1
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Mapel DW, Roberts MH, Davis J. Budesonide/formoterol therapy: effective and appropriate use in asthma and chronic obstructive pulmonary disease. J Comp Eff Res 2020; 9:231-251. [PMID: 31983228 DOI: 10.2217/cer-2019-0161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Quality, real-world comparative effectiveness (CE) studies of asthma and chronic obstructive pulmonary disease therapy efficacy are scarce. We identified and evaluated peer-reviewed CE and appropriate-use evaluations of budesonide/formoterol combination (BFC) maintenance therapy. Materials & methods: Analyses were limited to retrospective, real-world utilization studies of BFC delivered by pressurized metered-dose inhalers. Results: In a CE study of BFC versus fluticasone/salmeterol combinations (FSC) in asthma, BFC users had fewer total exacerbations. In appropriate-use studies of asthma treatment, BFC patients were consistently more likely to meet treatment escalation recommendations. BFC comparisons with FSC or tiotropium for chronic obstructive pulmonary disease found differences in exacerbation rates and rescue inhaler use. Conclusion: We found available, good quality BFC CE and appropriate-use articles; however, all had limitations.
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Affiliation(s)
- Douglas W Mapel
- University of New Mexico College of Pharmacy, MSC09 5360, University of New Mexico, Albuquerque, NM 87131, USA.,LCF Research, 2309 Renard Place SE Ste 103, Albuquerque, NM 87106, USA
| | - Melissa H Roberts
- University of New Mexico College of Pharmacy, MSC09 5360, University of New Mexico, Albuquerque, NM 87131, USA
| | - Jill Davis
- AstraZeneca LP, 1800 Concord Pike, Wilmington, DE 19897, USA
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2
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Khakban A, FitzGerald JM, Tavakoli H, Lynd L, Ehteshami-Afshar S, Sadatsafavi M. Extent, trends, and determinants of controller/reliever balance in mild asthma: a 14-year population-based study. Respir Res 2019; 20:44. [PMID: 30819154 PMCID: PMC6394061 DOI: 10.1186/s12931-019-1007-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 02/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The majority of patients with asthma have the mild form of the disease. Whether mild asthma patients receive appropriate asthma medications has not received much attention in the literature. We examined the trends in indicators of controller/reliever balance. METHODS Using administrative health databases of British Columbia, Canada (2000 to 2013), we created a population-based cohort of adolescents/adults with mild asthma using validated case definition algorithms. Each patient-year of follow-up was assessed based on two markers of inappropriate medication prescription: whether the ratio of controller medications (inhaled corticosteroids [ICS] and leukotriene receptor antagonists [LTRA]) to total asthma-related prescriptions was low (cut-off 0.5 according to previous validation studies), and whether short-acting beta agonists (SABA) were prescribed inappropriately according to previously published criteria that considers SABA in relation to ICS prescriptions. Generalized linear models were used to evaluate trends and to examine the association between patient-, disease-, and healthcare-related factors and medication use. RESULTS The final cohort consisted of 195,941 mild asthma patients (59.5% female; mean age at entry 29.6 years) contributing 1.83 million patient-years. In 48.8% of patient-years, controller medications were suboptimally prescribed, while in 7.2%, SABAs were inappropriately prescribed. There was a modest year-over-year decline in inappropriate SABA prescription (relative change - 1.3%/year, P < 0.001) and controller-to-total-medications (relative change - 0.5%/year, P < 0.001). Among the studied factors, the indices of type and quality of healthcare (namely respirologist consultation and receiving pulmonary function test) had the strongest associations with improvement in controller/reliever balance. CONCLUSIONS Large number of mild asthma patients continue to be exposed to suboptimal combinations of asthma medications, and it appears there are modifiable factors associated with such phenomenon.
