Oral corticosteroid prescription patterns for asthma in France, Germany, Italy and the UK

Longitudinal patterns of intermittent oral corticosteroid therapy for asthma in the United Kingdom

Background

Increasing frequency of intermittent oral corticosteroid (OCS) prescription and cumulative OCS exposure increase the risk of OCS-related adverse outcomes.

Objective

We sought to describe the evolution and trajectory of intermittent OCS prescription patterns in patients with asthma and investigate risk factors independently associated with transitioning to a frequent prescription pattern.

Methods

This historical cohort study included patients with active asthma managed in UK primary care and included in the Optimum Patient Care Research Database (OPCRD; opcrd.co.uk). Intermittent OCS prescription patterns were categorized as sporadic, infrequent, moderately frequent, or frequent. Prescription pattern sequences were described for those who had a frequent sequence in their final year of prescribing. We examined associations between OCS prescription pattern and the hazard of transitioning into a frequent intermittent OCS prescription pattern using multivariable Cox regression with a 10-year look-back period.

Results

Of 105,229 patients with intermittent OCS prescriptions, 57.1% (n = 60,083) had a frequent OCS prescription pattern at some point. Irrespective of baseline pattern, most patients transitioned to frequent prescription during the look back. The strongest risk factors were a more frequent prescription pattern at the start of look-back period, a lower percentage peak expiratory flow rate, and higher Global Initiative for Asthma treatment step. Older age, female sex, obesity, and active smoking were also associated with a higher risk of transitioning.

Conclusion

Our findings help identify those most at risk of transitioning to frequent intermittent OCS receipt and encourage earlier intervention with OCS-sparing treatments.

The relationship between prescription rates of oral corticosteroids for respiratory diseases and deprivation in England

Respiratory diseases, including asthma and chronic obstructive pulmonary disease (COPD), are common in England with the worst respiratory outcomes observed in the most deprived areas. There is limited published research to establish whether the rate of oral corticosteroid (OCS) prescribing for asthma and COPD is linked to levels of deprivation. This study carried out a multivariable regression analysis of publicly available data and found that deprivation is associated with a statistically significant increase in the proportion of patients receiving an OCS prescription for asthma or COPD at a GP practice level (p < 0.001). The model estimated that the proportion of prescriptions is 1.88% (95% CI 1.83% to 1.92%) and 2.84% (95% CI 2.70% to 2.98%) for the least deprived GP practice and the most deprived GP practice, respectively. This study lays the groundwork for future research using individual patient level data to consider the impact of variation in OCS prescribing rates.

Trends in Systemic Glucocorticoid Utilization in the United Kingdom from 1990 to 2019: A Population-Based, Serial Cross-Sectional Analysis

Purpose

Associations between systemic glucocorticoid (SGC) exposure and risk for adverse outcomes have spurred a move toward steroid-sparing treatment strategies. Real-world changes in SGC exposure over time, after the introduction of steroid-sparing treatment strategies, reveal areas of successful risk mitigation as well as unmet needs.

Patients and Methods

A population-based ecological study was performed from the Optimum Patient Care Research Database to describe SGC prescribing trends of steroid-sparing treatment strategies in primary care practices before and after licensure of biologics in the United Kingdom from 1990 to 2019. Each analysis year included patients aged ≥5 years who were registered for ≥1 year with a participating primary care practice. The primary analysis was SGC exposure, defined as total cumulative SGC dose per patient per year, for asthma, severe asthma, chronic obstructive pulmonary disease (COPD), nasal polyps, Crohn's disease, rheumatoid arthritis, ulcerative colitis, and systemic lupus erythematosus. Secondary outcomes were percentages of patients prescribed SGCs and number of SGC prescriptions per patient per year.

Results

The number of patients who met study inclusion criteria ranged from 219,862 (1990) to 1,261,550 (2019). At the population level, patients with asthma or COPD accounted for 67.7% to 73.2% of patients per year with an SGC prescription. Over three decades, decreases in SGC total yearly dose ≥1000 mg have been achieved in multiple conditions. Patients with COPD prescribed SGCs increased from 5.8% (1990) to 34.8% (2017). SGC prescribing trends for severe asthma, Crohn's disease, and ulcerative colitis show decreased prescribing trends after the introduction of biologics.

Conclusion

Decreases in total yearly SGC doses have been shown in multiple conditions; however, for conditions such as severe asthma and COPD, an unmet need remains for increased awareness of SGC burden and the adoption or development of SGC-sparing alternatives to reduce overuse.

Determining prescriptions in electronic healthcare record data: methods for development of standardized, reproducible drug codelists

Objective

To develop a standardizable, reproducible method for creating drug codelists that incorporates clinical expertise and is adaptable to other studies and databases.

Materials and Methods

We developed methods to generate drug codelists and tested this using the Clinical Practice Research Datalink (CPRD) Aurum database, accounting for missing data in the database. We generated codelists for: (1) cardiovascular disease and (2) inhaled Chronic Obstructive Pulmonary Disease (COPD) therapies, applying them to a sample cohort of 335 931 COPD patients. We compared searching all drug dictionary variables (A) against searching only (B) chemical or (C) ontological variables.

Results

In Search A, we identified 165 150 patients prescribed cardiovascular drugs (49.2% of cohort), and 317 963 prescribed COPD inhalers (94.7% of cohort). Evaluating output per search strategy, Search C missed numerous prescriptions, including vasodilator anti-hypertensives (A and B:19 696 prescriptions; C:1145) and SAMA inhalers (A and B:35 310; C:564).

