Drug Factors Affecting Asthma Medication Adherence in Egypt

Background:

Optimal asthma management has been found largely due to patients’ medication adherence and correct inhaler technique. This study aimed to examine drug-related factors affecting medication adherence among Egyptian asthma patients

Methods: A descriptive cross-sectional study was carried out among 110 clinically diagnosed asthma patients attending at a university hospital, in Sohag, Egypt. Inhaler criteria and adherence were evaluated by a standardized tool “Morisky Medication Adherence Scale, 2008'.

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Results: Findings of the study revealed that out of 110 patients 22.9% had a medium level, 42.2% had a high level, and 34.9% had a low level of medication adherence. There was no relationship between demographic data and adherence in asthmatic patients. However, Good adherence was frequently encountered among asthmatic patients who used an inhaler twice daily, who used drugs its onset of action 5- 20 minutes, who used aerosolized and turbo haler devices and who used budesonide and budesonide/formoterol.

Conclusion: Nonadherence is high among asthma patients attending sohag university hospital in Upper Egypt. There was a strong relationship between inhaled drug criteria and the degree of adherence in asthmatic patients.

Key Words: COPD, bronchial asthma, adherence, inhaled therapy.

Introduction:

Adherence to medication is a crucial part in the long-term management of asthma. In asthmatic patients, non-adherence or inhaler mishandling increases mortality, morbidity, and hospital admission [1, 2].

Factors related to adherence to inhaled therapy include the complexity of the inhalation regimen, type of inhaler device, type of inhaled agent, and a variety of patient beliefs and sociocultural and psychological factors(2). Therefore, promoting optimal medication adherence is essential to optimize the benefits of treatment. Consequently, assessment of the degree of adherence to inhaled therapy in asthmatic patients becomes increasingly important in daily practice.

By opposition, nonadherence leads to poor clinical outcomes, an increase in morbidity and mortality, and unnecessary healthcare expenditure (3). There are limited studies that have examined adherence to asthma therapy in Egypt. The aim of the study: was to assess adherence to inhaled therapy in patients with bronchial asthma and to examine drug-related factors affecting medication adherence among Egyptian asthma patients

Patients and Method:

Study subjects and design

A descriptive cross-sectional study design was used, and 110 clinically diagnosed asthma patients were selected from the inpatient department and outpatient clinic of chest diseases, at Sohag university Hospital. Before the data collection, the study was approved by the local ethical committee of Sohag university hospitals and written informed consent was taken from every patient included in the study.

After taking informed consent from the patients, the information regarding age sex, literacy, residence, occupation, smoking habits, Socioeconomic status, co-morbidities, date of diagnosis of asthma and pulmonary function tests were recorded.

Inhaler Use

Further questions related to the currently prescribed aerosol therapy for asthma-like the number of medications prescribed per day, type of device, type of drug, the onset of action of inhaler and frequency of administration of inhaler. .

The currently prescribed medications for asthma were identified for all included patients: long-acting β2-agonists (LABA), inhaled corticosteroids, combined LABA/ inhaled corticosteroids, short-acting anticholinergics, short-acting β2-agonists, long-acting anticholinergics. Most patients were on combination therapy.

Morisky medication adherence scale scores

Medication adherence was tested using the eight-item Morisky Medication Adherence Scale [4]. The MMAS-8 is an eight-item questionnaire with seven yes/no questions and the last question is a five-point scale. On the basis of the scoring system of MMAS-8, adherence was rated as follows: high adherence (score: 8), moderate adherence (score: 6 to Statistical analysis:

The data collected by using a structured questionnaire and reviewing medical record forms were entered in a separate spreadsheet using EXCEL (2010). The entered data was analyzed using Statistical package for social sciences (SPSS) software version 20. Quantitative data was represented as mean± standard deviation. Data was analyzed using ANOVA for comparison of the means of three groups. Qualitative data was presented as numbers, and percentages and compared using the Chi-square test. P-value < 0.05 was considered as statistically significant.

Results:

The demographic and medical characteristics of the studied patients are shown in Table 1.A total of 110 took part in the study at Sohag University Hospitals and Clinics, Sohag, Egypt. The patients had a mean age of 39.22±13.51 years. There were more females than males (69/ 41; 62.72%). 50% of patients are illiterate.

The most commonly used inhaled therapy in asthma patients is presented in Table (2). As regards the frequency of administration of the inhaler, it was found that asthma patients were frequently using the inhaler twice daily, also asthmatic patients used the on need more frequently. As regards the onset of action of inhalers, it was found that the inhaler that of 5 minutes of the onset of action was more frequently used by asthma patients than other types of inhalers. As regards type of device, it was found that aerosolized, MDI, turbo haler and hand haler were frequently used by asthma in order than other types of devices. As regards type of drug, it was found that budesonide, formoterol, salbutamol and budesonide/ formoterol were more frequently used by asthma in order than other types of drugs.

