Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children

Wantida Chuenjit; Vorapan Engchuan; Araya Yuenyongviwat; Pasuree Sangsupawanich

doi:10.12688/f1000research.10710.1

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Research Note

Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children

[version 1; peer review: 2 approved, 1 approved with reservations]

Wantida Chuenjit¹, Vorapan Engchuan¹, Araya Yuenyongviwat¹, Pasuree Sangsupawanich ¹

PUBLISHED 14 Mar 2017

Author details Author details

¹ Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand

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Abstract

Background: The metered-dose inhalers (MDIs) currently available for inhaled corticosteroid delivery do not offer an integrated dose counter; therefore, it is difficult to evaluate adherence of patients. The present authors developed a linear regression equation using canister weight to calculate the number of doses actuated from the MDIs. This study aimed to assess medical adherence after the integration of regular weighing of the canisters into the routine service. Methods: A cohort study was carried out between May 2013 and April 2014. Children aged less than 8 years with a diagnosis of asthma were recruited. The duration of adherence assessment was 24 weeks. Participants had a regular schedule every 8 weeks to obtain a new FLIXOTIDE® 125 inhaler. Parents were asked to collect the discarded MDI canisters, which were then weighed by a laboratory scale. The weight of each canister was replaced in the regression equation to calculate the number of doses actuated from the MDIs. Results: A total of 52 asthmatic children participated in the study. The median age was 52.7 months. At the end of 24 weeks, 44, 33, and 23 discarded MDI canisters were collected from visits 1, 2, and 3, respectively. The median percentages of adherence were 96.8%, 96.3%, and 96.3%, respectively. In 11 discarded canisters (11%), the remaining medication was more than 30% of the labeled doses. Approximately 90% of the participants had no asthma exacerbation during 24-week study period. Conclusion: High adherence rates were achieved after integration of canister weighing into the asthma care service.

Keywords

canister weight, adherence, compliance, inhaled corticosteroids, asthma, wheezing, children, cohort study

Corresponding author: Pasuree Sangsupawanich

Competing interests: No competing interests were disclosed.

Grant information: The study was funded by Faculty of Medicine, Prince of Songkla University (55-021-01-1-2).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2017 Chuenjit W et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

How to cite: Chuenjit W, Engchuan V, Yuenyongviwat A and Sangsupawanich P. Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children [version 1; peer review: 2 approved, 1 approved with reservations]. F1000Research 2017, 6:266 (https://doi.org/10.12688/f1000research.10710.1) First published: 14 Mar 2017, 6:266 (https://doi.org/10.12688/f1000research.10710.1) Latest published: 14 Mar 2017, 6:266 (https://doi.org/10.12688/f1000research.10710.1)

Introduction

Inhaled corticosteroids (ICSs) are the standard treatment for asthmatic children. Non-adherence with prescribed ICS treatment clearly causes uncontrolled asthma¹. Feedback from parents is the traditional approach to assess the adherence to the treatment regimen; however, there is an overestimation by the patients of the remaining amount of medication². Even though integration of a dose counter into the inhaler device improves the tracking adherence to prescribed medication³, the metered-dose inhalers (MDIs) currently available for ICS delivery do not offer integrated dose counters.

Weighing of the MDI canisters may be an alternative method to assess a patient's medication adherence. The present authors previously developed a linear regression equation using canister weight to calculate the number of doses actuated from the MDIs⁴. Weighing of the canisters was implemented into our asthma care system in March 2013. This study was designed to assess a patient's medication adherence after the integration of regular weighing of the canisters into the routine service.

Methods

Study design and subjects

A cohort study was carried out between May 2013 and April 2014. The inclusion criteria were children aged less than 8 years with a diagnosis of asthma who attended the Pediatric Allergy Clinic at Songklanagarind Hospital (Hat Yai, Songkhla, Thailand) and had exacerbation of asthma requiring hospitalization or an emergency department visit within the previous year. Patients who had a previous history of intubation or other chronic conditions were excluded.

The research protocol (REC 55-021-01-1-2) was approved by the Human Research Ethics Committee, Faculty of Medicine, Prince of Songkla University. Informed consent was obtained from the parents/guardians.

