How to encourage adherence in patients with respiratory disease

Introduction

Chronic respiratory diseases affect the airway and other lung structures^​1​. Globally, the most common chronic respiratory diseases include COPD, asthma, occupational lung diseases and pulmonary hypertension^​1​. In the UK, respiratory disease affects one in five people. After cancer and cardiovascular disease, respiratory disease is the third largest cause of death^​2​, with a disproportionate impact on disadvantaged population groups and those living in socially deprived areas^​3​. Important risk factors for respiratory disease include smoking, exposure to air pollution, contact with occupational chemicals and dusts, and recurrent respiratory infections in childhood^​1​. 

Hospital admissions for lung disease have risen three times faster than overall hospital admissions over the past seven years, doubling in the winter months and placing increased pressure on an already stretched healthcare system^​2​. It is important to consider why these figures are increasing. Risk factors and increasing social deprivation in the UK, driven by economic challenges, are probable contributors. With an increasing number of medicines and inhaler devices available, pharmacists need to be better at helping patients to use them. 

There is evidence that patients with respiratory disease have poorer rates of adherence compared with other chronic conditions^​4​. Non-adherence can be classified as intentional or non-intentional (see Figure 1)^​5,6​. 

In cases of poor adherence, it is essential to identify any underlying beliefs, behavioural drivers or potential barriers. A patient-centred and collaborative approach to consultation and communication is important to ensure that patients are motivated, informed and supported to take their medicines, while appreciating that the patient’s beliefs about the perceived benefits and risks may differ to that of the healthcare professional^​6​. Evidence suggests that a range of interventions tailored to the individual’s needs, beliefs and social context is likely to be most successful in promoting good adherence^​5,6​.

Consequences of non-adherence

Poor adherence to prescribed treatments may result in a clinical presentation that mimics severe or uncontrolled disease^​7​. It presents clinically as frequent asthma or COPD exacerbations, poor disease control and, often, increased use of beta-agonist relievers and oral corticosteroids. Poor adherence can lead to patients experiencing avoidable side effects and inappropriate treatment escalation, such as progression along asthma treatment pathways, and unnecessary initiation of biological therapies^​7​. In one study of adherence patterns in moderate–severe asthma sufferers, published in 2020, nearly 50% of patients who were non-adherent to treatment required two or more courses of oral corticosteroids and antibiotics within one year^​8​.

Poor adherence in respiratory disease has consistently shown to increase hospitalisation and mortality, as well as reduce quality of life^​8,9​. ‘Good adherence’ (i.e. >80% of the time) significantly improves clinical outcomes in patients with asthma and COPD^​9​.

In addition, poor adherence in respiratory disease has a negative economic impact. Direct healthcare costs increase through more hospital stays and medication, while indirect costs increase owing to lost productivity and missed school or working days in that patient population^​9​. According to the NHS, over £500m could be saved annually if adherence was improved in asthma patients^​10​.

Why patients with respiratory disease struggle with adherence

Patients with respiratory disease have trouble adhering to medicines for many reasons, which can be loosely broken into three categories: patient factors, treatment factors and health-system factors. 

A full discussion of these factors is beyond the scope of the article; however, an awareness of the different types of factors can help pharmacists tailor their approach and select strategies with the best chance of success.

Table 1 describes several examples of how these factors can cause non-adherence.

How to overcome barriers to adherence in respiratory patients

Pharmacists — in prescribing and non-prescribing roles and across all sectors — are well positioned to intervene at multiple points along the patient journey to enhance care. Unfortunately, many strategies for tackling non-adherence often fail^​11​. Effective support should be personalised, address beliefs about illness and treatment, and tackle practical barriers to medicine use and regimen compliance^​11​.

Figure 2 outlines strategies that pharmacists can employ to address adherence challenges in patients with respiratory disease^{​4,12–14​}.

How these strategies can be employed will vary depending on practice setting and context of the patient interaction. Most pharmacists are not respiratory specialists and often face time constraints during patient interactions that limit their ability to make complex behavioural interventions. However, pharmacists can still make meaningful contributions in support of medicine adherence by applying the core pharmacist competencies, particularly in medication review, medicines optimisation and patient counselling. Brief yet impactful interventions, such as reviewing inhaler technique and providing targeted patient education, can be effectively integrated into routine practice, regardless of role, prescribing status or sector. Pharmacists also have opportunities to hold more in-depth consultations when providing services such as structured medication reviews, the new medicines service (NMS) or primary care clinic work. 

The focus during medication review in respiratory patients should be on inhaled therapies. Most patients do not use inhalers as prescribed, with few demonstrating consistent and correct technique^​8​. Common issues include poor technique, misinterpretation of instructions and ‘cluster use’, which is when patients only use inhaled therapies during symptomatic periods^​8​. Even with high adherence, poor inhalation technique can worsen patient outcomes and economic impact^​9​.

