Transcript
Announcer Introduction
You’re listening to Deep Breaths: Updates from CHEST on ReachMD. This is a non-promotional, non-CME disease state disease education podcast series brought to you by American College of CHEST Physicians in collaboration with and paid for by GSK.
DR. TURCK:
Welcome to Deep Breaths: Updates from CHEST on ReachMD. I'm Dr. Charles Turck. And joining me to share strategies for treatment adherence and discuss multiple versus single inhaler triple therapy in chronic obstructive pulmonary disease, or COPD, is Dr. Chitra Lal, Professor of Medicine at the Medical University of South Carolina in Charleston. Dr. Lal, welcome to the program.
DR. LAL:
Thank you, Dr. Turck, it's a pleasure to be here today.
DR. TURCK:
To start us off, Dr. Lal, let's take a look at adherence to inhaled therapy in patients with COPD. What do we need to know about that?
DR. LAL:
Adherence in COPD is estimated to be about 23.4 percent in the United States. And this is a fairly low level of adherence to COPD therapy, and this has several causes. Patients may not start their therapy, they might not use the medication as intended, or they may not stay on the therapy. Patients can also exhibit both intentional as well as unintentional nonadherence. Intentional nonadherence is an active decision made by the patient that they may not fill the therapy at all. And 15 percent of patients do not fill a new prescription or they might discontinue their therapy after six months. On the other hand, unintentional nonadherence is a passive process where the patient may not adhere to therapy, because of reasons which are out of their control, such as old age or dexterity issues, or socioeconomic status, where they might fail to fill the medication for financial reasons. Prevalence estimates for unintentional nonadherence are also fairly high. And they vary from 20 percent to more than 50 percent.
DR. TURCK:
So what are some factors that you see in your patients as well as in the literature that impact adherence in COPD? Are there any barriers that you often see play a role in adherence in these patients?
DR. LAL:
That's a great question. So non-persistence to therapy is often seen in younger COPD patients, and also those who are still smoking. And unfortunately, patients with more severe COPD also generally tend to be nonadherent to therapy. Using multiple inhalers and higher regimen complexity can also increase rates of nonadherence to therapy. In addition to that, there are some other factors which might also impact adherence, such as advanced age, high cost of treatment, disease state, and medication knowledge of the patient, poor communication with the healthcare professional, adverse effects of medications, and, last but not least, you know, there are several comorbid conditions such as depression, congestive heart failure, diabetes, and so on, which can also impact medication adherence in respiratory diseases such as COPD.
DR. TURCK:
So what are some of the potential consequences of poor therapy adherence in patients with COPD?
DR. LAL:
So unfortunately, poor therapy adherence in COPD results in poor control of symptoms, which in turn can result in a poor quality of life. And patients also tend to have a higher exacerbation frequency for their COPD, which results in recurrent hospitalizations and increased healthcare utilization and costs.
And I often see this in my clinical practice as well, that patients who are noncompliant with their treatments tend to have more frequent COPD exacerbations. We have also seen a higher mortality rate in these patients who tend to be less compliant with therapy. And in fact, there was a subanalysis in the TORCH study, where this was shown that patients who had good adherence to therapy had a lower mortality rate as compared to patients who had poor adherence to COPD therapy. The mortality was about 11.3 percent in patients with good adherence to COPD therapy, as compared to 26.4 percent in patients who had poor adherence to COPD therapy.
DR. TURCK:
Now, earlier you'd mentioned multiple inhalers as a factor that impacts adherence. Let's dive a little deeper into that topic. What can you tell us about the impact of single inhaler versus multiple inhalers on treatment adherence?
DR. LAL:
I'm glad you asked that, Dr. Turck, because I feel that single inhalers do have a significant impact on treatment as compared to multiple inhalers. So in fact, there was a very large market scan data based study conducted from 2004 to 2008, where patients with two or more COPD medical claims, and two or more prescriptions for a long-acting inhaler within the last one year, were classified as users of single or multiple inhalers on the basis of their treatment regimen. And this was a large study. They had a total of 23,000 plus patients who were grouped into evenly matched pairs. And after they had adjusted for confounding factors, they found that patients who were using multiple inhalers had a significantly higher discontinuation rate for their treatment, as compared to patients who were using single inhalers. So users of multiple long-acting inhalers were found to have lower treatment persistence and adherence rates as compared to patients who were using single long-acting inhalers.
DR. TURCK:
And are those observations from the literature consistent with what you see in your clinical practice?
DR. LAL:
Yes, indeed, they are actually. And I have often found that when patients are prescribed too many inhalers, it is often difficult for them to follow the instructions and to know what the indication of each inhaler is. And this in turn can result in poor treatment compliance, which results in worsening symptom control, and recommend hospitalizations for COPD.
On the other hand, if the inhaler regimen can be simplified, say for example, a single combination inhaler with all the medications that the patient needs to have, such as single inhaler triple therapy with bronchodilators and inhaled steroids, that in turn can translate into better patient compliance with treatment, better symptom control. So this is certainly consistent with my own clinical experience.
DR. TURCK:
Now focusing on just single inhaler triple therapy, how can this treatment option improve adherence compared to multiple inhaler triple therapy for patients with COPD?
DR. LAL:
Now there's another fairly large study which was a retrospective analysis from the IQVIA real world data claims database in patients with COPD, and they looked at patients who were on single inhaler therapy as compared to those who were on multiple inhalers. The study found that patients who were on single inhaler triple therapy were significantly more adherent to therapy as compared to those who were initiated on multiple inhaler triple therapy. Adherence in this study was defined as proportion of days covered of 0.8 or greater. It was also found that the mean treatment duration was 81 days longer for patients initiated on single inhaler, triple therapy with lower use of other COPD medications. For example rescue inhalers or steroids during follow-up, as compared to patients were initiated on multiple inhaler triple therapy.
DR. TURCK:
And before we close, Dr. Lal, do you have any advice for those in our audience looking to improve adherence to treatment for their COPD patients?
DR. LAL:
Yes, so I feel that the data is clear that fixed dose combination therapies such as bronchodilators, which would be a LABA and a LAMA combination, as well as bronchodilators and inhaled corticosteroids have therapeutic benefits, and they can also potentially improve patient compliance with treatments. Ultimately, our goal is for patients to remain well controlled on a single combination inhaler. And also, for the patient to better understand how and when to use their maintenance and treatment medications.
DR. TURCK:
With those insights in mind, I want to thank my guest, Dr. Chitra Lal, for discussing single versus multiple inhalers and the role inhalers play in adherence to COPD treatment. Dr. Lal, it was great speaking with you today.
DR. LAL:
Thank you, Dr. Turck. Likewise, it was a pleasure to talk to you.
Announcer Close
This episode of Deep Breaths: Updates from CHEST was brought to you by American College of CHEST Physicians in collaboration with and paid for by GSK. To access other episodes of this series, visit ReachMD.com/CHEST, where you can Be Part of the Knowledge.