Asthma management

Fluticasone propionate was selected as the ICS therapy for the study. A FLIXOTIDE® 125 Inhaler (GlaxoSmithKline) is a pressurized metered-dose inhaler, which delivers 125 microgram of fluticasone propionate per actuation. Each canister supplies 120 actuations. FLIXOTIDE® 125 Inhaler and BabyHALER® (GlaxoSmithKline), a device to help patients taking inhaled medicine, were prescribed to all participants. The dosage of fluticasone propionate was one actuation twice a day. The add-on asthma therapies were provided according to the GINA guideline⁵. Participants needed to participate in a regular schedule every 8 weeks to obtain a new FLIXOTIDE® 125 inhaler. For patients who did not achieve adequate control or maintain the adherence rate, the inhalation technique and medication doses were revised at the time they visited the clinic. Exacerbation was defined as asthma deterioration that required treatment with systemic corticosteroids or emergency department utilization or hospitalization.

Adherence assessment

The duration of adherence assessment was 24 weeks. Each participant received three canisters of FLIXOTIDE® 125 Inhaler. Parents were asked to collect the discarded inhalers at the 8-week (visit 1), 16-week (visit 2), and 24-week (visit 3) after recruitment. The discarded MDI canisters were weighed by a laboratory scale (Sartorius Basic®). The weight of each canister was replaced in the regression equation to calculate the number of doses actuated from the MDIs. A regression equation for a fluticasone propionate MDI canister gives the number (n) of doses actuated from the MDIs:

n = 276.16 – (14.62 × canister weight).⁴

Statistical analysis

All of the statistical analyses were conducted with R software (version 3.3.2) by the R Foundation for Statistical Computing. Adherence in each 8-week interval was calculated as the amount of medication actuated divided by the amount prescribed. Percentage of adherence was reported as median and range.

Results

A total of 52 asthmatic children participated in the study. The characteristics of the participants are shown in Table 1. Half of the participants were male. The median age was 52.7 months (range, 18.3–91.7) and the age at the onset of asthma was 12 months (range, 1.0–48.0). Parents were the major caregivers. In total, 32% of the participants had other allergic co-morbidities. Most of participants had received ICS therapy for longer than 3 months. At the end of 24 weeks, 44, 33, and 23 (total 100) discarded MDI canisters were collected from visits 1, 2, and 3, respectively. The remaining median weights of the discarded canisters from visits 1, 2, and 3 were 11.172g, 11.229g, and 11.113 g, respectively, and the median percentages of adherence were 96.8%, 96.3%, and 96.3%, respectively. In 11 discarded canisters (11%), the remaining medication was more than 30% of the labeled doses. Approximately 90% of the participants had no asthma exacerbation during 24-week study period (Table 2).

Table 1. Demographic data of asthmatic children.

Variable	Results (N=52)
Male, n (%)	29 (55.8)
Weight, kg, median (range)	18.2 (10.9–30.0)
Height, cm, median (range)	107.4 (84.6–127.5)
Age, months, median (range)	52.7 (18.3–91.7)
Age onset, months, median (range)	12 (1.0–48.0)
Allergic disease, n (%) • Atopic dermatitis • Allergic rhinitis • Food allergy	17 (32.7) 3 (5.8) 12 (23.1) 5 (9.6)
Caregiver, n (%) • Parents • Grandparents	44 (84.6) 7 (13.5)
Number of hospitalizations, times/ person, median (range)	1 (1–5)
Number of exacerbations within previous year, times/person, median (range)	3 (1–9)
Duration from last exacerbation, months, median (range)	4 (3–11)
Duration of ICS therapy, n (%) • 0–3 months • More than 3 months	15 (28.9) 37 (71.1)
Number of studied canisters, n (%) • Visit 1 • Visit 2 • Visit 3	44 (84.6) 33 (63.4) 23 (44.2)

Table 2. Canister weight and percentage of adherence.

