Community Pharmacists Tackle Asthma Medication Adherence

Asthma is a heterogeneous lung disease defined by a history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity.¹ Chronic airway inflammation and variable expiratory airflow limitation is also typically present. Asthma treatment usually involves a maintenance controller regimen and as-needed reliever therapy, depending on asthma severity.

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The main risk factors for asthma exacerbations, increased hospitalizations, and even death are prolonged excessive use of short-acting beta-agonists (SABA) and inadequate use of inhaled corticosteroids (ICS).² As a result, current asthma guidelines no longer recommend as-needed SABA inhalers alone for asthma treatment. Instead, ICS should be initiated at the time of asthma diagnosis either for daily or as-needed use in conjunction with formoterol.¹

Adherence to asthma controllers is important for improving outcomes in patients with asthma, but approximately 50% of adults and children on long-term treatments for asthma fail to take medications as directed at least part of the time.³ Community pharmacists are well-positioned to provide patient counseling regarding asthma control, and spark discussions surrounding reliance on SABA inhalers and the potential risks of overuse.

A small, non-randomized, before and after feasibility study conducted in Auckland, New Zealand, assessed whether a community pharmacy intervention to reduce SABA overuse and improve adherence to maintenance therapy for asthma was practical.⁴ The study enrolled 35 adult patients who were prescribed a SABA for the relief of their asthma symptoms, across four pharmacy locations.

Pharmacists provided usual care to participants in the control arm. In addition to usual care, pharmacists administered the Risk of Reliance Test (RRT) to participants in the intervention arm. The RRT is a brief, online intervention for patients with asthma, designed to identify and change patient beliefs driving inappropriate SABA use. It personalizes behavior change messages depending on the participant’s responses to the SABA Reliance Questionnaire (SRQ). As part of the RRT, patients received standardized written information about SABA and asthma tailored to their SRQ responses, and personalized verbal discussion with the pharmacist. Pharmacists referred patients to their primary care provider if they were at risk of SABA overuse (SRQ score ≥18) or self-reported not using a controller inhaler. The researchers conducted follow-up surveys at 30 and 90 days.

Although the study reported challenges with patient recruitment and retention, it did show that a brief community pharmacy-delivered behavior change intervention to shift patients’ beliefs about SABA is feasible and mostly acceptable to patients and pharmacists.

The researchers concluded that the RRT highlighted SABA-related issues for patients, and informed pharmacists of the widespread SABA overuse among the cohort. Pharmacists reported that the RRT was useful and that they valued the resources and strategies provided to them. Participants stated that the information they received was easy to understand, and over half reported that they liked the information provided and that a pharmacist was providing the intervention.

This study is the first to preliminarily show that a community pharmacist intervention can produce a positive effect on reducing SABA reliance and improvement of ICS adherence in patients with asthma. Due to the small number of patients, the results were not statistically significant. A larger, sufficiently powered randomized-controlled trial is necessary to confirm these findings.

References

1. 2023 Global Initiative for Asthma (GINA) Report: Global Strategy for Asthma Management and Prevention. Accessed on April 25, 2024. www.ginasthma.org/2023-gina-main-report

2. Zhang X, Ding R, Zhang Z, Chen M, Yin Y, Quint JK. Medication Adherence in People with Asthma: A Qualitative Systematic Review of Patient and Health Professional Perspectives. J Asthma Allergy. 2023;16:515-527. doi:10.2147/JAA.S407552

3. Murphy J, McSharry J, Hynes L, Matthews S, Van Rhoon L, Molloy GJ. Prevalence and predictors of adherence to inhaled corticosteroids in young adults (15-30 years) with asthma: a systematic review and meta-analysis. J Asthma. 2021;58(5):683-705. doi:10.1080/02770903.2020.1711916

4. Foot H, Beyene K, Horne R, Fingleton J, Harrison J, Chan AHY. Evaluating the Feasibility of a Community Pharmacy-Delivered Behaviour Change Intervention to Reduce Reliever Reliance in Asthma. Patient Prefer Adherence. 2024;18:361-371. doi:10.2147/PPA.S445763