The document discusses adherence to inhaler treatment for conditions like asthma and COPD. It begins by explaining how reward circuitry in the brain reinforces behaviors that promote survival. It then defines adherence and compliance, noting that adherence involves active patient participation while compliance is more passive following of doctor's orders. The document outlines factors influencing adherence like treatment complexity and social support. It reviews data showing poor adherence to inhalers and notes lower adherence for pulmonary diseases. Finally, it discusses the importance of patient education and inhaler type on adherence, emphasizing the need for simple, effective treatment plans to improve outcomes.

1. Adherence to inhaler treatment
Radu CRIȘAN-DABIJA, Traian MIHĂESCU

2. „ Reward circuitry, the cascade of neurotransmission in the
brain that leads to the release of dopamine, is kicked off by any
pleasurable experience. Everything from eating, to having sex
and even skydiving can get it going.
The point of the reward circuitry is to positively reinforce
actions that promote the survival of the species „
Dr. Kenneth BLUM, 2012

3. Adherence and compliance
(Dictionary) ADERENCE, fr. Adherence.
A force that keeps two bodies in contact.
Adhesion between the wheels of a vehicle and the road. Bonding phenomenon between
concrete and steel in reinforced concrete.
Adherence, solidarity conscious of something.
(Dictionary) COMPLIANCE, fr. Compliance.
Size indicating the degree of elasticity of a mechanical system.
Variation in pulmonary volume due to pressure change.
Agreement, obedience, obedience, behavioral compliance.
Adherence of the patient to the therapeutic means necessary to improve his / her health.

4. Adherence vs Compliance
Compliance
The patient listens to the doctor and complies
with the prescribed treatment, accepts it as
coming from a professional and integrates it as
a "job" in his life.

5. Aderență vs Complianță
Adherence
The patient actively participates in the act of therapy, understands
why he needs treatment, understands the steps and purpose of the
treatment, understands how it works, possible side effects,
balances the therapeutic benefit, and creates a therapeutic
alliance with the doctor.

6. Factors that influence adherence
PATIENT
Patient's beliefs
Overall health
Psychological profile
Cognitive abilities
TREATMENT
Administration method
Effectiveness
Safety
Complexity
DOCTOR-PATIENT
RELATIONSHIP
SOCIAL SUPPORT
ACCESS TO TREATMENT
Lareau S, Yawn B. International Journal of COPD 2010; 5 401–406

7. Sursa imaginii : http://www.acpm.org/?MedAdherTT_ClinRef

8. Adherence in Asthma and COPD
Data from the SPIRO study and the Italian Society of
Pneumology 11 have shown that:
The most important cause of non-adherence to COPD is
smoking cessation
The prescribed medication, more precisely the inhalation, is
used by the vast majority of patients in error
14%
19%
38%
29%
Don't use inhaler
Stopped using
intermitent use
Correct use

9. Sursa imaginii : http://www.acpm.org/?MedAdherTT_ClinRef

10. The lowest adherence is for Pulmonary Obstructive
Pathology
To calculate adherence to treatment, "medication possession ratios" (MPR) were used in 8 pathologies, a study evaluating
15,334 patients. The MPR indicator uses pharmacy data regarding meet prescriptions, to determine how long a patient
possesses a prescribed medication.

11. Adherence in COPD
• In a study involving 55,076 COPD patients, adherence to treatment was
strongly correlated with the frequency of medication dosed.
• Patients whose medication is administered once or twice a day have the
highest adherence to treatment.

12. Types of Inhalatory Devices
Adapted fromSanduzzi et al. Multidisciplinary Respiratory Medicine 2014 9:60 doi:10.1186/2049-6958-9-6
The participation of the senses plays an important role in increasing / maintaining adherence to the administration of medication
Different modalities used in different devices to check that the product was actually delivered
Breezhaler® Handihaler® Respimat® Genuair® Diskus® Turbohaler®
Auditory
certainty
YES NO NO YES NO NO
Gustatory
certainty
YES YES NO NO NO NO
Visual
certainty
YES
(capsule
empty)
NO
Indirect
(Plume)
Indirect
(window)
NO NO

13. Adherence to inhaler type
Adapted after Sanduzzi et al. Multidisciplinary Respiratory Medicine 2014 9:60 doi:10.1186/2049-6958-9-6