Variables	Visit 1	Visit 2	Visit 3
Number of canisters	44	33	23
New canister weight, g, median (range)	18.838 (18.663–18.929)	18.819 (18.607–18.907)	18.812 (18.470–18.913)
Discard canister weight, g, median (range)	11.172 (7.889–16.042)	11.229 (7.825–17.146)	11.113 (9.400–16.020)
Actuated doses calculated from canister weight, median (range)	112.8 (41.6–160.8)	112.0 (25.5–161.8)	113.7 (42.0–138.7)
Percentage of adherence, median (range)	96.8% (33.0–143.6)	96.3% (20.2–126.4)	96.3% (36.8–118.7)
Number of participants with exacerbation	1	2	1

date_original	original weight	date_discard	discard weight	results of the actuated dose equation	day of canister use	prescribed dose	percent of adherence	visit
4/4/2013	18.895	30/5/2013	11.462	109	56	112	97	1
22/5/2013	18.811	24/7/2013	10.748	119	63	126	94	1
2/7/2013	18.892	1/9/2013	10.258	126	61	122	103	1
1/8/2013	18.881	2/10/2013	14.141	69	62	124	56	1
20/8/2013	18.839	22/10/2013	10.133	128	63	126	102	1
1/9/2013	18.929	29/10/2013	11.027	115	58	116	99	1
15/9/2013	18.864	12/11/2013	10.454	123	58	116	106	1
8/10/2013	18.779	3/12/2013	12.027	100	56	112	90	1
8/10/2013	18.811	3/12/2013	14.761	60	56	112	54	1
8/10/2013	18.849	3/12/2013	10.63	121	56	112	108	1
9/10/2013	18.859	3/12/2013	11.544	107	55	110	98	1
9/10/2013	18.787	4/12/2013	12.354	96	56	112	85	1
8/10/2013	18.852	11/12/2013	10.465	123	64	128	96	1
22/10/2013	18.791	17/12/2013	15.921	43	56	112	39	1
22/10/2013	18.808	17/12/2013	11.317	111	56	112	99	1
22/10/2013	18.837	17/12/2013	7.889	161	56	112	144	1
22/10/2013	18.855	17/12/2013	12.633	91	56	112	82	1
25/10/2013	18.89	20/12/2013	12.65	91	56	112	81	1
22/10/2013	18.663	24/12/2013	16.042	42	63	126	33	1
25/10/2013	18.821	24/12/2013	15.323	52	60	120	43	1
30/10/2013	18.829	24/12/2013	11.881	102	55	110	93	1
30/10/2013	18.843	24/12/2013	10.731	119	55	110	108	1
1/11/2013	18.874	24/12/2013	12.274	97	53	106	91	1
30/10/2013	18.818	25/12/2013	10.776	119	56	112	106	1
8/11/2013	18.82	3/1/2014	10.691	120	56	112	107	1
8/11/2013	18.864	3/1/2014	12.061	100	56	112	89	1
8/11/2013	18.854	3/1/2014	10.831	118	56	112	105	1
5/11/2013	18.809	7/1/2014	10.568	122	63	126	97	1
6/11/2013	18.856	8/1/2014	10.56	122	63	126	97	1
6/11/2013	18.819	8/1/2014	13.803	74	63	126	59	1
13/11/2013	18.862	8/1/2014	11.908	102	56	112	91	1
8/11/2013	18.89	9/1/2014	9.833	132	62	124	107	1
8/11/2013	18.876	9/1/2014	10.03	130	62	124	104	1
20/11/2013	18.845	15/1/2014	9.358	139	56	112	124	1
22/11/2013	18.814	17/1/2014	11.434	109	56	112	97	1
29/11/2013	18.838	24/1/2014	10.847	118	56	112	105	1
4/12/2013	18.827	5/2/2014	7.934	160	63	126	127	1
18/12/2013	18.794	19/2/2014	14.978	57	63	126	45	1
8/1/2014	18.796	7/3/2014	9.994	130	58	116	112	1
8/1/2014	18.826	12/3/2014	10.07	129	63	126	102	1
10/1/2014	18.843	12/3/2014	10.48	123	61	122	101	1
10/1/2014	18.803	14/3/2014	12.352	96	63	126	76	1