For simple wins for optimising medication regimes, which include examples across sectors and services, see the case studies below.

Case study 1: Supporting adherence to using the new medicine service

A 38-year-old patient collected a prescription for montelukast 10mg, once daily, following a raised fractional exhaled nitric oxide (FeNO) level and reporting more frequent waking at night to use maintenance and reliever therapy (MART). The pharmacist identified the patient as eligible for the new medicine service (NMS) and invited her for a consultation. The pharmacist explained that montelukast is a leukotriene-receptor antagonist, which is used to reduce inflammation and prevent asthma symptoms. The patient expressed concern about taking a daily tablet when she felt ‘mostly fine’ day to day and did not take any other tablets. The pharmacist discussed the importance of consistent use to prevent symptoms and reduce reliance on MART. 

The pharmacist also reviewed potential side effects, such as sleep disturbances and mood changes, and advised the patient to report any concerns. For the final follow up, the pharmacist called the patient to check on her progress. The patient admitted to missing two doses, forgetting to take the tablet in the evening. The pharmacist suggested linking the dose to a daily routine (e.g. brushing teeth) and setting a phone reminder. The patient reported no side effects and felt reassured about continuing the medication. At the final NMS review, the patient reported improved consistency with dosing and less night-time waking with symptoms. The pharmacist reinforced the importance of long-term adherence and encouraged the patient to keep a symptom diary and engage with the next asthma review at the GP surgery. 

In this scenario, the patient gained a greater understanding of her condition and the role of montelukast in managing it. Early support helped establish good adherence habits and prevented premature discontinuation in a patient not used to taking oral medication.

Strategies used:

• Patient education by explaining the role of montelukast in managing asthma and discussing side effects;
• Aligned goals and treatment plans with patient values and preferences, which addressed concerns about long-term medication use;
• Created routine and organisation by linking medication-taking to a daily habit;
• Educated and empowered the patient to utilise adherence aids such as telephone alarm reminders;
• Healthcare professional intervention via the NMS;
• Addressed patient beliefs about disease or treatments by acknowledging the patient’s perception of being ‘mostly fine’ and clarifying the role of montelukast.

Case study 2: Structured medication review in primary care

A 76-year-old patient with moderate COPD, hypertension and type 2 diabetes mellitus was invited for a pharmacist-led structured medication review (SMR) at his GP surgery.

The patient’s medication list (pre-review) included:

• Duaklir Genuair dry powder inhaler (aclidinium bromide 396 mg per dose + formoterol 11.8mg per dose) — two doses twice daily;
• Salbutamol pressurised metered dose inhaler — one to two doses when required;
• Amlodipine 10mg once daily;
• Ramipril 2.5mg twice daily;
• Metformin 500mg twice daily;
• Paracetamol 1g four times daily when required;
• Amitriptyline 25mg once daily at night, which was prescribed four years ago for neuropathic pain following a road traffic accident.

During the SMR, the patient described feeling sluggish in the mornings and sleepy upon waking. The patient described frustration with the number of medicines he had to take each day and couldn’t tell the pharmacist why he took the amitriptyline. The patient described not having any pain. Additionally, the pharmacist discovered that the patient only used his Duaklir Genuair inhaler once daily in the mornings. 

Several interventions could be made after discussion and agreement with the patient: 

• Discuss the amitriptyline with the patient’s GP, given its contribution to sedation and unclear need, as well as that the patient reported no neuropathic pain. This can be deprescribed and gradually tapered off to prevent any withdrawal effects;
• The ramipril dose could be changed to 5mg once daily in the morning, with monitoring of symptoms of hypotension;
• The metformin dose could be changed to 1g once daily in the morning if the patient was able to tolerate gastrointestinal (GI) symptoms;
• Discuss with the patient a stepwise approach to introducing these changes;
• The Duaklir Genuair inhaler could be changed to an Anoro Ellipta inhaler, which will have the same clinical benefit as Duaklir Genuair but with a once-daily dosing profile. 

The pharmacist arranged a follow-up call two weeks later to ensure disease control remained well and that there were no adverse effects following the changed dosing schedules. The pharmacist documented the review and shared the plan with the patient’s GP. The patient reported tolerating the dose schedule changes, no neuropathic pain, stable blood pressure, no GI symptoms and sustained control of COPD. The patient appreciated only having to remember to take medicines in the morning.

Strategies used:

• Patient education, which clarified the need for amitriptyline and the rationale for medication changes; 
• Aligned goals and treatment plans with patient values and preferences, which addressed concerns about pill burden and morning sedation; 
• Created routine and organisation, which focused on morning dosing;
• Addressed comorbidities, which considered negative impact of and lack of indication for amitriptyline and deprescribed;
• Optimised medication regimes that were adjusted to once-daily dosing, used combined therapies and reduced polypharmacy by deprescribing amitriptyline;
• Healthcare professional intervention via an SMR;
• Addressed patient beliefs about disease or treatments, which helped the patient’s understanding of and frustrations with medications;
• Provided clear and simple instructions. 

