According to the CDC, 1 out of 13 people have asthma and more than 11.2 million people report having experienced 1 or more asthma attacks or episodes in 2018.1-2 Asthma is a condition that causes the airways to narrow and swell, making it hard to breathe. This can affect a person’s quality of life by limiting them to do their daily activities. Medications can play an important role in asthma management. Therefore, adherence to medications is important to optimize treatment and improve quality of life.

Regarding asthma treatment, an estimated 30% to 70% of adults and up to 50% of children have poor adherence.3 This poor adherence can lead to uncontrolled asthma and a reduced quality of life. In the past, asthma treatment generally consisted of an inhaled corticosteroid (ICS) controller with a short acting beta agonist (SABA) as rescue therapy. However, new updates from the 2020 Global Initiatives for Asthma (GINA) Guidelines show that the overuse of a SABA (dispensing >3 canisters/year) may lead to exacerbating lung conditions.

Pharmacists can play an important role in a patient’s asthma management by examining the patient’s refill history, adherence, and proper inhaler techniques. A systematic review and meta-analysis in 2018 showed that pharmacist-led interventions can significantly improve medication adherence.4

LIST OF COMMONLY USED INHALERS5
Class Generic  Brand
Short-Acting Beta2 Agonist (SABA) Albuterol
Levalbuterol
Proair, Proventil, Ventolin
Xopenex
Long-Acting Beta2 Agonist (LABA) Indacaterol
Salmeterol
Olodaterol
Aracapta
Serevent
Striverdi
Short-Acting Muscarinic Antagonist (SAMA) Ipratropium Atrovent
Long-Acting Muscarinic Antagonist (LAMA) Umeclidinium
Glycopyrrolate
Tiotropium
Aclidinium
Incruse
Seebri
Spiriva
Tudorza
Inhaled Corticosteroid (ICS) Ciclesonide
Fluticasone
Mometasone
Budesonide
Beclomethasone
Alvesco
ArmonAir, Arnuity, Flovent
Asmanex
Pulmicort
Qvar
Combination SAMA + SABA Ipratropium + Albuterol Combivent
Combination ICS + LABA Fluticasone + Salmeterol
Fluticasone + Vilanterol
Mometasone + Formoterol
Budesonide + Formoterol
Advair, Airduo, Wixela
Breo
Dulera
Symbicort
Combination LAMA + LABA Umeclidinium + Vilanterol
Glycopyrrolate + Formoterol
Tiotropium + Olodaterol
Indacaterol + Glycopyrrolate
Anoro
Bevespi
Stiolto
Utibron
Combination ICS + LABA + LAMA Fluticasone + Umeclidinium + Vilanterol Trelegy
Image adapted from Allergy and Asthma Network 20205

New 2020 GINA guidelines now recommend low dose ICS-formoterol as the preferred rescue therapy over albuterol. This is because recent studies have shown that patients with asthma have a degree of airway inflammation, and the use of ICS-formoterol can be a safety net in patients by providing anti-inflammatory benefits that SABAs do not offer. Two studies published in 2019 showed that the use of as needed ICS-formoterol produced significant reduction in severe lung exacerbations compared to SABA alone.5-6

THE IMPACT OF PHARMACISTS

Checking Refill Histories on Rescue Inhalers
Pharmacists can check how often patients refill their rescue inhalers the next time they are verifying a rescue inhaler. There is an opportunity for an intervention if patients are filling frequently and dispensing more than 3 canisters a year based on the GINA Guidelines. Pharmacists can refer the patient to see their provider if they suspect the patient is using their rescue inhaler more than recommended.

Checking Adherence on Maintenance Inhalers
Adherence to maintenance inhalers can help control asthma symptoms and avoid the overuse of a rescue inhaler. Pharmacists can play an important role in reminding patients to refill their maintenance inhalers and to use it daily as directed to prevent asthma exacerbations.

Proper Inhaler Technique
Poor inhaler technique can lead to non-adherence and subtherapeutic treatment. It is important that patients know how to properly use inhalers for optimal treatment. Inhalers, such as an ICS, require specific instructions to avoid undesirable effects, such as thrush.

Patient Education
Talk to patients about recent changes in guidelines and educate them on how changing their rescue inhaler to include an ICS can be life-saving and may improve their quality of life. Patients can have their as needed albuterol as a backup as well.

Provider Education
After discussing with the patient, pharmacists may communicate with the provider if a patient has been filling frequently and provide recommendations based on updated guidelines. The dynamic nature of guideline recommendations makes it challenging to stay up to date. Communicate with the provider to ensure their reasonings and recommend accordingly.

REFERENCES
  1. CDC.gov. (2019). CDC - Asthma. [online] Available at: https://www.cdc.gov/asthma/default.htm [Accessed 3 December 2020].
  2. CDC.gov. (2018). CDC - Asthma - Most Recent Asthma Data. [online] Available at: https://www.cdc.gov/asthma/most_recent_data.htm [Accessed 3 December 2020].
  3. Engelkes M, Janssens HM, de Jongste JC, Sturkenboom MC, Verhamme KM. Medication adherence and the risk of severe asthma exacerbations: a systematic review. Eur Respir J. 2015;45(2):396-407. doi:10.1183/09031936.00075614
  4. Mes MA, Katzer CB, Chan AHY, Wileman V, Taylor SJC, Horne R. Pharmacists and medication adherence in asthma: a systematic review and meta-analysis. Eur Respir J. 2018;52(2):1800485. Published 2018 Aug 23. doi:10.1183/13993003.00485-2018
  5. Allergy and Asthma Network 2020. Respiratory Treatments. Allergy Asthma Network. Updated June 2020. Accessed December 18, 2020. https://members.allergyasthmanetwork.org/store/viewproduct.aspx?ID=9982674
  6. Beasley R, Holliday M, Reddel HK, et al. Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma. N Engl J Med. 2019;380(21):2020-2030. doi:10.1056/NEJMoa1901963
  7. Hardy J, Baggott C, Fingleton J, et al. Budesonide-formoterol reliever therapy versus maintenance budesonide plus terbutaline reliever therapy in adults with mild to moderate asthma (PRACTICAL): a 52-week, open-label, multicentre, superiority, randomised controlled trial [published correction appears in Lancet. 2020 May 2;395(10234):1422]. Lancet. 2019;394(10202):919-928. doi:10.1016/S0140-6736(19)31948-8
  8. "2012 GINA Main Report – Global Strategy for Asthma Management and Prevention” Global Initiative for Asthma.

Michelle George, PharmD, is a pharmacist at the University of Iowa's Hospital and Clinic.  

Julie Nguyen is a PharmD candidate 2021 at the University of Iowa's College of Pharmacy.