Over-the-counter β2-agonist purchase versus script: a cross-sectional study

Over-the-Counter Bronchodilators Use Among Asthmatic Patients in Al-Medina Al-Monawwara

Asthma is a prevalent chronic disease that affects a significant number of individuals worldwide. Proper diagnosis and assessment of asthma patients are crucial before determining the appropriate inhaler for them. Many asthmatic patients self-medicate with over-the-counter (OTC) inhaled and orally taken bronchodilators, leading to overuse and serious adverse effects. This study aims to identify the extent of OTC bronchodilator usage in the Al-Medina Al-Monawwara region. and urge health authorities to address the issue and prevent potential side effects arising from the overuse of bronchodilators. This cross-sectional observational study was conducted among individuals with asthma residing in the Al-Medina Al-Monawwara region of Saudi Arabia. The study encompassed multiple hospitals. It was carried out between September 2021 and February 2023, utilizing a convenience sampling method. A total of 419 participants were included in the study; the majority of them, 362 (86.4%), reported being prescribed asthma inhalers at least once in their lives, while 57 (13.6%) always used asthma inhalers without a prescription. However, most of our participants reported having a prescription for their short-acting bronchodilators, with 46.3% always obtaining them with a prescription and the remaining obtaining them over the counter. The current study indicates that the use of OTC Bronchodilators increases the risk of significant ER visits; this observation is quite concerning as the increasing use of short-acting beta-agonists (SABA) might indicate less asthma control and more SABA overuse; further research is needed to address the issue of short-acting bronchodilators overuse.

Over-the-counter use of short-acting beta-2 agonists: a systematic review

BACKGROUND

The widespread use of short-acting beta-2 agonists (SABA) as an as-needed treatment for asthma is well-established. However, excessive use of SABA has been linked to undesirable outcomes such as increased risk of asthma attacks, exacerbations, and even death. The availability of SABA as an over-the-counter (OTC) medication has contributed to their overuse, leading to undertreated asthma and reduced access to asthma education.

OBJECTIVE

This systematic review aimed to summarize the prevalence, characteristic features of, and factors contributing to over-the-counter SABA purchase or overuse.

METHODS

The databases searched included PubMed, Scopus, Springer Link, Google Scholar, CINAHL, and APA PsycArticles. Original research articles reporting the prevalence, characteristics features, and factors regarding over-the-counter SABA use, available as full text, published in English language between the year 2000 and April 2023 were included in this review. Commentaries, letters to editor, review articles, qualitative studies, clinical trials, and conference proceedings were excluded. Data extraction was followed by a review of the quality of studies included and data were then synthesized for meaningful findings. This systematic review had been registered in the PROSPERO with registration number CRD42023421007.

RESULTS

A total of 18 articles were included. The prevalence range of OTC SABA users in populations were 1.4% to 39.6% and SABA over-users among OTC users were 14% to 66.4%. Factors mostly associated with this behavior were moderate-severe asthma, and less use of preventers. On top of that, not understanding the risk of SABA overuse was clear in many studies that explored this factor.

CONCLUSION

Over-the-counter purchase and overuse of SABA medication is a common problem, leading to adverse consequences such as uncontrolled asthma and increased healthcare utilization. Addressing these issues requires improved patient education about their conditions and adequate information regarding the potential long-term effects of SABA use by the healthcare providers. Management and education of asthma patients, including regular monitoring and follow-up, can help reduce overuse of SABA medication and prevent negative consequences.

Over-prescription of short-acting β2-agonists is associated with poor asthma outcomes: results from the African cohort of the SABINA III study

BACKGROUND

The extent of short-acting β₂-agonist (SABA) overuse in Africa remains poorly documented. As part of the SABA use IN Asthma (SABINA) III study, we assessed SABA prescriptions/clinical outcomes in 3 African countries.

METHODS

Data on disease characteristics/asthma treatments were collected from patients (≥12 years) using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma) and practice type (primary/specialist care). Multivariable regression models analyzed associations between SABA prescriptions and outcomes.