The proportion of patients in the different categories of adherence according to the MMAS-8 questionnaire is shown in Fig 1. Based on the MMAS-8 questionnaire, 42.2% of patients had good adherence, 22.9% intermediate adherence, and 34.9% poor adherence.

Table (3) shows the relation between demographic data and adherence in asthmatic patients already on inhaler therapy. There was no statistically significant relationship between demographic data and adherence in asthmatic patients (P>0.05).

The relation between drug characteristics and adherence patterns in asthma patients already on therapy is shown in Table (4) (Fig 2 A, B, C, D). It was found that there was a statistically significant relationship between adherence pattern and frequency of administration, onset of action, type of device, type of drug with P=(0.001, 0.002, 0.001, 0.001) respectively. It was found that good adherence was frequently encountered among patients who used an inhaler twice daily, who used drugs its onset of action

Discussion

Medication adherence is important for asthma patients for the effectiveness of the therapy. Adherence was measured using the MMAS-8 – a scale that has been used widely to investigate adherence to medication in many disease areas including asthma (5) and COPD (6), where it has been used to investigate adherence to inhaled medications.

Analysis of the demographics of the study population revealed the majority of asthma patients are female (62.72%). The study was conducted in 110 asthma patients among which 69 were female and other 41 were male. The mean age was of 39.22±13.51 years. 52.72% came from an urban area, 86.36 % had middle socioeconomic class, and .50% was illiterate. The mean duration of asthma was 11.21±8.91 years. Likewise, more than half (75.45%) of the patients had one co-morbidity.

In our study, we found that, among the studied population poor adherence was observed in 34.9%, 22.9% intermediate adherence, and 42.2% of patients had good adherence. This result matches with the results of the study of (7, 8) who found that adherence among asthmatic patients was 49%. This percentage shows that still many asthmatic patients are not adherent to their inhalational medications. Previously done research shows that adherence to inhaled therapies is worse than that seen with oral or injected therapies in patients with asthma in different age groups [9–12]. Whereas in previous studies, among asthma patients, medication adherence rates have consistently been shown to be 30–40% and may increase as high as 70% [13–17]. This discrepancy in findings may be due to the difference in knowledge regarding asthma among participants, use of different measurement tool and the inclusion of different groups of the sample population in the study.

In this study, none of the variables related to sociodemographic information (such as age, gender, place of residence, educational status, co-morbidity, the severity of symptoms and smoking habit), were associated with the patient's level of medication adherence. Consistent to these findings, Senior et al., 2004 showed that there was no association between the level of adherence with sociodemographic and clinical variables (age, gender, marital status, and place of residence, education, type of occupation and current smoking status, and severity of asthma (18). However, these findings are contradictory to other studies (19). The difference in findings might be due to the inclusion of patients of different duration of disease, different study designs and use of different validated tools in the studies.

As regard the frequency of administration of inhaler in our study we found that 75.5% preferred twice-daily therapy, 2.7% preferred once daily and 21.8% used inhaler on need. There was a statistically significant relationship between good adherence and the use of an inhaler twice daily in asthmatic patients in comparison with the use of a need inhaler However, this result is not comparable with that of the result of (20) which showed that 61% of patients expressed a preference for once-daily treatment, 12% preferred twice-daily treatment and 27% expressed no preference. Other studies found that adherence in asthmatic patients was unrelated to the number of daily doses of inhaler therapy (21 - 23). Others observed that reliever inhalers were frequently used in asthmatic patients (24 - 25).

As regards the onset of action of an inhaler, we found in our study that the inhaler of 5- 20 minutes of the onset of action was more frequently used by patients than other types of inhalers and this was statistically significant, this result due to asthma patients almost always complaining and need rescue bronchodilators medications which rapidly acting, also it is believed that the perception of the product delivering its action rapidly may lead the patient to continue taking the therapy on a daily basis (26).

In our study, there was a statistically significant relationship between good adherence and the use of turbo haler and aerosolized in asthmatic patients in comparison with the use of MDI. Our study result agrees with a previous study of (27) which found that using dry-powder inhalers (DPIs) versus metered-dose inhalers (MDIs) was linked to adherence in this study's results.

Moreover, we found that there was a statistically significant relationship between good adherence and the use of budesonide/ formoterol and budesonide in asthmatic patients in comparison with the use of salbutamol. This observation agrees with that of Axelsson et al. who found better adherence to ICS/LABA compared to ICS and/or LABA and/or SABA) (28) and compared with ICS in monotherapy or in combination with LABA or montelukast in the study of (29)

Conclusion: Findings of the study showed good adherence frequently encountered among asthmatic patients who used an inhaler twice daily, who used drugs its onset of action 5 - 20 minutes, who used Aerolizer and turbo haler and who used budesonide and budesonide/ formoterol and it was statistically significant. Educational programs should be included in for improving adherence to inhaled medications in asthma patients.

Conflict of Interests: The authors declare that there is no conflict of interest regarding the publication of this paper.

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