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Affiliation(s)
- Amir Khakban
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, Canada.,Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, Canada
| | - J Mark FitzGerald
- Division of Respiratory Medicine and Institute for Heart and Lung Health, Vancouver General Hospital, the University of British Columbia, Vancouver, Canada
| | - Hamid Tavakoli
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, Canada
| | - Larry Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, Canada.,Center for Health Evaluation and Outcome Sciences, Vancouver, Canada
| | - Solmaz Ehteshami-Afshar
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, Canada
| | - Mohsen Sadatsafavi
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, Canada. .,Division of Respiratory Medicine and Institute for Heart and Lung Health, Vancouver General Hospital, the University of British Columbia, Vancouver, Canada. .,Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, Canada.
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3
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Baldacci S, Simoni M, Maio S, Angino A, Martini F, Sarno G, Cerrai S, Silvi P, Pala AP, Bresciani M, Paggiaro P, Viegi G. Prescriptive adherence to GINA guidelines and asthma control: An Italian cross sectional study in general practice. Respir Med 2018; 146:10-17. [PMID: 30665506 DOI: 10.1016/j.rmed.2018.11.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/31/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although general practitioners (GPs) are frequently the first healthcare professionals whom asthma patients refer to for their symptoms, few studies have explored the extent of adherence to guidelines for asthma management based on data provided directly by GPs. Aims of the present study were to assess drug prescriptions for asthma by GPs and to evaluate prescriptive adherence to GINA guidelines (GL) and its relationship with disease control in real life. METHODS 995 asthmatic patients (45% males, mean age 43.3 ± 17.7 yrs) were enrolled by 107 Italian GPs distributed throughout the country. Data on diagnosis, disease severity, prescribed anti-asthmatic drugs and control were collected through questionnaires filled out by GPs taking into consideration the 2009 GINA Guidelines. Data on drug use and chronic sinusitis, nasal polyposis, chronic bronchitis, emphysema were reported by patients through a self-administered questionnaire. RESULTS The large majority of patients were classified by GPs as having intermittent (48.4%) or mild persistent asthma (25.3%); 61% had co-morbid allergic rhinitis (AR). The prevalent therapeutic regimen used by patients was a combination of inhaled corticosteroids (ICS) plus long-acting β2-agonists (LABA) (54.1%), even in the intermittent/mild persistent group. ICS as mono-therapy or in combination with other drugs but LABA, was the second most frequently adopted treatment (14.4%). In general, the GPs adherence to GL treatment indications was 28.8%, with a significant association with a good asthma control (OR 1.85, 95% CI 1.18-2.92). On the other hand, comorbidity (OR 0.52, 95% CI 0.32-0.84), moderate (0.44, 0.28-0.69) and severe (0.06, 0.02-0.20) persistent asthma showed significant negative effects on asthma control. CONCLUSIONS Our results show that over-treatment of intermittent/mild persistent asthma is frequent in the GPs setting while therapeutic regimens are more appropriately applied for moderate/severe asthma. In general, we found low adherence to GINA GL treatment recommendations even if its relevance in asthma control was confirmed.