7/2/2014	18.88	4/4/2014	11.984	101	56	112	90	1
12/2/2014	18.775	11/4/2014	11.98	101	58	116	87	1
30/5/2013	18.874	30/7/2013	14.329	67	61	122	55	2
1/9/2013	18.819	29/10/2013	10.52	122	58	116	105	2
2/10/2013	18.872	6/12/2013	13.903	73	65	130	56	2
22/10/2013	18.888	17/12/2013	11.229	112	56	112	100	2
29/10/2013	18.767	24/12/2013	10.607	121	56	112	108	2
12/11/2013	18.867	7/1/2014	10.742	119	56	112	106	2
3/12/2013	18.875	5/2/2014	8.614	150	64	128	117	2
3/12/2013	18.823	5/2/2014	9.494	137	64	128	107	2
3/12/2013	18.856	5/2/2014	8.988	145	64	128	113	2
4/12/2013	18.815	5/2/2014	10.589	121	63	126	96	2
3/12/2013	18.737	5/2/2014	7.825	162	64	128	126	2
11/12/2013	18.739	11/2/2014	9.16	142	62	124	115	2
17/12/2013	18.848	18/2/2014	15.572	48	63	126	38	2
17/12/2013	18.69	18/2/2014	17.146	25	63	126	20	2
25/12/2013	18.815	19/2/2014	12.508	93	56	112	83	2
20/12/2013	18.82	21/2/2014	12.024	100	63	126	80	2
17/12/2013	18.865	25/2/2014	10.942	116	70	140	83	2
24/12/2013	18.825	25/2/2014	13.948	72	63	126	57	2
24/12/2013	18.788	25/2/2014	11.555	107	63	126	85	2
24/12/2013	18.788	25/2/2014	9.962	131	63	126	104	2
24/12/2013	18.845	25/2/2014	14.122	70	63	126	55	2
3/1/2014	18.809	25/2/2014	11.503	108	53	106	102	2
3/1/2014	18.835	4/3/2014	10.862	117	60	120	98	2
8/1/2014	18.801	4/3/2014	11.715	105	55	110	95	2
7/1/2014	18.815	7/3/2014	12.28	97	59	118	82	2
8/1/2014	18.778	7/3/2014	11.321	111	58	116	95	2
8/1/2014	18.907	7/3/2014	14.441	65	58	116	56	2
8/1/2014	18.607	7/3/2014	10.359	125	58	116	108	2
9/1/2014	18.723	7/3/2014	10.557	122	57	114	107	2
3/1/2014	18.883	7/3/2014	10.064	129	63	126	102	2
17/1/2014	18.803	14/3/2014	14.232	68	56	112	61	2
24/1/2014	18.852	21/3/2014	10.796	118	56	112	106	2
5/2/2014	18.806	2/4/2014	12.384	95	56	112	85	2
30/7/2013	18.856	9/10/2013	9.4	139	71	142	98	3
29/10/2013	18.804	24/12/2013	10.813	118	56	112	105	3
6/12/2013	18.822	5/2/2014	10.213	127	61	122	104	3
17/12/2013	18.819	18/2/2014	10.906	117	63	126	93	3
24/12/2013	18.809	25/2/2014	10.632	121	63	126	96	3
7/1/2014	18.835	7/3/2014	10.081	129	59	118	109	3
5/2/2014	18.848	2/4/2014	9.797	133	56	112	119	3
5/2/2014	18.87	2/4/2014	11.556	107	56	112	96	3
11/2/2014	18.47	4/4/2014	13.096	85	52	104	81	3
5/2/2014	18.74	4/4/2014	11.376	110	58	116	95	3
5/2/2014	18.815	4/4/2014	11.244	112	58	116	96	3
5/2/2014	18.84	4/4/2014	10.253	126	58	116	109	3
21/2/2014	18.771	18/4/2014	10.905	117	56	112	104	3
18/2/2014	18.789	23/4/2014	11.831	103	64	128	81	3
25/2/2014	18.761	23/4/2014	16.02	42	57	114	37	3
25/2/2014	18.755	23/4/2014	10.832	118	57	114	103	3
25/2/2014	18.812	23/4/2014	11.019	115	57	114	101	3
25/2/2014	18.792	23/4/2014	15.804	45	57	114	40	3
25/2/2014	18.876	23/4/2014	11.113	114	57	114	100	3
7/3/2014	18.714	30/4/2014	13.806	74	54	108	69	3
7/3/2014	18.846	30/4/2014	13.463	79	54	108	73	3
7/3/2014	18.913	30/4/2014	14.177	69	54	108	64	3