14. The most important factors that influence adherence to
treatment in COPD
• Frequency of administration - number of administrations / day
and complicated treatment schemes (increased number of
medications due to comorbidities)
• The rapid onset of action - patients are thought to continue to
use daily treatment if they perceive that their action is fast
• Inhaler and inhalation device
Conseqvences of adherence reduction
• Low symptoms control
• Impact on Quality of Life
• Increased exacerbations and high hospital bills (⇡ Nursing costs)
• High Mortality
• Negative impact on budgets (patient & system)
Sanduzzi A. et al. Multidisciplinary Respiratory Medicine 2014, 9:60

15. Inhaler Device and Adherence to Treatment
• In patients with asthma, a statistically significant correlation between
inhalant satisfaction and adherence to treatment was demonstrated1
• ERS recommends that patients continue to use their inhaler if the
disease is stable and that another inhaler device is not recommended2
• Changing the inhalation device may be followed by difficulties in understanding
and applying a correct use technique and administering higher or lower doses
than necessary
• The inhaler device should not be changed without the patient agreeing to it2,3
1.Small M et al. Adv Ther 2011;28:202-212. 2. Laube BL et al. Eur Respir J 2011; 37:1308 -331. 3. Makela MJ et al. Respiratory Med 2013;
107:1481-1490

16. Ideal Inhaler Characteristics
Adaptat după Borgstrom L. Int J Clin Pract, 2005; 59(12): 1488–1495 și Small M. et al. Adv Ther 2011; 28(3):202-212.
Constant and
precise dose
delivery
Easy to use
Preferred by the
patients
Reduced
dimensions
Robust Design
100% substance
deposed in lower
airways

17. Using a treatment plan
• Using the written treatment plan as part of the symptomatic
control education has been shown to improve the development of
asthma
• Benefits have been shown to improve knowledge, increase patient
confidence and control over symptoms
British Guideline on the Management of Asthma, 2012. Disponibil pe www.sign.ac.uk, accesat în 7 martie 2013
Recommendation of British and other international guidelines
is to introduce the treatment plan
as a part of the physician-patient structured discussion

18. Using a treatment plan
• The treatment plan in COPD helps patients
• to identify early signs of exacerbation
• to understand the steps to be taken in case of
• exacerbation,
• modification of the therapeutic scheme,
• initiating antibiotic treatment,
• medical emergency visit
• Proper administration of maintenance medication and promise
of treatment in case of exacerbation have been shown to be
associated with faster post-exacerbation recovery compared to
patients not following these instructions
• Statistically significant reduction (p <0.0001) and clinically (5
days less) of total recovery time after an exacerbation
1. Bischoff EWMA et al. Thorax 2011; 66: 26-31.

19. Educating the Patients
 Patients education improves
inhalatory technique1,2
 International guidelines underline the
need to train patients about correct
inhalation technique and regular
evaluation of how to use the device
3,4
However, 25% of patients do not receive the information
required to use the device, and 45% receive these
instructions in one session lasting less than 10 minutes5
1. Capstick TG, et al. Expert Rev Respir Med 2012; 6: 91–101; 2. Bosnic-Anticevich SZ, et al. J Asthma 2010; 47: 251–6; 3. Raport GINA 2015.
www.ginaasthma.org; 4. GOLD: Global Strategy for Diagnosis, Management, and Prevention of COPD 2015. www.goldcopd.org/; 5. Lavorini F, et al.
Respir Med 2008; 102: 593–604.

20. Increasing adherence is a medical responsibility
• The efforts of health professionals to improve adherence should
have as their sole focus the needs and particularities of the
patient.
• Things need to be simplified.
• S- Simplifying regimen characteristics
I- Imparting knowledge
M- Modifying patient beliefs
P- Patient communication;
L- Leaving the bias
E- Evaluating adherence
Strategies to Enhance Patient Adherence: Making it Simple. Ashish Atreja and Susan R. Levy. MedGenMed. 2005; 7(1): 4