RESULTS

Data from 1778 patients (mean age, 43.7 years) were analyzed. Most patients were female (62.4%) and had moderate-to-severe asthma (63.3%), with 57.1 and 42.9% of patients treated in specialist and primary care, respectively. Asthma was partly controlled/uncontrolled in 66.2% of patients, with 57.9% experiencing ≥1 severe exacerbation in the previous 12 months. Overall, 46.5% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (over-prescription); 26.2% were prescribed ≥10 canisters. SABAs were purchased over-the-counter by 32.6% of patients, of whom 79.3% had received SABA prescriptions; 71.9% and 40.1% for ≥3 and ≥10 canisters, respectively. Higher SABA prescriptions (vs. 1-2 canisters) were associated with increased incidence rate of severe exacerbations and lower odds of having at least partly controlled asthma (except 3-5 canisters).

CONCLUSIONS

Findings from this African cohort of the SABINA III study indicate that SABA over-prescription and SABA over-the-counter purchase are common and associated with poor asthma-related outcomes. This highlights the need for healthcare providers/policymakers to align clinical practices with the latest treatment recommendations.

Short-acting β2-agonist prescription patterns in patients with asthma in Turkey: results from SABINA III

Background

Over-reliance on short-acting β₂-agonists (SABAs) is associated with poor asthma outcomes. However, the extent of SABA use in Turkey is unclear owing to a lack of comprehensive healthcare databases. Here, we describe the demographics, disease characteristics and treatment patterns from the Turkish cohort of the SABA use IN Asthma (SABINA) III study.

Methods

This observational, cross-sectional study included patients aged ≥ 12 years with asthma from 24 centres across Turkey. Data on sociodemographics, disease characteristics and asthma treatments were collected using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma [GINA]) and practice type (primary/specialist care). The primary objective was to describe SABA prescription patterns in the 12 months prior to the study visit.

Results

Overall, 579 patients were included (mean age [standard deviation; SD]: 47.4 [16.1] years; 74.3% female), all of whom were treated by specialists. Most patients had moderate-to-severe asthma (82.7%, GINA steps 3–5), were overweight or obese (70.5%), had high school or university/post-graduate education (51.8%) and reported fully reimbursed healthcare (97.1%). The mean (SD) asthma duration was 12.0 (9.9) years. Asthma was partly controlled/uncontrolled in 56.3% of patients, and 46.5% experienced ≥ 1 severe exacerbation in the preceding 12 months. Overall, 23.9% of patients were prescribed ≥ 3 SABA canisters in the previous 12 months (considered over-prescription); 42.9% received no SABA prescriptions. As few patients had mild asthma, only 5.7% were prescribed SABA monotherapy. Therefore, most patients (61.5%) were prescribed SABA in addition to maintenance therapy, with 42.8% receiving ≥ 3 SABA canisters in the previous 12 months. Inhaled corticosteroids (ICS), ICS + a long-acting β-agonist fixed-dose combination and oral corticosteroids were prescribed to 14.5%, 88.3% and 28.5% of all patients, respectively. Additionally, 10.2% of patients purchased SABA over the counter, of whom 27.1% purchased ≥ 3 canisters in the preceding 12 months.

Conclusions

Despite all patients being treated by specialists and most receiving fully reimbursed healthcare, nearly a quarter of patients received prescriptions for ≥ 3 SABA canisters in the previous 12 months. This highlights a public health concern and emphasizes the need to align clinical practices with the latest evidence-based recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02008-9.

Ensuring Access to Albuterol in Schools: From Policy to Implementation. An Official ATS/AANMA/ALA/NASN Policy Statement

Rationale: For children with asthma, access to quick-relief medications is critical to minimizing morbidity and mortality. An innovative and practical approach to ensure access at school is to maintain a supply of stock albuterol that can be used by any student who experiences respiratory distress. To make this possible, state laws allowing for stock albuterol are needed to improve medication access.

Objectives: To provide policy recommendations and outline steps for passing and implementing stock albuterol laws.

Methods: We assembled a diverse stakeholder group and reviewed guidelines, literature, statutes, regulations, and implementation documents related to school-based medication access. Stakeholders were divided into two groups—legislation and implementation—on the basis of expertise. Each group met virtually to review documents and draft recommendations. Recommendations were compiled and revised in iterative remote meetings with all stakeholders.

