (69); (H) SmartTrack (MDI) (69,74); (I) Inspiromatic (DPI) (75); (J) Prohaler (DPI) (76); (K) Updated SmartTouch for Symbicort (MDI) (77-79); (L) eMDI (pMDI) (80); (M) Turbu+ (MDI) (81); (N) Electronic Breezhaler (DPI) (82); (O) Hailie for Flovent, available for multiple devices (Ventolin, ProAir, Seretide) (MDI) (83,84); (P) CareTRx (MDI) (69,85); (Q) Propeller sensor Diskus (DPI) (86,87); (R) HeroTracker (DPI & MDI) (88); (S) GSK Elipta inhaler (propeller sensor) (DPI) (89,90); (T) Propeller sensor for Neohaler (and Breezhaler) (DPI) (91,92) ; (U) Findair (MDI) (93); (V) Propeller sensor for Symbicort (pMDI) (94); (W) Enerzair Breezhaler (DPI) (95); (X) I-neb (Nebulizer) (96,97); (Y) Verihaler (MDI) (98); (Z) T-haler (MDI) (99); (A1) RSO1 (DPI) (100); (B1) INCA (DPI) (101); (C1) Respiro Sense diskus (DPI), also available for Easyhaler, Zephir, Handihaler and Elipta (102); (D1) Inspair (pMDI) (103); (E1) Pneumahaler (Soft mist inhaler) (104); (F1) Proair Digihaler (mDPI) (105). *, FDA approved smart inhalers; **, Smartdisk (DPI), Smartturbo (DPI), Smartflow (pMDI), Smartmat (SMI) are devices from the same company but not FDA approved. They all have reminder and feedback function and count the number of inhalation and record time and date, but they are suited for different inhaler devices. This company is now Hailie; #, do predict exacerbations and does not give reminders.
Figure 3
Figure 3
Different types of non-adherence occur among patients with asthma/COPD. The purple boxes represent the steps where smart inhalers could be useful. COPD, chronic obstructive pulmonary disease.
See this image and copyright information in PMC

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