Dataset 1.Canister weight and percent of adherence.

Raw data of canister weight (original and discarded weight), results of the actuated dose equation and percent of adherence.

Discussion

The present study demonstrated high adherence rates with low variations between the three visits. The percentage of discarded canisters, which had more than 30% of the labeled dosage of medication remaining, reduced from 22% in our previous cross-sectional study⁶ to 11% in this study. Achieving good adherence in this cohort could be explained by the Hawthorn effect: the parents and participants knew that their adherence would be measured by weighing the canisters; therefore, the individuals modified or improved their adherence in response to the awareness of being observed.

Approximately 90% of the participants had no asthma exacerbation throughout the study period. In our previous study, only 59% of the patients had adequate control⁶. Patients had access to the same educational and medication intervention, but the adherence rates were significantly different. Previous studies verified that the adherence rates had an association between lower adherence rates and poor asthma control^7,8.

Although weighing of canisters was less accurate than a dose counter for measuring adherence⁹, the present study demonstrated that a weight-remaining dose correlation could be used to determine the inhaler medication adherence in real life, and intensive monitoring of adherence was successful in achieving control.

In conclusion, our results demonstrated that high adherence rates were achieved after integration of canister weighing into the asthma care service. The present study highlighted the need to incorporate a method to monitor medical adherence in clinical practice, which may contribute to adequate asthma control.

Data availability

Dataset 1: Canister weight and percent of adherence. Raw data of canister weight (original and discarded weight), results of the actuated dose equation and percent of adherence. doi, 10.5256/f1000research.10710.d150970¹⁰

Author contributions

All authors contributed to study design, interpretation of study findings, manuscript preparation, and approved the final manuscript. WC, VE and AY contributed to data acquisition and validation. PS was responsible for project management, data analysis and funding.

Competing interests

No competing interests were disclosed.

Grant information

The study was funded by Faculty of Medicine, Prince of Songkla University (55-021-01-1-2).

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

F1000 recommended

References

1. Ismaila A, Corriveau D, Vaillancourt J, et al.: Impact of adherence to treatment with fluticasone propionate/salmeterol in asthma patients. Curr Med Res Opin. 2014; 30(7): 1417–25. PubMed Abstract | Publisher Full Text
2. Holt S, Holt A, Weatherall M, et al.: Metered dose inhalers: a need for dose counters. Respirology. 2005; 10(1): 105–6. PubMed Abstract | Publisher Full Text
3. Jentzsch NS, Camargos PA, Colosimo EA, et al.: Monitoring adherence to beclomethasone in asthmatic children and adolescents through four different methods. Allergy. 2009; 64(10): 1458–62. PubMed Abstract | Publisher Full Text
4. Sahajarupat T, Sangsupawanich P: Relationship of canister weight to the amount of medication actuated from metered-dose inhalers. J Allergy Clin Immunol. 2012; 129(2 Supplement): AB41. Publisher Full Text
5. Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention. Reference Source
6. Dampanrat W, Sangsupawanich P, Yuenyongviwat A: Medication Remaining In Discarded Metered Dose Inhalers Of Asthmatic Children. J Allergy Clin Immunol. 2014; 133(2 Supplement): AB179. Publisher Full Text
7. Lasmar L, Camargos P, Champs NS, et al.: Adherence rate to inhaled corticosteroids and their impact on asthma control. Allergy. 2009; 64(5): 784–9. PubMed Abstract | Publisher Full Text
8. Jentzsch NS, Camargos P, Sarinho ES, et al.: Adherence rate to beclomethasone dipropionate and the level of asthma control. Respir Med. 2012; 106(3): 338–43. PubMed Abstract | Publisher Full Text
9. Bender B, Wamboldt FS, O'Connor SL, et al.: Measurement of children's asthma medication adherence by self report, mother report, canister weight, and Doser CT. Ann Allergy Asthma Immunol. 2000; 85(5): 416–21. PubMed Abstract | Publisher Full Text
10. Chuenjit W, Engchuan V, Yuenyongviwat A, et al.: Dataset 1 in: Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children. F1000Research. 2017. Data Source

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VERSION 1 PUBLISHED 14 Mar 2017

Author details Author details

¹ Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand

Competing interests

No competing interests were disclosed.

