Introduction

In China, the prevalence of paediatric asthma has increased over the past 20 years and is now approximately 3%. The long-term goals of asthma management according to the Global Initiative for Asthma (GINA) 2020 update are to improve and individualize the care of patients with asthma so that patients are able to achieve good control of symptoms and maintain normal activity levels, and have minimized risk of: asthma-related death, exacerbations, persistent airflow limitation and side effects.3The 2020 GINA guidelines suggest that poor adherence can be identified in clinical practice by empathic questioning that encourages open discussion, and acknowledges the probability of incomplete adherence. For optimal control of chronic diseases such as asthma, long-term adherence to treatment is required. If symptom control is poor and/or exacerbations persist despite 3 months of controller therapy, before considering a step-up of controller treatment, the relationship of symptoms to asthma should be confirmed, inhaler technique checked, good adherence confirmed or for children under 5-years old, an alternative treatment considered.

Methods

The CARE study was a 12-week, multicentre, prospective, observational study across 12 tertiary hospitals in China. Patients were aged 0–14 years, clinically diagnosed with asthma and prescribed home nebulizer inhaled corticosteroid (ICS) therapy for ⩾3 months. The primary endpoint was electronically monitored treatment adherence. Patients attended onsite visits at 0, 4, 8 and 12 weeks to assess asthma control, severity and treatment adherence (recorded by electronic monitoring devices and caregivers).

Results

The full analysis set included 510 patients. Median treatment adherence reported by electronic monitoring devices was 69.9%, and median caregiver-reported adherence was 77.9%. The proportion of patients with well-controlled asthma increased from 12.0% at baseline to 77.5% at visit 4. Increased time between asthma diagnosis and study enrolment was a significant predictor for better adherence [coefficient: 0.01, p = 0.0138; 95% confidence interval (CI): 0.00, 0.01] and asthma control (odds ratio = 1.001, p = 0.0498; 95% CI: 1.000, 1.002). Negative attitude to treatment by the caregiver was associated with poorer asthma control.

Discussion

To the best of our knowledge, this study is the first multicentre real-world study in China to record adherence to home nebulization of ICS treatment in asthmatic children using electronic monitoring devices.

In the present study, the median treatment adherence rate reported by portable home nebulizer devices was 69.9%, which compares favourably with many previous reports among children in other regions worldwide: the median electronically monitored adherence was 58.4% and 46%, respectively, in two studies in the USA, changing from 54% and 41% at month 4 to 47% and 31.5% at month 12 in patients with controlled and uncontrolled asthma, respectively, in a study from Brazil,16 and 49.5% in a study from The Netherlands. Results of the present study also compared favourably with other studies in China investigating treatment adherence in patients with asthma (adults or children). Furthermore, the World Health Organization reported that mean adherence was approximately 50% based on key studies in adults and children. Most of these studies reported adherence to metered-dose inhaler (MDI); comparatively, this results suggest that a home nebulizer device may facilitate better treatment adherence in paediatric patients.

Conclusion

Results of this study show that the rate of adherence to home nebulizer treatment in Chinese paediatric patients is good relative to prior reports in other countries and compared with other methods of ICS delivery. Furthermore, GINA-defined asthma control improved as the duration of treatment increased. We conclude that home nebulization of ICS is an effective long-term treatment method for paediatric patients with asthma.

Reference

1. Guo X, Li Z, Ling W, et al. Epidemiology of childhood asthma in mainland China (1988–2014): a meta-analysis. Allergy Asthma Proc 2018; 39: 15–29.

2. Hong J, Bao Y, Chen A, et al. Chinese guidelines for childhood asthma 2016: major updates, recommendations and key regional data. J Asthma 2018; 55: 1138–1146.

3. Global Initiative for Asthma. Global strategy for asthma management and prevention

4. Coutts JA, Gibson NA, Paton JY. Measuring compliance with inhaled medication in asthma. Arch Dis Child 1992; 67: 332–333.

5. Jentzsch NS, Camargos PA, Colosimo EA, et al. Monitoring adherence to beclomethasone in asthmatic children and adolescents through four different methods.

6. Milgrom H, Bender B, Ackerson L, et al. Noncompliance and treatment failure in children with asthma. J Allergy Clin Immunol

7. Boulet LP, Vervloet D, Magar Y, et al. Adherence: the goal to control asthma.