21. Increasing adherence is a medical responsibility
• S I M P L E
Simplify Imparting Modify Patient Leave Evaluate
Treatment Knowledge Beliefs Communication Bias Adherence
• Adjusting
frequency, dosage
and quantity
• Match
administration
with daily
activities
• Encourage the use
of assistive
devices
(dispensers,
alarms, etc.)
• Empowering the
patient with the
consequences of
non-treatment
• Addressing fears
and anxieties
• Encourage
adherence with
incentives
• Encourage
discussions with
medical staff
• Calling on simple,
common language
instructions with
up to 3 clear
points
• Engaging family,
friends, relatives
in treatment
• Exercise active,
assertive, open
communication
• Requesting
patient
involvement in
the therapeutic
decision
presenting
alternatives with
risks and benefits
• Emotional support
• Learning different
customs, rituals,
ethnic, religious
beliefs, etc
• Establishes a
therapeutic
connection
regardless of the
ethnic group
being treated
• Educate the
patient in his / her
environment
• Evaluate
adherence to each
visit
• Assess the
patient's opinion
about the chosen
therapeutic
option
• Establish a non-
adherence
intervention plan

22. Conclusions
• The consequences of non-adherence may be different - from reduced
quality of life and worsening of symptoms, to death
• Every control visit must consist in.
• assessing adherence to treatment
• identified barriers that prevent the patient from taking the treatment as prescribed
• Applying, in agreement with the patient, the necessary measures to optimize disease
control and reduce the risk of an acute episode
• Using WHO strategy: S.I.M.P.L.E.

23. Conclusions
• Long-term adherence is critical to achieving optimal clinical
outcomes
• Adherence to treatment in chronic illness decreases over time and is
very low in respiratory illnesses
• Inhaled treatment is essential for patients with asthma and COPD
• The use of a single inhaler was associated with higher adherence rates
compared to the administration of drugs in separate inhalers
• Patients should continue to use their inhaler if the disease is stable and no
other inhalation device is recommended

24. “Drugs don’t work in patients
who don’t take them”.
C. Everett Koop (1916 – 2013)
Sursa imaginii
https://upload.wikimedia.org/wikipedia/commons/thumb/b/be/C
._Everett_Koop%2C_1980s.jpg/220px-
C._Everett_Koop%2C_1980s.jpg

25. 1. Makela, M.J., Backer, V., Hedegaard, M., Larsson, K. Adherence to inhaled therapies, health outcomes and costs
in patients with asthma and COPD. Respir Med. 2013;107:1481–1490.
2. Foden J, Hand CH. Does use of a corticosteroid/long-acting beta-agonist combination inhaler increase adherence to inhaled
corticosteroids? Prim Care Resp J 2008; 17: 246-247.
3. James B Fink and Bruce K Rubin. Problems With Inhaler Use: A Call for Improved Clinician and Patient EducationRespir
Care, October 1, 2005 50:10 1360-1375 Atreja A, Bellam N, Levy S. Strategies to enhance patient adherence: Making it simple.
Medacapt Gen Med. 2005:7(1): 4.
4. Borgström, L., Asking, L. and Thorsson, L. (2005), Idealhalers or realhalers? A comparison of Diskus and Turbuhaler.
International Journal of Clinical Practice, 59: 1488–1495. doi: 10.1111/j.1368-5031.2005.00747.x
5. Lareau SC, Yawn BP: Improving adherence with inhaler therapy in COPD. Int J Chron Obstruct Pulmon Dis 2010, 5:401-406.
World Health Organization: Adherence to long-term therapies: policy for action. Meeting report 4–5 June 2001 2008.
6. Cartabellotta A: La non-compliance alla terapia farmacologica: strategie diagnostico-terapeutiche. Evid Publ GIMBE
Found 2013, 5(7):e1000051.
7. Restrepo RD, Alvarez MT, Wittnebel LD, Sorenson H, Wettstein R, Vines DL, Sikkema-Ortiz J, Gardner DD, Wilkins
RL: Medication adherence issues in patients treated for COPD. Int J Chron Obstruct Pulmon Dis 2008, 3:371-384.
8. Charles MS, Blanchette CM, Silver H, Lavallee D, Dalal AA, Mapel D: Adherence to controller therapy for chronic obstructive
pulmonary disease: a review. Curr Med Res Opin 2010, 26:2421-2429.
9. Giraud V, Roche N: Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Resp
J 2002, 19:246-251.
10. http://colliersmagazine.com/article/addictive-brain-all-roads-lead-dopamine
Bibliografie

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