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Introduction
Inhaled Steroids in Childhood Asthma
PN Black1, E Garratt1, L Noonan1, C Arandjus1, BT Salmon2, G Sutherland3
University of Auckland=
1, Counties-Manukau District
Health Board2 and Nexus 63; Auckland, New Zealand.
Abstract
Results
Methods
Conclusions
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Backg=
round: Poor compliance with inhaled medic=
ines
is an important cause of poor asthma control. Covert electronic monitoring=
of
inhaler use suggests that the average compliance with inhaled steroids is
fifty percent. Strategies th=
at
remind patients to take their medication may lead to an improvement in ast=
hma
control.
Metho=
ds: We have stu=
died
an inhaler with an alarm that can be set to ring twice a day. The inhaler =
has
14 different ring tones, one for each morning and evening of the week. We
randomised children (7-16 yrs) with symptomatic asthma, despite being on
treatment with inhaled steroids, to two months treatment with the alarm tu=
rned
on (n=3D20) or off (n=3D20). The prescribed dose of inhaled steroid did no=
t change
during the study. Endpoints were changes in quality of life (AQLQ), FEV1, =
use
of salbutamol and compliance with inhaled steroid (the use of the inhalers=
was
measured with covert electronic monitoring).
Resul=
ts: In the last two weeks of the study
median compliance with inhaled steroids was 92.0% with ring tones and 51.5=
% in
controls (p<0.0001). The pre-bronchodilator FEV1 increased from 78.6%
predicted to 88.4% predicted with the ring tones and from 89.8% predicted =
to
94.1% predicted in the control group. The change in AQLQ scores over the s=
tudy
were 1.1 and 1.3 respectively.
Concl=
usions: The use of inhalers with ring tones
leads to improved compliance with inhaled steroids and may be a useful
strategy for improving asthma control.
Regular use of inhaled steroids is more effective in
reducing
symptoms, improving lung function and reducing
exacerbations. Unfortunately many patients have poorly
controlled asthma because they do not take their
inhaled
steroids on regularly. INSPIRE study surveyed 3415 adul=
ts
with asthma on treatment with inhaled steroids or
=
combination therapy(1). Half were classified as having=
3;
uncontrolled asthma.
§&#=
13;
Evidence that lack of control is related to poor
adherence
comes from studies where inhaler use is monitored
covertly
Milgrom et al used covert monitoring in children and
found
median use of inhaled steroids was 58%(2). In the patients
with exacerbations the median compliance was only 14%.
§&#=
13;
One way to improve compliance may be to incorporate an&=
#13;
electronic reminder alarm into the inhaler. Charles et =
al
found an alarm that sounded twice a day improved
<=
/span>
compliance with inhaled fluticasone(3). Mean percentage=
of
medication taken in last 12 weeks of the study was 88%
with
alarm and 66% for controls (p<0.0001). We have
conducted
a study in children with a reminder alarm but in this c=
ase
using a variety of ring tones.
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The use of an inhaler with ringtones a=
s a
reminder alarm
was associated with significantly grea=
ter
adherence with
inhaled steroids during study.
There was a greater improvement in lung
function
with the ringtones but this was not
statistically
significant. A larger study may have m=
ore
clearly
shown the benefits of greater adherenc=
e on
asthma control.
&#=
13;
It is possible that the benefits of us=
ing
ringtones to improve
adherence will also prove to be greater outside the con=
text
of clinical trials (which can promote
adherence)=
, in patients =
3;
with very low adherence at baseline and
those who are on
lower doses of inhaled steroids.
<=
/span>
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Participants
were children (7-16 years) with diagnosis
of
asthma and symptoms despite inhaled steroids. All
were
treated with twice daily inhaled fluticasone (in
same
dose they were receiving before study) along
with
salbutamol as required. Patients on treatment with
beclomethasone
or budesonide were changed to
equivalent
dose of fluticasone. Children on treatment
with
LABA continued on salmeterol.
§
Children
were randomised to standard inhaler or one
with
ringtones. There were 14 different ringtones one
for
each morning and evening of the week. Throughout
the
study inhaler use was covertly monitored with a
microprocessor
concealed in the inhaler.
§
40
children were randomised to treatment. Children
took
part in study for 8 weeks. They were seen on
three
occasions – at beginning of the study, 4 weeks
and
end of the study. On each occasion spirometry was
performed
and QoL assessed using Paediatric Asthma
Quality
of Life Questionnaire (PAQLQ). Children
were
not asked to monitor PEF at home or fill in daily
record
card because this was not something they
usually
did and we were concerned it would modify
compliance.
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Controls
(n=3D20)=
Ringtones
<=
/span>
(n=3D20)
Age (yrs)
<=
/span>
mean (SD)
9.9 (2.4=
)
9.8 (2.8=
)
Gender (M/F)=
3;
&#=
13;
15/5
12/8
FEV1 % pred
Baseline (pre)
mean (SD)
89.9 (13=
.8)
78.6 (20.5)
FEV1 % pred
=
;
Baseline
(post)
mean (SD)
94.5 (13=
.5)
86.9 (16=
.3)
Daily do=
se fluticasone μg mean (SD)
263 (144=
)
203 (120=
)
Use of LABA
=
;
(n)
7=
9=
![3DFlixotide](3D"slide0009_image016.gif")
![3D"FEV1_%_predicted_Prebronchodilator_graph"](3D"slide0009_image018.gif")
![3D"PAQLQ_Overall_graph"](3D"slide0009_image020.gif")
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References
![3D"Median_%Adherence_Inhaled_Steroids_graph"](3D"slide0009_image023.gif")
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1. Partridge MR, van der Molen T, Myrseth S-E, Busse WW. Attitud=
es
and actions of asthma patients on regular maintenance
therapy: the INSPIRE study. BMC Pulm Med 2006; 6:
13.
•2. Milgrom H, Bender B, Ackerso=
n L,
Bowry P, Smith B, Rand C. J Allergy Clin Immunol 1996; 9=
8:
1051-7.
3. Charles T, Quinn D, Weathera=
ll M,
Aldington S, Beasley R, Holt S. An audiovisual reminder function improves adherence w=
ith
inhaled corticosteroid therapy in asthma. J Allergy C=
lin
Immunol 2007; 119: 811-6.
=
Fig
1. Median adherence for inhaled steroids (as % of prescribed dose) is shown
for weeks 1 to 2, 3 to 4, 5 to 6 and 7 to 8 during the stud=
y.
Adherence was significantly greater with ringtone inhalers from weeks 3-4
onwards and decline in adherence from beginning to end of study was signficantly less with =
the
ringtones (p<0.0001).
Fig 2. Prebronchodilator FEV1 (% predicted) at beginnin=
g,
middle (week 4) and end of study (week 8). Change in FEV1 (% predicted) fr=
om
beginning to end of study did not differ significantly between treatments.=
=
Fig
3. Overall score for PAQLQ at
beginning, middle (week 4) and end of study (week 8). The change in PAQLQ score from beginning to end of
study did not differ significantly between treatments.
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