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Affiliation(s)
- Sandra Baldacci
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Marzia Simoni
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Sara Maio
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Anna Angino
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Franca Martini
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Giuseppe Sarno
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Sonia Cerrai
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Patrizia Silvi
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Anna Paola Pala
- Technoscience Unit, CNR Institute of Clinical Physiology, Via G. Moruzzi no. 1, 56124, Pisa, Italy
| | - Megon Bresciani
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Via Paradisa no. 2, 56124, Pisa, Italy
| | - Giovanni Viegi
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste no. 41, 56126, Pisa, Italy; CNR Institute of Biomedicine and Molecular Immunology "A. Monroy", Via U. La Malfa no. 153, 90146, Palermo, Italy
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4
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Tavakoli H, Mark FitzGerald J, Lynd LD, Sadatsafavi M. Predictors of inappropriate and excessive use of reliever medications in asthma: a 16-year population-based study. BMC Pulm Med 2018; 18:33. [PMID: 29433489 PMCID: PMC5809893 DOI: 10.1186/s12890-018-0598-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding factors associated with the inappropriate or excessive use of short-acting beta agonists (SABA) can help develop better policies. METHODS We used British Columbian (BC)'s administrative health data (1997-2014) to create a retrospective cohort of asthma patients aged between 14 and 55 years. The primary and secondary outcomes were, respectively, inappropriate and excessive use of SABA based on a previously validated definition. Exposures were categorised into groups comprising socio-demographic variables, indicators of type and quality of asthma care, and burden of comorbid conditions. RESULTS 343,520 individuals (56.3% female, average age 30.5) satisfied the asthma case definition, contributing 2.6 million person-years. 7.3% of person-years were categorised as inappropriate SABA use and 0.9% as excessive use. Several factors were associated with lower likelihood of inappropriate use, including female sex, higher socio-economic status, higher continuity of care, having received pulmonary function test in the previous year, visited a specialist in the previous year, and the use of inhaled corticosteroids in the previous year. An asthma-related outpatient visit to a general practitioner in the previous year was associated with a higher likelihood of inappropriate SABA use. Similar associations were found for excessive SABA use with the exception that visit to respirologist and the use of systemic corticosteroids were associated with increased likelihood of excessive use. CONCLUSIONS Despite proven safety issues, inappropriate SABA use is still prevalent. Several factors belonging to patients' characteristics and type/quality of care were associated with inappropriate use of SABAs and can be used to risk-stratify patients for targeted attempts to reduce this preventable cause of adverse asthma outcomes.
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Affiliation(s)
- Hamid Tavakoli
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada. .,Department of Medicine, Institute for Heart and Lung Health, University of British Columbia, Vancouver, Canada. .,Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, Canada.
| | - J Mark FitzGerald
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.,Department of Medicine, Institute for Heart and Lung Health, University of British Columbia, Vancouver, Canada
| | - Larry D Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.,Department of Medicine, Institute for Heart and Lung Health, University of British Columbia, Vancouver, Canada.,Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, Canada
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5
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Baker MA, Butler MG, Seymour S, Zhang F, Wu Y, Wu AC, Levenson MS, Wu P, Iyer A, Toh S, Iyasu S, Zhou EH. The impact of FDA regulatory activities on incident dispensing of LABA-containing medication: 2005-2011. J Asthma 2017; 55:907-914. [PMID: 28910559 DOI: 10.1080/02770903.2017.1378355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Evidence of safety issues associated with long-acting beta2-agonist (LABA) treatment has led to multiple regulatory activities by the U.S. Food and Drug Administration (FDA) on this class of medications. This study describes the impact of the regulatory activities on incident LABA-containing medication dispensing. METHODS A monthly rolling cohort of asthma patients who were eligible to initiate a LABA-containing product was created in the Mini-Sentinel Distributed Database between January 2005 and June 2011. Cohorts of individuals who initiated LABA were examined for the changes in the proportions of single-ingredient to fixed-dose inhaled corticosteroid (ICS)-LABA initiators, appropriate initiation of LABA-containing products, and use of controller medications. The impact of the 2005 and 2010 FDA regulatory activities associated with LABA-containing products was measured using interrupted time series with segmented regression. RESULTS LABA-containing product initiation was declining prior to the 2005 regulatory activities and continued to decline over the study period, accompanied by increased initiation of fixed dose ICS-LABA among LABA initiators. While the 2010 regulatory activities had no immediate impact on the proportion of LABA initiation in patients with prior controller medication dispensing and/or poor asthma control, there was an increasing positive trend toward LABA initiation in the appropriate patient population after the regulatory activities. CONCLUSION The 2005 and 2010 FDA regulatory activities likely had an impact on communicating the safety concerns of LABA products. However, the impact cannot be viewed independent of scientific publications, guidelines for asthma treatment and other regulatory activities.
