Inhaler Adherence in Severe Unstable Asthma

Asthma Clinical Trial

— INCA-SUN  

Official title:

A Study on Inhaler Adherence to Improve Poor Asthma Control

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT02307669
• Other study ID #: INCA-Sun
• Status: Recruiting
• Phase: N/A
• Start date: December 2015
• Est. completion date: December 31, 2020

Study information

• Verified date: August 2019
• Source: Beaumont Hospital
• Contact: Elaine MacHale, RN MSC
• Email: emachale[@]rcsi.ie
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The investigators hypothesize that aligning digital data on PEF and adherence with the patient's own clinical course achieves better asthma control and identifies risks for future loss of control, compared to current best practice. The study has an adherence optimisation phase, week 1-12 followed by a medication management phase, week 12 to week 32.

The investigators will compare two asthma education interventions, standard Guideline recommended practice and feedback from the individual's own INCA device, which assesses inhaler adherence and relates adherence with changes in PEF and symptom scores over time.

The study has two co-primary endpoints, one will be a comparison of the adherence to therapy and the other will be a comparison of the appropriateness of medication prescriptions between the two study groups.

Description:

The investigators hypothesize that aligning adherence, inhaler technique and digitally recorded PEF to inform patients and as the basis of prescribing decisions achieves better inhaler adherence and technique and also allows physicians to make appropriate prescribing decisions, compared to current best practice.

The investigators will compare two asthma education interventions, standard BTS/SIGN Guideline recommended practice and feedback from the individual's own INCA device, which assesses inhaler adherence and relates adherence with changes in PEF and symptom scores over time.

This education phase is followed by a medication optimisation phase (weeks 12-32) in which there are 3 cycles of medication optimisation guided by a digital script. The script either adjusts the medications following the GINA recommendation or uses the GINA recommendation but is supplemented with data on adherence and PEF that are recorded to digital, time-stamped, recording devices.

The aim of the study is to improve and maintain adherence to preventer therapy, so that medication and other costs as well as the quality of life, exacerbation rates are optimal.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 220
• Est. completion date: December 31, 2020
• Est. primary completion date: January 1, 2020
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Must be willing to give voluntary informed consent

• Must have a clinical diagnosis of asthma supported by objective measures, one of the following by FEV1/FVC <70% and FEV1 <80% or - a 12% change in FEV1 following administration of a beta-agonist or spontaneously over 1 year period, a positive bronchial provocation test, or a 10% variability in PEF within a 7 day period.

• Must have a bronchodilator FEV1 > 40% and <80% in the past 1 year

• Current unstable asthma i.e. ACT score = 19 at enrolment despite already being managed with GINA step 3-5 therapy.

• One or more courses of oral corticosteroids in the prior year, or a hospitalization or ED attendance with an asthma exacerbation in the last year

• Age 18 years or older at time of consent.

• Capable of understanding and complying with the requirements of the protocol, including the ability to attend for all required visits.

• Able and willing to take inhaled medication via a Diskus.

• In the opinion of the investigator suitable for use of a salmeterol/fluticasone Diskus inhaler or already using a salmeterol/fluticasone inhaler.

Exclusion Criteria:

• Have used any investigational product or device within 3 months of the enrolment visit.

• Have known previous sensitivity to Seretide (salmeterol/fluticasone).

• Have a known significant (in the opinion of the investigator) concurrent medical disease, pregnancy that might mean that the participant cannot complete the study.

• Be taking omalizumab or other biological agent used in the treatment of asthma

• Concurrent treatment with potent cytochrome P450 3A4 (CYP3A4) inhibitors; Ketoconazole and Ritonavir.

• Current smokers and ex-smokers with a greater than 20 pack year history of cigarette smoke

Related Conditions & MeSH terms

• Asthma

Intervention

Behavioral:
• INCA feedback
The study team have developed a device which is attached to inhalers that makes an audio recording of the inhaler being used. Analysis of this audio data provides objective evidence of the time of inhaler use, technique of use and the peak inspiratory flow the patient makes each time they use their inhaler. Our preliminary experiences with the information obtained from this device indicate that adherence is poor in patients with severe asthma due to any one the following issues poor time of use, errors in handling and low peak inspiratory flow rates.
• Usual Care
The core features of the "usual care" group are: The patient's inhaler technique will be checked using a checklist, at each visit. If there are errors these will be corrected using teach-to-goal principals. Adherence will be discussed and barriers to adherence addressed, using motivational interview techniques. Written action plans for managing asthma, based on changes in PEF and symptoms will be given. In follow up, medication changes in response to the above will be directed by these, as suggested by Guidelines.