Grant information

The study was funded by Faculty of Medicine, Prince of Songkla University (55-021-01-1-2).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (1)

version 1

Published: 14 Mar 2017, 6:266

https://doi.org/10.12688/f1000research.10710.1

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© 2017 Chuenjit W et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

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Chuenjit W, Engchuan V, Yuenyongviwat A and Sangsupawanich P. Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children [version 1; peer review: 2 approved, 1 approved with reservations]. F1000Research 2017, 6:266 (https://doi.org/10.12688/f1000research.10710.1)

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Reviewer Report 09 Aug 2017

Orathai Piboonpocanun, Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

Approved

https://doi.org/10.5256/f1000research.11547.r24513

The authors tried to use canister weight to calculate the number of doses actuated from the MDIs and to assess medical adherence to MDIs.
There are some issues which need clarification

Please clarify why the

The authors tried to use canister weight to calculate the number of doses actuated from the MDIs and to assess medical adherence to MDIs.
There are some issues which need clarification

Please clarify why the numbers of collected MDI canisters were not the same in each visit.
Please mentioned about patients who had exacerbation. Were they the same patients? Were these patients nonadherence to medication or did they have any specific problem?

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

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Reviewer Report 24 Apr 2017

Bee Wah Lee, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

Approved with Reservations

https://doi.org/10.5256/f1000research.11547.r22150

This study evaluated adherence to ICS prophylaxis in asthmatic children by using weight of canister as a means to determine inhaler compliance, by calculating doses used by using a regression equation based on canister weight. The authors conclude that in ... Continue reading

This study evaluated adherence to ICS prophylaxis in asthmatic children by using weight of canister as a means to determine inhaler compliance, by calculating doses used by using a regression equation based on canister weight. The authors conclude that in the absence of an inbuilt dose counter, weighing the canister was a useful means of improving adherence to daily treatment with ICS.

Detailed comments:

There were 52 children participating in the study. However, with each follow up visit (n=3)the number of canisters measure reduced progressively (44, 33, 23). Was there loss to follow up or did these patients fail to return their canisters? Could these patients be used as their comparative group in terms of asthma control over the period of follow up?
For the subjects with the 11 canisters that had remaining medication, was their asthma control affected by non compliance?
It may be more appropriate to use the term ‘used’ rather than ’discarded’ canisters.
Under the paragraph: adherence assessment. Some editing of sentences may improve readability:

Parents were asked to ‘return’ the ‘used inhalers at the 8 week…..

‘The weight of the canister was replaced in the regression equation’ to “The number of remaining doses

of remaining doses was extrapolated by using the weight of the used MDI canisters into the regression equation as shown:……..

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 21 Apr 2017

Wiparat Manuyakorn, Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Approved

https://doi.org/10.5256/f1000research.11547.r21967

The article is well written. However, there is some minor comment.
1. The authors mentioned that "The metered-dose inhalers (MDIs) currently available for inhaled
corticosteroid delivery do not offer an integrated dose counter". This statement was true at ... Continue reading

The article is well written. However, there is some minor comment.
1. The authors mentioned that "The metered-dose inhalers (MDIs) currently available for inhaled
corticosteroid delivery do not offer an integrated dose counter". This statement was true at the time when this study was performed. But currently, there are some MDIs that have dose counter. So this statement needs some amendment.
2. Method: the authors mentioned that "Participants needed to participate in a regular schedule every 8 weeks to obtain a new FLIXOTIDE® 125 inhaler." And the duration of treatment was 24 weeks. So it means that each participant would receive 3 inhalers. A total of 52 children was participated. So I wonder why only 100 MDI canister was evaluated. It should be 52*3=156?. This may need the clarification.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

CITE

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Version 1

VERSION 1 PUBLISHED 14 Mar 2017

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Version 1 14 Mar 17	read	read	read

Wiparat Manuyakorn, Mahidol University, Bangkok, Thailand
Bee Wah Lee, National University of Singapore, Singapore, Singapore
Orathai Piboonpocanun, Mahidol University, Bangkok, Thailand

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Reviewer Report

5 Views

09 Aug 2017 | for Version 1

Orathai Piboonpocanun, Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

5 Views Cite this report Responses(0)

Approved

The authors tried to use canister weight to calculate the number of doses actuated from the MDIs and to assess medical adherence to MDIs.
There are some issues which need clarification

Please clarify why the numbers of collected MDI canisters were not the same in each visit.
Please mentioned about patients who had exacerbation. Were they the same patients? Were these patients nonadherence to medication or did they have any specific problem?

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

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Reviewer Report

11 Views

24 Apr 2017 | for Version 1

Bee Wah Lee, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

11 Views Cite this report Responses(0)

Approved With Reservations

This study evaluated adherence to ICS prophylaxis in asthmatic children by using weight of canister as a means to determine inhaler compliance, by calculating doses used by using a regression equation based on canister weight. The authors conclude that in the absence of an inbuilt dose counter, weighing the canister was a useful means of improving adherence to daily treatment with ICS.

