Taking Too Many Inhalers: Adherence Benefits of Once-Daily Options
In practice, many patients become overwhelmed by polypharmacy. A diagnosis of COPD or asthma can significantly increase the medication administration burden. I’ve heard many patients report that they are taking “too many inhalers.” The basic strategy to remedy medication adherence issues is to assess adherence status, identify the cause of nonadherence, and apply a focused intervention. The use of multiple drugs and/or inhalers several times per day is a common barrier to adherence as patients frequently report that they forget to take their medications. The reported adherence rates vary from 22% to 63% among patients with asthma. Nonadherence can lead to reduced quality of life, missed school or work, unnecessary escalation or addition of therapy, and increased mortality.
A 2016 study by Gollwitzer et al found that adherence was significantly worsened when two or more daily doses were prescribed for antiepileptic drugs. Similarly, a 2013 study by Kuypers et al found that adherence was significantly better when patients were prescribed once-daily regimens versus twice-daily regimens of tacrolimus after solid-organ transplant.
An example of a medication that was designed to improve this issue is Trelegy Ellipta. Trelegy Ellipta was approved by the FDA in 2017 for once-daily maintenance of COPD and in 2020 for maintenance of asthma in adult patients. Trelegy Ellipta contains fluticasone, umeclidinium, and vilanterol as an inhalation powder, offering patients a convenient one-inhalation once-daily option to manage their asthma or COPD.
In patients who require all three inhaled drug classes (LABA, LAMA, and corticosteroids), Trelegy is uniquely able to help patients whose current therapy is inconvenient or inadequate. Consider switching patients who struggle with or dislike frequent dosing, patients who desire to reduce their number of administrations, or patients who are not responding to their current therapy.
Let’s consider a patient currently using two inhalers to manage her COPD: Symbicort (formoterol/budesonide) and Spiriva (tiotropium). The current regimen requires her to carry two inhalers and dose twice daily. She previously had adequate symptom control, however, she is busier during the summer months and tends to forget her evening dose of Symbicort. This patient would be a great candidate for a combination agent like Trelegy because she is already stable on a LABA, inhaled corticosteroid, and anticholinergic, and her busy schedule is posing adherence issues.
The reality of newly-approved brand-name drugs is that they are often expensive. The manufacturer (GSK) boasts Trelegy coverage for Medicare, Medicaid, and privately insured patients, with a majority of patients paying less than $50 per month. Still, some insurers may prefer other options over Trelegy despite the improved convenience it offers.
Assuming the results from Gollwitzer et al and Kuypers et al can be applied to asthma and COPD inhaler adherence, once-daily options Trelegy may be beneficial for improving adherence rates, solving the “too many inhalers” complaint, reducing hospitalization risk, and improving our patients’ quality of life.
This article was written by Sarah Jackson PharmD Candidate in collaboration with Eric Christianson, PharmD, BCGP, BCPS
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DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. T920261, Enhancing Patient Adherence to Asthma Therapy; [updated 2018 Nov 30, cited June 7, 2021]. Available from https://www.dynamed.com/topics/dmp~AN~T920261. Registration and login required.
Kuypers DRJ, Peeters PC, Sennesael JJ, Kianda MN, Vrijens B, Kristanto P, Dobbels F, Vanrenterghem Y, Kanaan N. Improved adherence to tacrolimus once-daily formulation in renal recipients: a randomized controlled trial using electronic monitoring. Transplantation 2013;95(2):333-40.Trelegy pricing and coverage: https://www.gskforyou.com/gsk-pricing/trelegy/