Main Results: We offer several recommendations for crafting state legislation and facilitating program implementation. 1) Create a coalition of stakeholders to champion legislation and implement stock albuterol programs. The coalition should include school administrators, school nurses and health personnel, parents, or caregivers of children with asthma, pediatric primary care and subspecialty providers (e.g., pulmonologists/allergists), pharmacists, health department staff, and local/regional/national advocacy organizations. 2) Legislative components critical for effective implementation of stock albuterol programs include specifying that medication can be administered in good faith to any child in respiratory distress, establishing training requirements for school staff, providing immunity from civil liability for staff and prescribers, ensuring pharmacy laws allow prescriptions to be dispensed to schools, and suggesting inhalers with valved holding chambers/spacers for administration. 3) Select an experienced and committed legislator to sponsor legislation and guide revisions as needed during passage and implementation. This person should be from the majority party and serve on the legislature’s health or education committee. 4) Develop plans to disseminate legislation and regulations/policies to affected groups, including school administrators, school nurses, pharmacists, emergency responders, and primary/subspecialty clinicians. Periodically evaluate implementation effectiveness and need for adjustments.

Conclusions: Stock albuterol in schools is a safe, practical, and potentially life-saving option for children with asthma, whether asthma is diagnosed or undiagnosed, who lack access to their personal quick-relief medication. Legislation is imperative for aiding in the adoption and implementation of school stock albuterol policies, and key policy inclusions can lay the groundwork for success. Future work should focus on passing legislation in all states, implementing policy in schools, and evaluating the impact of such programs on academic and health outcomes.

Fine particulate matter exposure and medication dispensing during and after a coal mine fire: A time series analysis from the Hazelwood Health Study

Limited research has examined the impacts of coal mine fire smoke on human health. The aim of this study was to assess the association between prolonged smoke PM_2.5 exposure from a brown coal mine fire that burned over a seven week period in 2014 and medications dispensed across five localities in South-eastern Victoria, Australia. Spatially resolved PM_2.5 concentrations were retrospectively estimated using a dispersion model coupled with a chemical transport model. Data on medications dispensed were collected from the national Pharmaceutical Benefits Schedule database for 2013-2016. Poisson distributed lag time series analysis was used to examine associations between daily mine fire-related PM_2.5 concentrations and daily counts of medications dispensed for respiratory, cardiovascular or psychiatric conditions. Factors controlled for included: seasonality, long-term trend, day of the week, maximum ambient temperature and public holidays. Positive associations were found between mine fire-related PM_2.5 and increased risks of medications dispensed for respiratory, cardiovascular and psychiatric conditions, over a lag range of 3-7 days. A 10 μg/m³ increase in coal mine fire-related PM_2.5 was associated with a 25% (95%CI 19-32%) increase in respiratory medications, a 10% (95%CI 7-13%) increase in cardiovascular medications and a 12% (95%CI 8-16%) increase in psychiatric medications dispensed. These findings have the potential to better prepare for and develop more appropriate public health responses in the event of future coal mine fires.

Risks associated with managing asthma without a preventer: urgent healthcare, poor asthma control and over-the-counter reliever use in a cross-sectional population survey

OBJECTIVES

Overuse of asthma relievers, particularly without anti-inflammatory preventers, increases asthma risks. This study aimed to identify how many reliever-only users have urgent healthcare, explore their attitudes and beliefs about asthma and its treatment, and investigate whether purchasing over-the-counter relievers was associated with worse asthma outcomes than by prescription.

DESIGN AND SETTING

Cross-sectional population-based Internet survey in Australia.

PARTICIPANTS

Of 2686 participants ≥16 years with current asthma randomly drawn from a web-based panel, 1038 (50.7% male) used only reliever medication.

MAIN OUTCOME MEASURES

Urgent asthma-related healthcare; Asthma Control Test (ACT); patient attitudes about asthma and medications; reliever purchase (with/without prescription).

RESULTS

Of 1038 reliever-only participants, 23.3% had required urgent healthcare for asthma in the previous year, and only 36.0% had a non-urgent asthma review. Those needing urgent healthcare were more likely than those without such events to be male (56.5% vs 49.0%, p=0.003) and current smokers (29.4% vs 23.3%, p=0.009). Only 30.6% had well-controlled asthma (ACT ≥20) compared with 71.0% of those with no urgent healthcare (p<0.0001), and 20.8% used relievers regularly to prevent asthma symptoms (vs 5.5% of those without urgent healthcare). Those with urgent healthcare were more frustrated by their asthma and less happy with how they managed it, and they were less confident about their ability to manage worsening asthma, but just as likely as those without urgent healthcare to manage worsening asthma themselves rather than visit a doctor. Reliever-only users purchasing over-the-counter relievers were no more likely than those purchasing relievers by prescription to have uncontrolled asthma (35.9% vs 40.6%, p=0.23) but were less likely to have had a non-urgent asthma review.

