Review and Feature Article
“Trying, But Failing” — The Role of Inhaler Technique and Mode of Delivery in Respiratory Medication Adherence

The Expert Adherence Panel Meeting from which the concepts presented in this article were first discussed and the manuscript submission costs were supported by the Respiratory Effectiveness Group. Teva supported the meeting costs at which the concepts in this paper were discussed by the co-authors and the open access publication fee for this article. The authors had full editorial control over the ideas presented.
https://doi.org/10.1016/j.jaip.2016.03.002Get rights and content
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Inhaled therapies are the backbone of asthma and chronic obstructive pulmonary disease management, helping to target therapy at the airways. Adherence to prescribed treatment is necessary to ensure achievement of the clinician's desired therapeutic effect. In the case of inhaled therapies, this requires patients' acceptance of their need for inhaled therapy together with successful mastery of the inhaler technique specific to their device(s). This article reviews a number of challenges and barriers that inhaled mode of delivery can pose to optimum adherence—to therapy initiation and, thereafter, to successful implementation and persistence. The potential effects on adherence of different categories of devices, their use in multiplicity, and the mixing of device categories are discussed. Common inhaler errors identified by the international Implementing Helping Asthma in Real People (iHARP) study are summarized, and adherence intervention opportunities for health care professionals are offered. Better knowledge of common errors can help practicing clinicians identify their occurrence among patients and prompt remedial actions, such as tailored education, inhaler technique retraining, and/or shared decision making with patients regarding suitable alternatives. Optimizing existing therapy delivery, or switching to a suitable alternative, can help avoid unnecessary escalation of treatment and health care resources.

Key words

Adherence
Implementation
Initiation
Persistence
Inhaler device
Inhaler technique
Patient preference

Abbreviations used

BAI
breath-actuated pressurized metered-dose inhaler
COPD
chronic obstructive pulmonary disease
DPI
dry powder inhaler
iHARP
Helping Asthma In Real People
ICS
inhaled corticosteroid
pMDI
pressurized metered-dose inhaler
RCT
randomized clinical trial
REALISE
REcognise Asthma and LInk to Symptoms and Experience

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Conflicts of interest: H. Chrystyn is on the board of and is director of Talmedica Ltd; has received consultancy fees from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Innovata Biomed, Meda, Napp Pharmaceuticals, Mundipharma, NorPharma, Norvartis, Orion, Sanofi, Teva, Truddell Medical International, UCB, and Zentiva; has received research support from Engineering and Physical Sciences Research Council and Medical Research Council; has received lecture fees from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Innovata Biomed, Meda, Napp Pharmaceuticals, Mundipharma, NorPharma, Norvartis, Orion, Sanofi, Teva, Truddell Medical International, UCB, and Zentiva; has received payment for developing educational presentations from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Innovata Biomed, Meda, Napp Pharmaceuticals, Mundipharma, NorPharma, Norvartis, Orion, Sanofi, Teva, Truddell Medical International, UCB, and Zentiva; and is owner of (with stock in) Inhalation Consultancy Ltd. S. Bosnic-Anticevich is on the Teva Devices Advisory Board; is on the Mundipharma Advisory Board; has received consultancy fees from Mundipharma; has received lecture fees from Teva, GlaxoSmithKline, and Mundipharma; and has received payment for the development of educational presentations from Teva. T. van der Molen has received consultancy fees from Boehringer Ingelheim, Teva, Mundipharma, and AstraZeneca; is employed by Universitair Medisch Centrum Goningen; has received research support from AstraZeneca and GlaxoSmithKline; has received lecture fees from Novartis, Teva, and AstraZeneca; and has received payment for developing educational presentations from Teva. R. J. Dandurand has received research support from Almiral, AstraZeneca, Boehringer Igelheim, Merck, and Novartis; has received lecture fees from Novartis; and has received payment for developing educational presentations from AstraZenenca D. Price is on the boards for Aerocrine, Almirall, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, and Teva; has received consultancy fees from Almirall, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Meda, Mundipharma, Napp, Novartis, Pfizer, and Teva; has received research support from UK National Health Service, British Lung Foundation, Aerocrine, AKL Ltd, Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Eli Lilly, GlaxoSmithKline, Meda, Merck, Mundipharma, Napp, Novartis, Orion, Pfizer, Respiratory Effectiveness Group, Takeda, Teva, and Zentiva; has received lecture fees from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Meda, Merck, Mundipharma, Novartis, Pfizer, SkyePharma, Takeda, and Teva; has received payment for manuscript preparation from Mundipharma and Teva; has a patent with AKL Ltd; has received payment for developing educational presentations from GlaxoSmithKline and Novartis; has stock in AKL Ltd; has received travel support from Aerocrine, Boehringer Ingelheim, Mundipharma, Napp, Novartis, and Teva; has received funding for patient enrollment or completion of research from Almirall, Chiesi, Teva, and Zentiva; has served as a peer reviewer for grant committees Medical Research Council (2014), Efficacy and Mechanism Evaluation programme (2012), and Health Technology Assessment (2014); and is an 80% owner of Research in Real Life, Ltd (and its subsidiary social enterprise Optimum Patient Care), which receives unrestricted funding for investigator-initiated studies from Aerocrine, AKL Ltd, Almirall, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, Orion, Takeda, Teva, and Zentiva. The rest of the authors declare that they have no relevant conflicts of interest.