Maintenance ICS vs As-Needed ICS Treatment Regimens in Mild Asthma: Patient Perspectives

22 Mar, 22

Introduction

Many countries recommend as-needed low-dose combination budesonide-formoterol as an alternative to maintenance inhaled corticosteroids (ICS) for treatment of mild asthma based on the asthma guidelines. Knowing the patients’ attitudes and perspectives is very crucial for optimal treatment adherence. However, there is limited data on patient attitudes toward these regimens.

Aim

This study explores the comparative implementation experiences and future treatment preferences of mild asthma patients randomized to either twice daily budesonide plus as-needed salbutamol or as-needed budesonide-formoterol, who had used short-acting beta-agonist (SABA)-only treatment >3 months before enrollment.

Method

Study Design

Qualitative study.

Study Setting

The study included a subgroup of patients with mild asthma recruited in a multinational, 52-week open-label randomized controlled trial (NovelSTART).
The patients were randomized to twice-daily budesonide or as-needed budesonide-formoterol.
A single semi-structured, in-depth interview was conducted >10 months into the study to understand the patients’ motivation and treatment preferences.
The interviews were conducted by telephone and audiorecorded.
A total of 74 participants were interviewed; (Maintenance group: n=39, As-needed group n=35).

Results

Emergent themes from analysis comprised:
Theme 1 'How much my asthma affects me' to understand how their asthma's impact affected their self-management motivation.
- Most participants felt they had unproblematic asthma which required minimal active treatment.
- Some did not consider asthma as life-threatening
- One participant described their own and their healthcare professional’s complacency around mild asthma
- Another interesting point was that the interviewees described habituating to asthma symptoms or having difficulty in differentiating symptoms from other potential causes
- In contrast, some patients experienced uncontrolled asthma or progressively worsening control that required closer and/or intermittent treatment
Theme 2 'What I know about asthma' to gain insights on the limited knowledge and its impact on appropriate self-management decision making.
- Patients described limited knowledge about asthma and limited learning opportunities in the primary care setting
- Some interviewees mentioned doubts about the credibility of their asthma diagnosis
- Some participants felt that limited knowledge affected the management of asthma
Theme 3 'How much effort this treatment regimen involves for me' to understand the treatment complexity and/or difficulty establishing a medication routine impeded implementation, particularly in the Maintenance group.
- Patients had difficulty comprehending 2 different treatment approaches in the same regimen.
- The preventer inhaler was perceived to have comparatively lesser benefits than the reliever inhaler
- The interviewees expressed difficulty in establishing an effective inhaler corticosteroid (ICS) routine
- Some participants mentioned that they forget their preventer treatment when they do not perceive any symptoms
Theme 4 'My beliefs about the benefits and risks of this treatment' to analyze the patients’ perspectives on the efficacy of treatment.
- Interviewees failed to perceive any benefit from adding a preventer medication to their treatment regimen
- As-needed combination inhaler was perceived to have lesser symptom relief and speed than past relievers
- Small number of interviewees, especially females were concerned on the corticosteroid-related weight gain but that did not impact their medication use.
- Only 1 maintenance regimen patient who had experienced oral thrush, mentioned that this side effect could significantly impact the medication use in future.
The patients receiving maintenance treatment favored the as-needed combination therapy even though they had not yet tried it gave similar reasons as those who had used as-needed budesonide-formoterol in the RCT.
The reasons included: easy management, potential for lower prescription costs and support for preventer adherence.

Conclusions

Factors relating to perceived asthma burden, disease knowledge, treatment complexity and treatment usefulness or safety were identified as the key patient perspectives on the implementation of preventer treatments for mild asthma.
The as-needed budesonide-formoterol regimen was preferred to maintenance ICS treatment in mild asthma due to its simplicity and similar usage patterns.
However, patient education is urgently needed to increase the disease knowledge and address implementation barriers.

BMJ Open. 2022 Jan 21;12(1):e048537. Doi: 10.1136/bmjopen-2020-048537.