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Affiliation(s)
- Meghan A Baker
- a Department of Population Medicine , Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston , MA , USA.,b Division of Infectious Diseases, Department of Medicine , Brigham and Women's Hospital , Boston , MA , USA
| | - Melissa G Butler
- c Center for Clinical and Outcomes Research , Kaiser Permanente Georgia , Atlanta , GA , USA.,d The Evidence Space , Hamilton , Bermuda
| | - Sally Seymour
- e Office of New Drugs, Center for Drug Evaluation and Research , Food and Drug Administration , Silver Spring , MD , USA
| | - Fang Zhang
- a Department of Population Medicine , Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston , MA , USA
| | - Yute Wu
- f Office of Biostatistics, Center for Drug Evaluation and Research , Food and Drug Administration , Silver Spring , MD , USA
| | - Ann Chen Wu
- a Department of Population Medicine , Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston , MA , USA
| | - Mark S Levenson
- f Office of Biostatistics, Center for Drug Evaluation and Research , Food and Drug Administration , Silver Spring , MD , USA
| | - Pingsheng Wu
- g Vanderbilt University School of Medicine , Department of Medicine and Biostatistics , Nashville , TN , USA
| | - Aarthi Iyer
- a Department of Population Medicine , Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston , MA , USA
| | - Sengwee Toh
- a Department of Population Medicine , Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston , MA , USA
| | - Solomon Iyasu
- h Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research , U.S. Food and Drug Administration , Silver Spring , MD , USA
| | - Esther H Zhou
- h Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research , U.S. Food and Drug Administration , Silver Spring , MD , USA
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6
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Zhou EH, Seymour S, Goulding MR, Kang EM, Major JM, Iyasu S. The US Food and Drug Administration's drug safety recommendations and long-acting beta2-agonist dispensing pattern changes in adult asthma patients: 2003-2012. J Asthma Allergy 2017; 10:67-74. [PMID: 28356763 PMCID: PMC5360406 DOI: 10.2147/jaa.s124395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Emerging safety issues associated with long-acting beta2-agonist (LABA) have led to multiple regulatory activities by the US Food and Drug Administration (FDA) since 2003, including Drug Safety Communications (DSCs) in 2010. These DSCs had three specific recommendations for the safe use of LABA products in adult asthma treatment. Methods We examined the initiation of LABA-containing products for adult asthma treatment using an intermittent time series approach in a claims database from 2003 to 2012. We assessed the alignment of dispensing patterns with the following 2010 FDA recommendations: 1) contraindicated use of single-ingredient (SI)-LABA without an asthma controller medication (ACM); 2) a LABA should only be used when asthma is not adequately controlled on inhaled corticosteroids (ICSs) or ACM; and 3) step-down asthma therapy (e.g., discontinue LABA) when asthma control is achieved. Results There were 477,922 adults (18–64 years old) dispensed a new LABA during 2003–2012. Among LABA initiators, patients who initiated an SI-LABA and who did “not” have an ACM dispensed on the same date decreased from >9% in 2003 (the initial labeling change) to <2% post 2010 DSCs (p-value <0.0001 in the segmented regression model). The proportion of asthma patients dispensed an ICS in 6 months prior to initiating LABA treatment did not increase. The proportion of patients with longer than 4 months of continuous treatment did not decrease over the study period. Conclusion Although the decrease in SI-LABA initiation is consistent with FDA’s recommendations, low ICS dispensing before initiating a LABA and LABA continuation practices require further efforts to move toward the recommended safe practices.