Case study 3: Brief intervention at the community pharmacy counter

A 59-year-old patient arrives to collect his repeat prescription from the community pharmacy. On handing out his medication, you ask how he is getting on with his inhaler and ask if he can show you how he is using it. The patient uses a Sereflo 25/250 pMDI, which is an inhaled corticosteroid/long-acting β₂-agonist inhaler used to help treat his COPD. You can see from his patient medication record that the patient has been using this for a year. The patient also has a salbutamol pMDI on his patient medication record, but one was not ordered this time. 

When the patient demonstrates how he uses his inhaler, you notice that he did not shake the inhaler before use and that he inhales far too forcefully from the device. When asked if the patient rinses his mouth after use, he says, ‘why would I do that?’. 

The pharmacist utilised the interaction to counsel the patient on correct inhaler technique, including the importance of shaking the inhaler before use, inhaling slowly and steadily to ensure optimal drug delivery to the lungs, while rinsing the mouth after use to reduce the risk of side effects such as oral thrush. Using a placebo device, the pharmacist demonstrated the correct technique and advised the patient to apply the same technique when using their Salbutamol pMDI. The pharmacist was then able to watch the patient demonstrate using their own device. 

It can often feel like there is no time for this type of interaction during a busy day, but pharmacists should consider the impact that this type of simple interaction could have on respiratory care if it happened once per day in every pharmacy. 

Strategies used:

• Patient education by explaining rationale, correct use and inhaler technique;
• Pharmacist-led health coaching, which addressed patient misunderstanding of inhaler technique;
• Healthcare professional intervention via opportunistic medication review, inhaler training and counselling;
• Communication, which provided clear and simple instructions, which were reinforced through demonstration.

Case study 4: Medicines optimisation review on admission to hospital 

A 68-year-old woman was admitted to the head and neck ward post-hemithyroidectomy for thyroid cancer, requiring oxygen post-operatively. The surgical team attributed this to her COPD, yet no inhaled therapies were prescribed. Upon review, the ward pharmacist discovered she had been prescribed a dry powder inhaler and a short-acting beta-2 antagonist pressurised metered-dose inhaler by her GP eight weeks earlier. The patient demonstrated poor inhaler technique, revealing insufficient inspiratory effort for the device. The patient had not been shown how to use her inhalers at the point of prescribing or dispensing, and was unaware of the role of the inhalers in managing her COPD.

Using a placebo device and a whistle tool, the pharmacist assessed her ability to use an alternative inhaler and arranged a more suitable prescription. This also provided an opportunity to educate the patient on the importance of inhaler use and COPD control, describing to the patient how it could improve respiratory symptoms and her quality of life. Every healthcare interaction is an opportunity to improve adherence and outcomes, regardless of specialty and sector of practice. Adherence depends on motivation and ability to comply with a treatment, and this example demonstrates how a simple interaction could address it. 

While pharmacists may not always be trained to select the most appropriate inhaler device for patients, they should be able to identify poor inspiratory effort and ineffective inhaler use. For seven steps to using an inhaler device, which can be used to assess and reinforce patient competence, see Box 1^​15​.

Strategies used

• Patient education, which explained inhaled therapies and demonstrated correct inhaler technique;
• Aligned goals and treatment plans with patient values and preferences, which tailored the inhaler choice to the patient’s physical capability;
• Pharmacist-led health coaching, which provided personalised education and encouragement; 
• Healthcare professional intervention, which optimised medicines in secondary care, opportunistic medication review, inhaler training and counselling.
• Provided clear and simple instructions, which used visual and tactile tools to reinforce inhaler technique.

Pharmacists should advise patients on device-specific use, care and storage, including spacer devices, in line with manufacturer recommendations​^​15​. Additional support materials can be found on the RightBreathe website, Electronic Medicines Compendium and manufacturer websites. Patients should be offered support, follow up and review, where appropriate, with signposting to additional support and resources where needed.

Conclusion

Even the most effective treatment has no power if a patient is not taking it as intended. Pharmacists often restrict their focus to checking the drug, dose, strength, directions and place in local and national guidelines. We need to also check that what we are prescribing, dispensing or reviewing is something that the patient is able to use. We are all too often protocol driven and forget to treat the person in front of us.

A pharmacist does not need to be an expert in respiratory medicines or even inhalers to help patients make the best use of their respiratory medicines. Developing and utilising strategies for tackling non-adherence in respiratory patients will help to improve their respiratory disease and overall health and wellbeing. 

Healthcare professionals should incorporate routine assessment of treatment adherence and its determinants into clinical practice, particularly prior to considering therapeutic escalation, assigning it equal importance to evaluating the initial appropriateness of therapy and prior to therapeutic escalation^​7​.