Document Detail

The utility of fractional exhaled nitric oxide suppression in the identification of nonadherence in difficult asthma.
MedLine Citation:
PMID:  23024023     Owner:  NLM     Status:  MEDLINE    
RATIONALE: Nonadherence to inhaled corticosteroid therapy (ICS) is a major contributor to poor control in difficult asthma, yet it is challenging to ascertain.
OBJECTIVES: Identify a test for nonadherence using fractional exhaled nitric oxide (Fe(NO)) suppression after directly observed inhaled corticosteroid (DOICS) treatment.
METHODS: Difficult asthma patients with an elevated Fe(NO) (>45 ppb) were recruited as adherent (ICS prescription filling >80%) or nonadherent (filling <50%). They received 7 days of DOICS (budesonide 1,600 μg) and a test for nonadherence based on changes in Fe(NO) was developed. Using this test, clinic patients were prospectively classified as adherent or nonadherent and this was then validated against prescription filling records, prednisolone assay, and concordance interview.
MEASUREMENTS AND MAIN RESULTS: After 7 days of DOICS nonadherent (n = 9) compared with adherent subjects (n = 13) had a greater reduction in Fe(NO) to 47 ± 21% versus 79 ± 26% of baseline measurement (P = 0.003), which was also evident after 5 days (P = 0.02) and a Fe(NO) test for nonadherence (area under the curve = 0.86; 95% confidence interval, 0.68-1.00) was defined. Prospective validation in 40 subjects found the test identified 13 as nonadherent; eight confirmed nonadherence during interview (three of whom had excellent prescription filling but did not take medication), five denied nonadherence, two had poor inhaler technique (unintentional nonadherence), and one also denied nonadherence to prednisolone despite nonadherent blood level. Twenty-seven participants were adherent on testing, which was confirmed in 21. Five admitted poor ICS adherence but of these, four were adherent with oral steroids and one with omalizumab.
CONCLUSIONS: Fe(NO) suppression after DOICS provides an objective test to distinguish adherent from nonadherent patients with difficult asthma. Clinical trial registered with (NCT 01219036).
Diarmuid M McNicholl; Michael Stevenson; Lorcan P McGarvey; Liam G Heaney
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Publication Detail:
Type:  Comparative Study; Journal Article; Randomized Controlled Trial; Research Support, Non-U.S. Gov't     Date:  2012-09-28
Journal Detail:
Title:  American journal of respiratory and critical care medicine     Volume:  186     ISSN:  1535-4970     ISO Abbreviation:  Am. J. Respir. Crit. Care Med.     Publication Date:  2012 Dec 
Date Detail:
Created Date:  2012-12-03     Completed Date:  2013-02-01     Revised Date:  2014-01-02    
Medline Journal Info:
Nlm Unique ID:  9421642     Medline TA:  Am J Respir Crit Care Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1102-8     Citation Subset:  AIM; IM    
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MeSH Terms
Administration, Inhalation
Adrenal Cortex Hormones / administration & dosage*
Asthma / diagnosis,  drug therapy*
Breath Tests
Bronchodilator Agents / administration & dosage
Drug Administration Schedule
Exhalation / drug effects
Forced Expiratory Volume
Medication Adherence / statistics & numerical data*
Middle Aged
Nitric Oxide / analysis*
Patient Compliance
Prednisolone / administration & dosage
Prospective Studies
Reference Values
Reproducibility of Results
Respiratory Function Tests
Severity of Illness Index
Young Adult
Reg. No./Substance:
0/Adrenal Cortex Hormones; 0/Bronchodilator Agents; 31C4KY9ESH/Nitric Oxide; 9PHQ9Y1OLM/Prednisolone
Comment In:
Am J Respir Crit Care Med. 2012 Dec 1;186(11):1067-8   [PMID:  23204368 ]
Am J Respir Crit Care Med. 2013 Nov 15;188(10):1263   [PMID:  24236590 ]
Am J Respir Crit Care Med. 2013 Nov 15;188(10):1263-4   [PMID:  24236591 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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