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Affiliation(s)
- Esther H Zhou
- Division of Epidemiology, Office of Surveillance and Epidemiology
| | - Sally Seymour
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | | | - Elizabeth M Kang
- Division of Epidemiology, Office of Surveillance and Epidemiology
| | | | - Solomon Iyasu
- Division of Epidemiology, Office of Surveillance and Epidemiology
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7
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Dilokthornsakul P, Lee TA, Dhippayom T, Jeanpeerapong N, Chaiyakunapruk N. Comparison of Health Care Utilization and Costs for Patients with Asthma by Severity and Health Insurance in Thailand. Value Health Reg Issues 2016; 9:105-111. [PMID: 27881251 DOI: 10.1016/j.vhri.2016.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 01/19/2016] [Accepted: 03/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND To compare health care utilization and cost by asthma severity and type of health insurance in Thailand. METHODS A retrospective cohort study using an electronic database was conducted in patients with asthma. Patients who were diagnosed with asthma from 2009 to 2011, had at least two subsequent health care encounters for asthma during the first six months after the first asthma diagnosis, and had at least 90 days of follow-up were included. The primary outcome was direct health care costs of inpatient and outpatient care. We compared outcomes between groups on the basis of a proxy of severity (mild/moderate severe asthma vs. high severe asthma) and type of health insurance using a multivariable generalized linear model. Covariates such as Patients' demographic characteristics, comorbidities, and concurrent medications were included in the model. RESULTS Among 1982 patients included, the average age was 40.3 ± 24.0 years, with 60.7% being males. A total of 1936 patients had mild/moderate severe asthma, whereas 46 patients had high severe asthma. There were 1293 patients under the Universal Coverage Scheme, 264 patients under Social Security Insurance, and 626 patients under the Civil Servant Medical Benefit Scheme (CSMBS). The average annual cost per patient was $598 ± $871. In adjusted analyses, the health care cost of patients with high severe asthma was $71 higher than that of patients with mild/moderate severe asthma (95% confidence interval $-131 to $274). The cost of patients under the CSMBS was $110 (95% confidence interval $29-$191) higher than that of patients under Universal Coverage Scheme. CONCLUSIONS Health care costs of patients with asthma were substantial and were higher in patients with high severe asthma and patients under the CSMBS.
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Affiliation(s)
- Piyameth Dilokthornsakul
- Center of Pharmaceutical Outcomes Research, Faculty of Pharmaceutical Sciences, Department of Pharmacy Practice, Naresuan University, Phitsanulok, Thailand
| | - Todd A Lee
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Teerapon Dhippayom
- Pharmaceutical Care Research Unit, Faculty of Pharmaceutical Sciences, Department of Pharmacy Practice, Naresuan University, Phitsanulok, Thailand
| | | | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research, Faculty of Pharmaceutical Sciences, Department of Pharmacy Practice, Naresuan University, Phitsanulok, Thailand; School of Pharmacy, Monash University Malaysia, Selangor, Malaysia; School of Population Health, University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA.
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8
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Butler MG, Zhou EH, Zhang F, Wu YT, Wu AC, Levenson MS, Wu P, Seymour S, Toh S, Iyer A, Iyasu S, Baker MA. Changing patterns of asthma medication use related to US Food and Drug Administration long-acting β2-agonist regulation from 2005-2011. J Allergy Clin Immunol 2015; 137:710-7. [PMID: 26725997 DOI: 10.1016/j.jaci.2015.09.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Safety concerns associated with long-acting β2-agonists (LABAs) have led to many US Food and Drug Administration (FDA) regulatory activities for this class of drugs. Little is known about the effect of these regulatory activities on use of LABA-containing agents or other asthma medications. METHODS We created rolling cohorts of pediatric and adult asthmatic patients in the Mini-Sentinel Distributed Database between January 2005 and June 2011. The proportions of asthmatic patients using LABA-containing products, inhaled corticosteroids (ICSs), leukotriene modifiers, short-acting β2-agonists, oral corticosteroids, other bronchodilators, and no medications were measured on a monthly basis, and the changes were evaluated by using interrupted time series with segmented regression analysis. RESULTS When the 2005 regulatory activity was announced, there were statistically significant decreases in the use of fixed-dose ICS-LABA agents in children (-0.98 percentage points) and adults (-1.24 percentage points). Increased use of ICSs and leukotriene modifiers was observed just after the regulatory activities were announced in both children and adults. Although of smaller magnitude, continued favorable changes in the use of LABA agents were observed after the 2010 FDA regulatory activity. CONCLUSION The 2005 and 2010 FDA regulatory activities might have contributed to reduced use of LABA agents, as intended; however, their effect, independent of other factors, cannot be determined. Use of other classes of asthma medications was similarly affected.