Detailed comments:

There were 52 children participating in the study. However, with each follow up visit (n=3)the number of canisters measure reduced progressively (44, 33, 23). Was there loss to follow up or did these patients fail to return their canisters? Could these patients be used as their comparative group in terms of asthma control over the period of follow up?
For the subjects with the 11 canisters that had remaining medication, was their asthma control affected by non compliance?
It may be more appropriate to use the term ‘used’ rather than ’discarded’ canisters.
Under the paragraph: adherence assessment. Some editing of sentences may improve readability:

Parents were asked to ‘return’ the ‘used inhalers at the 8 week…..

‘The weight of the canister was replaced in the regression equation’ to “The number of remaining doses

of remaining doses was extrapolated by using the weight of the used MDI canisters into the regression equation as shown:……..

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

8 Views

21 Apr 2017 | for Version 1

Wiparat Manuyakorn, Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

8 Views Cite this report Responses(0)

Approved

The article is well written. However, there is some minor comment.
1. The authors mentioned that "The metered-dose inhalers (MDIs) currently available for inhaled
corticosteroid delivery do not offer an integrated dose counter". This statement was true at the time when this study was performed. But currently, there are some MDIs that have dose counter. So this statement needs some amendment.
2. Method: the authors mentioned that "Participants needed to participate in a regular schedule every 8 weeks to obtain a new FLIXOTIDE® 125 inhaler." And the duration of treatment was 24 weeks. So it means that each participant would receive 3 inhalers. A total of 52 children was participated. So I wonder why only 100 MDI canister was evaluated. It should be 52*3=156?. This may need the clarification.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

[1] 1. Ismaila A, Corriveau D, Vaillancourt J, et al.: Impact of adherence to treatment with fluticasone propionate/salmeterol in asthma patients. Curr Med Res Opin. 2014; 30(7): 1417–25. PubMed Abstract | Publisher Full Text

[2] 2. Holt S, Holt A, Weatherall M, et al.: Metered dose inhalers: a need for dose counters. Respirology. 2005; 10(1): 105–6. PubMed Abstract | Publisher Full Text

[3] 3. Jentzsch NS, Camargos PA, Colosimo EA, et al.: Monitoring adherence to beclomethasone in asthmatic children and adolescents through four different methods. Allergy. 2009; 64(10): 1458–62. PubMed Abstract | Publisher Full Text

[4] 4. Sahajarupat T, Sangsupawanich P: Relationship of canister weight to the amount of medication actuated from metered-dose inhalers. J Allergy Clin Immunol. 2012; 129(2 Supplement): AB41. Publisher Full Text

[5] 5. Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention. Reference Source

[6] 6. Dampanrat W, Sangsupawanich P, Yuenyongviwat A: Medication Remaining In Discarded Metered Dose Inhalers Of Asthmatic Children. J Allergy Clin Immunol. 2014; 133(2 Supplement): AB179. Publisher Full Text

[7] 7. Lasmar L, Camargos P, Champs NS, et al.: Adherence rate to inhaled corticosteroids and their impact on asthma control. Allergy. 2009; 64(5): 784–9. PubMed Abstract | Publisher Full Text

[8] 8. Jentzsch NS, Camargos P, Sarinho ES, et al.: Adherence rate to beclomethasone dipropionate and the level of asthma control. Respir Med. 2012; 106(3): 338–43. PubMed Abstract | Publisher Full Text

[9] 9. Bender B, Wamboldt FS, O'Connor SL, et al.: Measurement of children's asthma medication adherence by self report, mother report, canister weight, and Doser CT. Ann Allergy Asthma Immunol. 2000; 85(5): 416–21. PubMed Abstract | Publisher Full Text

[10] 10. Chuenjit W, Engchuan V, Yuenyongviwat A, et al.: Dataset 1 in: Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children. F1000Research. 2017. Data Source

Achieving good adherence to inhaled corticosteroids after weighing canisters of asthmatic children

Abstract

Keywords

Introduction

Methods

Study design and subjects

Asthma management

Adherence assessment

Statistical analysis

Results

Table 1. Demographic data of asthmatic children.

Table 2. Canister weight and percentage of adherence.

Discussion

Data availability

Author contributions

Competing interests

Grant information

References

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