Assessment of synthetic glucocorticoids in asthmatic sputum.

Nonadherence with anti-inflammatory treatment is a frequent cause of continued symptoms in asthmatic patients. Clinical assessments including patient-reported medication administration may provide the asthma specialist incomplete information regarding actual adherence to anti-inflammatory medications. The objective of this report was to describe the first case where adherence to inhaled asthma therapy was assessed by direct analysis of glucocorticoids in induced sputum. The patient’s blood, urine, and sputum were tested for synthetic corticosteroids using mass spectrometry. To evaluate a clinical suspicion of poor adherence, sputum, urine, and blood were used to assess for current compliance to medication use. We report a case where asthma specialists attributed poorly controlled asthma to nonadherence to medical therapy. After modification of the medical regimen, adherence with oral and inhaled steroids was assessed—via examination of the urine, blood, and sputum. Direct analysis of glucocorticoids in sputum is feasible and in theory could provide a novel tool to document current medication adherence. Concomitant assessment of glucocorticoids and eosinophils in the same induced sputum specimen could provide insight into possible steroid resistance in select referral patients with difficult asthma. (Allergy Rhinol 2:33–35, 2011; doi: 10.2500/ar.2011.2.0002) I the United States over 23 million people have been told they have asthma. Nonadherence with treatment has been estimated between 20 and 80%. Poor adherence has been associated with 27–33% of asthma deaths. Studies have shown that patient-reported adherence was 95.4% in diaries, but median actual use by electronic monitoring was only 58.4%, suggesting that a physician may be misled by accepting self-assessments of adherence to medication. Inhaled corticosteroids are currently the most effective long-term control medication for asthma and provide control for the majority of asthmatic patients. Unfortunately, the morbidity, mortality, and costs of asthma remain elevated, in part because of patient nonadherence. Asthma specialists perform clinical assessments of adherence while attempting to optimize anti-inflammatory therapy. These clinical assessments are thought for the most part to be accurate. Direct analysis of eosinophils in induced sputum has been beneficial in tailoring antiinflammatory therapy in asthma. Although there has been an increase in the number of publications involving sputum studies in the diagnosis and treatment of asthma, most studies provide limited information regarding adherence of inhaler use in study subjects. In select, refractory asthmatic patients and in patients undergoing asthma studies involving inflammation, there may be a role for a gold standard to monitor adherence of inhaled corticosteroid therapy.