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Affiliation(s)
- Melissa G Butler
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Ga; Evidence Space, Hamilton, Bermuda
| | - Esther H Zhou
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Md
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Yu-te Wu
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Md
| | - Ann Chen Wu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Mark S Levenson
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Md
| | - Pingsheng Wu
- Department of Medicine and Biostatistics, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Sally Seymour
- Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Md
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Aarthi Iyer
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Solomon Iyasu
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Md
| | - Meghan A Baker
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Mass.
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9
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Combination treatment in asthma: Reviewing old and new options. Pulm Pharmacol Ther 2015; 34:72-4. [PMID: 26365488 DOI: 10.1016/j.pupt.2015.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 11/24/2022]
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10
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Mapel DW, Roberts MH. Management of asthma and chronic obstructive pulmonary disease with combination inhaled corticosteroids and long-acting β-agonists: a review of comparative effectiveness research. Drugs 2015; 74:737-55. [PMID: 24797158 PMCID: PMC4030099 DOI: 10.1007/s40265-014-0214-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The value of combination therapy with inhaled corticosteroids and long-acting β-agonists (ICS/LABA) is well recognized in the management of asthma and chronic obstructive pulmonary disease (COPD). Despite differences in the pharmacological properties between two well-established ICS/LABA products (budesonide/formoterol and fluticasone/salmeterol), data from randomized clinical trials (RCTs) and meta-analyses suggest that these two products perform similarly under RCT conditions. In contrast, a few recently reported real-world comparative effectiveness studies have suggested that there are substantial differences between ICS/LABA combination treatments in terms of clinical and healthcare outcomes in patients with asthma or COPD. The purpose of this article is to provide a brief review of the benefits, as well as the limitations, of comparative effectiveness research (CER) in the therapeutic area of asthma and COPD. We conducted a structured literature review of the current CER studies on ICS/LABA combinations in asthma and COPD. These articles were then used to illustrate the unique challenges of CER studies, providing a summary of study results and limitations. We focus particularly on difficult biases and confounding factors that may be introduced before, during, and after the initiation of therapy. Beyond being a review of these two ICS/LABA combination treatments, this article is intended to help those who wish to assess the quality of CER published projects in asthma and COPD, or guide investigators who wish to design new CER studies for chronic respiratory disease treatments.
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Affiliation(s)
- Douglas W Mapel
- Lovelace Clinic Foundation, 2309 Renard Place SE, Albuquerque, NM, 87106, USA,
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11
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A systematic review of validated methods to capture acute bronchospasm using administrative or claims data. Vaccine 2014; 31 Suppl 10:K12-20. [PMID: 24331069 DOI: 10.1016/j.vaccine.2013.06.091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 06/08/2013] [Accepted: 06/21/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE To identify and assess billing, procedural, or diagnosis code, or pharmacy claim-based algorithms used to identify acute bronchospasm in administrative and claims databases. METHODS We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to bronchospasm, wheeze and acute asthma. We also searched the reference lists of included studies. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria. Two reviewers independently extracted data regarding participant and algorithm characteristics. RESULTS Our searches identified 677 citations of which 38 met our inclusion criteria. In these 38 studies, the most commonly used ICD-9 code was 493.x. Only 3 studies reported any validation methods for the identification of bronchospasm, wheeze or acute asthma in administrative and claims databases; all were among pediatric populations and only 2 offered any validation statistics. Some of the outcome definitions utilized were heterogeneous and included other disease based diagnoses, such as bronchiolitis and pneumonia, which are typically of an infectious etiology. One study offered the validation of algorithms utilizing Emergency Department triage chief complaint codes to diagnose acute asthma exacerbations with ICD-9 786.07 (wheezing) revealing the highest sensitivity (56%), specificity (97%), PPV (93.5%) and NPV (76%). CONCLUSIONS There is a paucity of studies reporting rigorous methods to validate algorithms for the identification of bronchospasm in administrative data. The scant validated data available are limited in their generalizability to broad-based populations.