CONCLUSIONS

One-quarter of the reliever-only population had needed urgent asthma healthcare in the previous year, demonstrating the importance of identifying such patients. Their attitudes and beliefs suggest opportunities for targeting this population in the community.

Continued Dispensing: what medications do patients believe should be available?

Background. Continued Dispensing (CD) is a new medication supply method for certain medications in Australia. It aims to prevent treatment interruption as a result of patients’ inability to obtain a new valid prescription. The only currently eligible patients for this service are statin and/or oral contraceptives users who have been using these medications for 6 months or more, have not utilized the CD method during the last 12 months, and cannot obtain an immediate appointment with the prescriber in order to get a new prescription. This study aimed to investigate patients’ attitudes towards potential extension and expansion of this medication supply method.

Methods. A randomly selected 301 users of these medications from all Australian States were recruited using Computer Assisted Telephone Interview (CATI).

Result. The response rate was 79%. The majority of the participants (73.3%) did not agree with current restriction on CD utilization frequency. They also supported, to varying degrees, inclusion of all the proposed medications (support ranged from 44.2–78.4%). In this regard, participants who suffered from a specific disease did not differ significantly from those without the disease except in case of patients with depression (p = 0.001).

Conclusions. Participants of this study strongly supported both CD extension and expansion. A future critical review of the current version of CD is highly recommended in order to enhance CD capability to achieve its goals.

Asthma medications should be available for over-the-counter use: pro

Medications that provide quick relief of symptoms and that control airway inflammation are the mainstays of asthma treatment. However, adherence to these medications is suboptimal. The inconvenience and costs associated with obtaining these prescription-only medications are factors that contribute to poor adherence. The Food and Drug Administration recently requested public comment on a new paradigm whereby specific prescription-only medications could be made available over the counter, provided that conditions for their safe use could be established. Many organizations expressed opposition, including the American Thoracic Society and other societies representing patients with respiratory diseases. These organizations cited unsubstantiated benefits and unnecessary risks as reasons to oppose greater over-the-counter availability of current prescription-only medications. This article examines the rationale for, and potential ramifications of, making asthma medications available for nonprescription use.

Assessing a conceptual model of over-the-counter medication misuse, adverse drug events and health-related quality of life in an elderly population

AIM

The objectives of the present study were to test Spilker's quality of life model in the elderly population consuming over-the-counter (OTC) medications. It was hypothesized that OTC medication misuse increases adverse drug events (ADEs), ADEs as a result of OTC medication misuse decrease health-related quality of life (HRQoL) and the impact of OTC medication misuse on patients' HRQoL is fully medicated by ADEs associated with OTC medications.

METHODS

Data were used from a previously carried out cross-sectional study using survey instruments with elderly patients consuming OTC medications in Houston, Texas, USA. The presence/absence of OTC misuse was assessed by an expert panel based on patient reported information on drug use characteristics; ADE was self-reported and HRQoL was measured using the Short Form-12v2, which contains a physical component summary score (PCS) and a mental component summary score (MCS).

RESULTS

Of the 154 respondents, 18.2% misused OTC medications and 22.1% reported ADE as a result of OTC medications. The mean ± SD score of PCS and MCS was 40.6 ± 6.8 and 46.4 ± 7, respectively. The hypothesized framework provided a well-fitted solution to the data (χ(2)  = 1.387, d.f. = 2, P = 0.49; weighted root mean square residual = 0.317). Misuse of OTC medications significantly increased ADEs associated with OTC medications (β = 0.298) and increased ADEs significantly decreased patient reported PCS (β = -0.312), but not MCS (β = -0.213). OTC medication misuse indirectly decreased PCS and MCS by mediating the effect of an increase in ADE; however, the association was not statistically significant.

CONCLUSIONS

Misuse of OTC medications is highly associated with ADEs. ADEs are capable of decreasing the physical health of elderly patients.

Educational intervention for older people with asthma: a randomised controlled trial

OBJECTIVES

To improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns.

METHODS

Community dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation.

OUTCOME MEASURES

asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention.

RESULTS

Intervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months.

CONCLUSION

Asthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs.

PRACTICAL IMPLICATIONS

Use of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.