**3.2 Adherence to non-drug therapy**

280 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

The Lung Health Study (Rand et al., 1995) was a double-blind, multicentre, randomised, controlled trial on smoking intervention and bronchodilator therapy (ipratropium or placebo) as early interventions of COPD. Satisfactory adherence was reported by 70% of the participants at the first 4-month follow-up visit, but this rate declined to 60% over the next 18 months. The overall adherence estimated by canister weighing was 72% in the first year and 70% in the second year. Nevertheless, in the first year, only 48% of the participants were classified as adherent with both methods. In an ancillary study within the Lung Health Study, medication adherence rates measured by both self-report and canister weighing were compared with data from electronic medication monitoring (Rand et al., 1992). This study found that self-reporting and canister weighing significantly overestimate adherence: only 15% of the participants used their inhaler 2.5 or more times per day (when three puffs per day were prescribed). In addition, 14% of the patients seemed to be "dumping" medication prior to the clinic visit by removing most of the medication at one time (i.e., actuating inhaler more than 100 times in a 3-h interval) to hide non-adherence. The level of adherence with the prescribed medication regimen was best immediately following each follow-up visit and declined during the interval between follow-up visits. The adherence after each visit was lower for each successive follow-up. These trends could be observed only with electronic medication monitors; self-reporting or weighing could not detect these changes

Studies also suggest that while the underuse of medication seems to be one of the largest problems in the management of COPD, overuse is also common. Symptom-relieving drugs, such as short-acting β2 agonists (SABA), are more often overused than maintenance therapies (Dekker et al., 1993). Krigsman et al. (Krigsman et al., 2007a) evaluated the primary adherence in patients with asthma and COPD. The obtained results indicated that 53% of the patients underused and 18% overused their prescribed medication regimens. In another study by Krigsman et al. (Krigsman et al., 2007b), it was found that 59% of COPD

Eighty-four percent of COPD patients have one or more co-morbidity (Yeo et al., 2006). For this reason, a question arises about whether the level of a patient's adherence is the same with therapies for different chronic diseases. Krigsman et al. (Krigsman et al., 2007c) investigated refill adherence in patients who suffered from diabetes and COPD. Participants showed higher

Long-term oxygen therapy (LTOT) plays an important role in the management of COPD (Würtemberger & Hütter, 2000). The daily duration of oxygen administration is crucial in the effectiveness of LTOT. Pepin et al. (Pepin et al., 1996) found that only 45% of the COPD patients who were prescribed oxygen therapy for an average of 16 hours per day (16±3 h/d) used oxygen for 15 hours or more per day. Another study reported that 23% of the patients who had been prescribed LTOT refused to use liquid oxygen away from home and that 12%

Immunisation with both the influenza and pneumococcal vaccines may produce a number of acute exacerbations, hospitalisation and COPD mortality (Nichol et al., 1999; Varkey et al., 2009). However, the vaccination rates in patients with chronic lung diseases are low (Nichol et al., 1999; Tuppin et al., 2011), and the willingness to vaccinate differs by age group. The influenza vaccination status is significantly higher in patients aged 65 years or older (86.2%)

patients had an undersupply and 12% had an oversupply of ICS medication.

adherence for their diabetes drugs (68%) than their COPD medications (42%).

underused their oxygen (Würtemberger & Hütter, 2000).

than in the younger population (65.7%) (Mehuys et al., 2010).

(Simmons et al., 1996).

Adherence to non-drug therapies, such as respiratory rehabilitation, exercise programs, healthy lifestyle or smoking cessation, is crucial in the management of COPD. Approximately 60% of the patients refuse to take part in rehabilitation programs, and out of those who join, 30% fail to complete the program (Nici et al., 2006). The most important barriers to rehabilitation adherence include exacerbations and progression of COPD (Bourbeau et al., 2007; Brooks et al., 2002). The literature in this field is quite weak; there is a clear need for further research to find out more about the suboptimal adherence to non-drug therapies in patients with COPD.