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Kaplan S, Zhou EH, Iyasu S. Characterization of long-acting beta₂-adrenergic agonists utilization in asthma patients. J Asthma 2012; 49:1079-85. [PMID: 23106094 DOI: 10.3109/02770903.2012.733990] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Because of the serious safety risks, Food and Drug Administration (FDA) has recommended that long-acting beta₂-adrenergic agonists (LABAs) be reserved for patients whose asthma cannot be adequately managed with asthma control medication. The objective of the study is to assess prescribing patterns for LABAs prior to the FDA's drug safety communication issued on 2 June 2010. METHODS Data were extracted from IMS Health Plan Claims database for asthma patients who had a new LABA therapy during 2005-2009. The proportion of LABA incident episodes preceded by inhaled corticosteroid (ICS) or leukotriene receptor antagonists (LTRAs) was examined. The medication-concurrent ratio (MCR), defined as the ratio of overlapping therapy days of single-ingredient (SI) LABAs and non-LABA products to the total days of SI LABAs, was calculated. Four criteria were used to estimate poorly controlled asthma prior to LABA initiation. RESULTS Of the 228 047 asthma patients, fixed-dose combination (FDC) LABAs were used by the majority of patients (96%). Prior use of ICS or LTRAs was observed in 64% and 31% of SI and FDC LABA incident episodes, respectively. The median MCR for SI LABAs was 62%. Approximately half of the patients met at least one criterion for poorly controlled asthma prior to LABA use. CONCLUSIONS Substantial proportion of patients was prescribed LABAs without prior use of ICS or LTRAs, or other indicators of poor asthma control. These findings suggest that asthma guidelines were not entirely followed in clinical practice during the study period.
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Affiliation(s)
- Sigal Kaplan
- Office of Surveillance and Epidemiology, Food and Drug Administration, Silver Spring, MD 20993, USA
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Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are common diseases which cause patients and society considerable difficulties. These are costly diseases which cause substantial morbidity and death. Health care policy makers have made improving outcomes in asthma and COPD a priority. Application of guideline recommended approaches to asthma and COPD care in the real-life setting has been emphasized but outcomes have not improved. Failure to improve outcomes may not be because of inconsistent applications of guideline recommendations, but rather because there are difficulties implementing the Expert Panel Report III (EPR 3) method for categorizing asthma severity and the Global Initiative for Obstructive Lung Disease (GOLD) method for diagnosing COPD. As these serve as the foundation for treatment recommendations for these diseases, alternative approaches should be considered for categorizing asthma severity and identifying COPD patients. Claims-based algorithms provide an intriguing option for identifying persistent asthma patients and symptomatic COPD patients in administrative databases. These methods could be used as the basis for pragmatic research, both retrospective and prospective, on assessing outcomes of guideline recommended treatment approaches in asthma and COPD. Important questions urgently need to be answered about how guideline recommended approaches regarding use of long-acting inhaled β-agonist/inhaled corticosteroid (LABA/ICS) in asthma and long-acting inhaled anti-muscarinic agent (LAMA) and LABA/ICS in COPD affect outcomes in real-life situations.