Locations

Country	Name	City	State
Ireland	Beaumont Hospital	Dublin

Sponsors (1)

Lead Sponsor	Collaborator
Beaumont Hospital

Country where clinical trial is conducted

Ireland, 

References & Publications (1)

Mokoka MC, Lombard L, MacHale EM, Walsh J, Cushen B, Sulaiman I, Carthy DM, Boland F, Doyle F, Hunt E, Murphy DM, Faul J, Butler M, Hetherington K, Mark FitzGerald J, Boven JFV, Heaney LG, Reilly RB, Costello RW. In patients with severe uncontrolled asthma, does knowledge of adherence and inhaler technique using electronic monitoring improve clinical decision making? A protocol for a randomised controlled trial. BMJ Open. 2017 Jun 15;7(6):e015367. doi: 10.1136/bmjopen-2016-015367. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Patient identified goal	Proportion of patients reaching stated clinical goal at week 12 and between that period and week 32.	Baseline to week 32
Primary	Mean rate of actual Adherence to preventer medication	This study will focus on severe asthma patients, who remain uncontrolled and with frequent exacerbations requiring oral steroids and have an Asthma control test (ACT) score of <19 on enrollment.	week 20 through 32
Primary	The between-group difference in the proportion of patients prescribed guideline appropriate medication at the end of the study.	The appropriateness of the prescribed therapy will be verified for each participant after study completion using all available adherence and PEF data.; Between-group differences will be further broken down by the following: The proportion of participants prescribed add-on therapy (e.g. Monoclonal antibody therapy); The proportion of participants whose ICS/LABA dose was increased; The proportion of participants whose ICS/LABA dose was reduced	week 20 through 32
Secondary	Cost-effectiveness and economic evaluation of the INCA educational intervention	An economic evaluation of national implementation of the INCA-SUN program will be provided. Data on the cost of the intervention (device, time taken to deliver, cost of training and salary cost of the trainer), medication costs, quality of life, exacerbations and other healthcare utilization and associated costs, such as unscheduled health care visits as well as work productivity losses will be collected alongside the 32-week study.; A cost-effectiveness and cost-utility analysis of the intervention compared to the control arm will be performed. Incremental cost-effectiveness ratios (or ICERS) will be calculated from the data, to estimate how much additional cost is required for an additional unit of benefit.	First 8 weeks of the study and week 20 to 32
Secondary	Change in Asthma Control Test scores at week 32	ACT scores will be obtained during the study visits.	Baseline to week 32
Secondary	Change in PEF variability	Differences between the two study groups will be calculated	Baseline to week 32
Secondary	Change in AQLQ	AQLQ scores will be obtained during the study visits.	Baseline to week 32
Secondary	Exacerbations over study period	It is hypothesised that with active education, exacerbation frequency can be reduced.	Baseline to week 32
Secondary	To compare the proportion of patients who were clinically stable	The proportion of patients who required no daily reliever use in the month prior to study end will be compared.	First 8 weeks of the study and week 20 to 32
Secondary	Relationship of biomarkers with adherence	A comparison of changes in blood eosinophil's, periostin and Fractional Exhaled Nitric Oxide (FeNO) between the active and control groups will be made.The relationship between 7-day FeNO suppression and clinical and biomarker outcomes will be investigated.10. The relationship between changes in FeNO (characterised into FeNo>45ppb Or FeNO<45ppb) and adherence will also be investigated.	Baseline to week 32
Secondary	The proportion of patients who are refractory to treatment	A comparison of the proportion of patients who are refractory, (defined as having actual adherence =80%, =1 exacerbation, PEF am/pm <80% and ACT =19) will be conducted.	First 8 weeks of the study and week 20 to 32
Secondary	The proportion of patients who are non-adherent and remain uncontrolled	The proportion of patients who are non-adherent and remain uncontrolled, (i.e. Actual Adherence <80%, PEF am/pm <80% and ACT=19) between the active and control groups will be compared.	First 8 weeks of the study and week 20 to 32
Secondary	The proportion of patients with inhaler related side effects	The proportion of patients with inhaler related side effects including oral candidiasis between the active and control groups will be compared.	First 8 weeks of the study and week 20 to 32