PHOENIX – Before considering oral steroids or biologic therapies, many people with difficult-to-control asthma can reduce symptoms by addressing medication adherence and inhaler technique – and digital monitoring devices can play a key role.
Often physicians “will approach a patient about a biologic if they’re not responding to standard therapy. But we need to sometimes go back to those basic building blocks, like, are you taking the standard therapy?” William C. Anderson, MD, codirector of the multidisciplinary asthma clinic at Children’s Hospital Colorado, Aurora, said in an interview.
At the annual meeting of the American Academy of Allergy, Asthma, and Immunology, he and others presented data highlighting the diagnostic and therapeutic potential of digital monitoring devices for difficult-to-control asthma, the theme of the 2022s meeting.
The Global Initiative for Asthma (GINA) defines asthma as “difficult to control” if it remains uncontrolled despite medium- or high-dose inhaled corticosteroids with a second controller or with maintenance oral steroids, or if the asthma requires high-dose treatment to curb symptoms and exacerbations. About 17% of adult asthma patients have difficult-to-control asthma, according to the 2021 GINA report.
However, correcting for inhaling technique and adherence cuts the 17% down to just 3.7%, Giselle Mosnaim, MD, an allergist at NorthShore University HealthSystem outside Chicago and AAAAI immediate past president, told attendees at a Feb. 25 session on digital technologies for asthma management.
The CRITIKAL study, which reviewed data from more than 5,000 asthma patients, “showed that, if you have critical errors in inhaler technique, this leads to worse asthma outcomes and increased asthma exacerbations,” Dr. Mosnaim said. Sadly, it also shows that, from 1975 to 2014, despite new devices and new technologies, “we still have poor inhaler technique.”
As for ways to measure adherence, physician judgments tend to be inaccurate, patient self-reporting has proved unreliable, and prescription refill data doesn’t indicate whether patients actually used the medications. “The ideal measure of adherence should be objective, accurate and unobtrusive to minimize impact on patient behavior and allow reliable data collection in real-world settings,” Dr. Mosnaim said. “So electronic medication monitors are the gold standard.”
Tracking adherence
A closing afternoon session featured three presentations on research tracking adherence and outcomes in difficult-to-treat asthma patients – two pediatric cohorts and one across all ages. All studies used the Propeller Health sensor, a Food and Drug Administration–cleared device that attaches to the patient’s inhaler and automatically collects information on where, when, and how often they use their medication. The sensor then sends that information to a data cloud accessible to the patient and their health care professional.
Dr. Anderson’s team scoured a nationwide Propeller Health database for 8,000 patients using the digital monitors with controller therapies for asthma or chronic obstructive pulmonary disease (COPD). The study explored whether adherence differed for once-daily versus twice-daily medications, and if adherence differed based on patient age (4-60+ years).
For both asthma and COPD patients, those on once-daily regimens had higher medication adherence, compared with those who were prescribed twice-daily therapies. Plus, a greater proportion of once-daily patients met the prespecified 80% adherence threshold.
Looking across ages, medication use in the youngest group (aged 4-11 years) looked comparable with 30-somethings, “probably because parents are the ones giving the drug,” Dr. Anderson said. Mirroring patterns from other studies, adherence levels dipped in adolescents and young adults, relative to other age subsets.
Since this population-level analysis didn’t include individualized data on exacerbations or asthma control, “we can’t relate this to outcomes,” Dr. Anderson noted. But he said the data correlating medication use with adherence suggest that once-daily formulations may be the better option.
In one of the two pediatric studies, Matt McCulloch, MD, an allergy and immunology fellow working with Dr. Anderson, and colleagues reviewed charts of 40 children who received care at the Colorado Children’s multidisciplinary asthma clinic between 2018 and 2021. Half of these patients used Propeller Health sensors with their daily inhaled controller; the other patients were matched for age, ethnicity, sex, medication level, and disease control and severity – but had no electronic monitoring device.
On the whole, children who used digital monitoring for 12 months did not fare much better than matched controls on lung function (judged by forced expiratory volume) or asthma control (measured by Asthma Control Test scores).
However, within the digital monitoring group, patients who stayed on the Propeller system for 12 months did have better asthma control, fewer exacerbations, and improved asthma severity scores (measured by the Composite Asthma Severity Index), compared with when they first began digital monitoring. These children had all received care at the clinic for a while before their families opted for the electronic sensor, so “the effect wouldn’t have just been from starting in the clinic,” Dr. McCulloch said in an interview.
The gains came despite waning medication adherence. Similar to other digital monitoring studies, use of daily controller therapies in this retrospective analysis began at 50%-80% but dropped considerably during the first 4-5 months before settling into the 20%-30% range by 1 year.
Rachelle Ramsey, PhD, a pediatric research psychologist at Cincinnati Children’s Hospital Medical Center, presented data from 20 children with difficult-to-treat asthma who received 8 weeks of a digital adherence intervention during a 12-month treatment period. They analyzed three subsets – each with interventions based on how well the patients were managing daily controller therapy at baseline.
One patient with high (>80%) baseline adherence just received digital monitoring. The seven patients who began the study with intermediate (50%-80%) adherence received digital monitoring plus prescriptive text messaging. And the 12 children with poorest (<50%) baseline adherence received digital monitoring and a telehealth session in which a behavioral health specialist helped them set goals and create strategies to overcome barriers – for example, keeping the inhaler near their toothbrush in order to pair medication use with a daily habit.
“Overall, we found that matching Propeller with a behavioral intervention really improved adherence,” Dr. Ramsey said in an interview. While patients were receiving the intervention, adherence averaged across all groups increased from 39% to 76%. However, once the intervention period ended, the group’s adherence regressed toward baseline (36%).
Although adherence did not associate with clinical gains in this small study, the use of digital monitoring to improve medication adherence has translated to better outcomes in other recent efforts.