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Affiliation(s)
- Gene L Colice
- The George Washington University School of Medicine, Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, Washington DC, USA
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Baldacci S, Maio S, Simoni M, Cerrai S, Sarno G, Silvi P, Di Pede F, Borbotti M, Pala AP, Bresciani M, Viegi G. The ARGA study with general practitioners: impact of medical education on asthma/rhinitis management. Respir Med 2012; 106:777-85. [PMID: 22436656 DOI: 10.1016/j.rmed.2012.02.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 01/26/2012] [Accepted: 02/21/2012] [Indexed: 11/20/2022]
Abstract
AIM To evaluate the impact of a medical education course (MEC) on the behaviour of general practitioners (GPs) to treat asthma and allergic rhinitis (AR). METHODS Data on 1820 patients (mean age 41 yrs ± 17 yrs) with asthma or AR were collected by 107 Italian GPs: 50% attended a MEC and 50% didn't (group B). The adherence for AR and asthma treatment was evaluated according to ARIA and GINA guidelines (GL). RESULTS AR and asthma were diagnosed in 78% and 56% of patients; 34% had concomitant AR and asthma. Regardless of the MEC, the adherence to GL was significantly higher for AR than for asthma treatment (52 versus 19%). Group B GPs were more compliant to ARIA guidelines in the treatment of mild AR, whereas group A were more compliant in the treatment of moderate-severe AR; the adherence didn't differ between the groups for AR patients with comorbid asthma. Adherence to GINA GL for asthma treatment did not differ between GPs of groups A and B, independently from concomitant AR. Though insignificantly, group A were more compliant to GINA GL in the treatment of patients with only severe persistent asthma (63 versus 46%) as group B were for patients with severe persistent asthma and concomitant AR. CONCLUSIONS GPs often tend to treat patients independently from GL. The impact of a single MEC did not improve adherence to GL in treating less severe AR and asthma patients, while there was a trend towards the opposite attitude in more severe AR patients without concomitant asthma.
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Affiliation(s)
- Sandra Baldacci
- Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Via Trieste, 41 - 56126 Pisa, Italy.
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Higashi A, Zhu S, Stafford RS, Alexander GC. National trends in ambulatory asthma treatment, 1997-2009. J Gen Intern Med 2011; 26:1465-70. [PMID: 21769507 PMCID: PMC3235617 DOI: 10.1007/s11606-011-1796-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 05/16/2011] [Accepted: 06/17/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite reductions in morbidity and mortality and changes in guidelines, little is known regarding changes in asthma treatment patterns. OBJECTIVE To examine national trends in the office-based treatment of asthma between 1997 and 2009. PARTICIPANTS AND DESIGN We used the National Ambulatory Care Survey (NAMCS) and the National Disease and Therapeutic Index™ (NDTI), nationally representative audits of office-based physicians, to examine patients diagnosed with asthma less than 50 years of age. MEASUREMENTS Visits where asthma was diagnosed and use of six therapeutic classes (short-acting β(2) agonists [SABA], long-acting β(2) -agonists [LABA], inhaled steroids, antileukotrienes, anticholinergics, and xanthines). RESULTS Estimates from NAMCS indicated modest increases in the number of annual asthma visits from 9.9 million [M] in 1997 to 10.3M during 2008; estimates from the NDTI suggested more gradual continuous increases from 8.7M in 1997 to 12.6M during 2009. NAMCS estimates indicated declines in use of SABAs (from 80% of treatment visits in 1997 to 71% in 2008), increased inhaled steroid use (24% in 1997 to 33% in 2008), increased use of fixed dose LABA/steroid combinations (0% in 1997 to 19% in 2008), and increased leukotriene use (9% in 1997 to 24% in 2008). The ratio of controller to total asthma medication use increased from 0.5 (1997) to a peak of 0.7 (2004). In 2008, anticholinergics, xanthines, and LABA use without concomitant steroids accounted for fewer than 4% of all treatment visits. Estimates from NDTI corroborated these trends. CONCLUSIONS Changes in office-based treatment, including increased inhaled steroid use and increased combined steroid/long-acting β(2)-agonist use coincide with reductions in asthma morbidity and mortality that have been demonstrated over the same period. Xanthines, anticholinergics, and increasingly, LABA without concomitant steroid use, account for a very small fraction of all asthma treatments.
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Affiliation(s)
- Ashley Higashi
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S. Maryland, MC 2007, Chicago, IL 60637 USA
| | - Shu Zhu
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S. Maryland, MC 2007, Chicago, IL 60637 USA
| | - Randall S. Stafford
- Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA USA
| | - G. Caleb Alexander
- Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S. Maryland, MC 2007, Chicago, IL 60637 USA
- Center for Health and Social Sciences, University of Chicago, Chicago, IL USA
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL USA
- Department of Pharmacy Practice, University of Illinois at Chicago School of Pharmacy, Chicago, IL USA
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