Discussion

We recommend the full search (A) for comprehensiveness. There are special considerations when generating adaptable and generalizable drug codelists, including fluctuating status, cohort-specific drug indications, underlying hierarchical ontology, and statistical analyses.

Conclusions

Methods must have end-to-end clinical input, and be standardizable, reproducible, and understandable to all researchers across data contexts.

Summer Olympic sports and female athletes: comparison of anti-doping collections and prohibited substances detected in Australia and New Zealand vs. France

Like any athlete, female athletes may be tempted to use prohibited substances during competition or training to enhance their performance. Anti-doping tests performed on female athletes in summer Olympic sports from two geographical areas: Australia/ New Zealand, and France were compared. First, the distribution of sample collections across different sports disciplines, as well as the distribution of substances was investigated. Then the distribution of collections and substances detected in the five sports categories (Strength/Speed, Endurance, Mixed, Motor Skills with High Energy Expenditure, and Motor Skills with Low Energy Expenditure) were studied with consideration of therapeutic use exemptions obtained by the athlete. Australia/New Zealand and France were similar in their overall number of anti-doping collections performed. Likewise, both regions had the same sports disciplines (athletics, aquatics, cycling) and sport categories (Mixed and Endurance) as having the highest number of sample collections. The Motor Skills with High Energy Expenditure, and Motor Skills with Low Energy Expenditure categories had the lowest number of sample collections. However, the number of substances detected was significantly different (p < 0.05) with a greater number of substances found in the French data. There were a few substances in common between the two geographical areas, namely prednisone/prednisolone, carboxy-THC, terbutaline, vilanterol and methylphenidate, but most were different. In-competition tests were the category where most of the AAFs were found.

Observational UK cohort study to describe intermittent oral corticosteroid prescribing patterns and their association with adverse outcomes in asthma

INTRODUCTION

Oral corticosteroids (OCS) for asthma are associated with increased risks of developing adverse outcomes (adverse outcomes); no previous study has focused exclusively on intermittent OCS use.

METHODS

This historical (2008-2019) UK cohort study using primary care medical records from two anonymised, real-life databases (OPCRD and CPRD) included patients aged≥4 years with asthma receiving only intermittent OCS. Patients were indexed on their first recorded intermittent OCS prescription for asthma and categorised by OCS prescribing patterns: one-off (single), less frequent (≥90 day gap) and frequent (<90 day gap). Non-OCS patients matched 1:1 on gender, age and index date served as controls. The association of OCS prescribing patterns with OCS-related AO risk was studied, stratified by age, Global Initiative for Asthma (GINA) 2020 treatment step, and pre index inhaled corticosteroid (ICS) and short-acting β2-agonist (SABA) prescriptions using a multivariable Cox-proportional hazard model.

FINDINGS

Of 476 167 eligible patients, 41.7%, 26.8% and 31.6% had one-off, less frequent and frequent intermittent OCS prescribing patterns, respectively. Risk of any AO increased with increasingly frequent patterns of intermittent OCS versus non-OCS (HR; 95% CI: one-off 1.19 (1.18 to 1.20), less frequent 1.35 (1.34 to 1.36), frequent 1.42 (1.42 to 1.43)), and was consistent across age, GINA treatment step and ICS and SABA subgroups. The highest risks of individual OCS-related adverse outcomes with increasingly frequent OCS were for pneumonia and sleep apnoea.

CONCLUSION

A considerable proportion of patients with asthma receiving intermittent OCS experienced a frequent prescribing pattern. Increasingly frequent OCS prescribing patterns were associated with higher risk of OCS-related adverse outcomes. Mitigation strategies are needed to minimise intermittent OCS prescription in primary care.

Aiming to Improve Equity in Lung Health: Sex and Gender

Sex and gender impact risk factors, presentations of, and response to therapy in lung diseases such as chronic obstructive pulmonary disease, asthma, lung cancer, interstitial lung disease, and obstructive sleep apnea. Many physicians lack training in the impact of sex and gender on lung disease, resulting in diagnostic delays. Scales and indices taught in the health care system are largely validated in male populations, thereby limiting their application to females. For transgender and lesbian, gay, bisexual, transgender, and questioning + patients, high rates of bias in health care may limit patients' willingness to seek health care.

The burden of systemic corticosteroid use in asthma management in Asia

For most patients, asthma can be effectively managed using inhaled medications. However, patients who have severe and/or uncontrolled asthma, or who experience exacerbations, may require systemic corticosteroids (SCSs) to maintain asthma control. Although SCS are highly effective in this regard, even modest exposure to these medications can increase the risk for long-term, adverse health outcomes, such as type 2 diabetes, renal impairment, cardiovascular disease and overall mortality. Clinical and real-world data from studies investigating asthma severity, control and treatment practices around the globe have suggested that SCS are overused in asthma management, adding to the already substantial healthcare burden experienced by patients. Throughout Asia, although data on asthma severity, control and SCS usage are limited and vary widely among countries, available data strongly suggest a pattern of overuse consistent with the broader global trend. Coordinated changes at the patient, provider, institutional and policy levels, such as increasing disease awareness, promoting better adherence to treatment guidelines and increasing availability of safe and effective alternatives to SCS, are likely necessary to reduce the SCS burden for patients with asthma in Asia.

The use of systemic corticosteroids in asthma management in Latin American countries

The stepwise treatment approach recommended by the Global Initiative for Asthma (GINA) includes systemic corticosteroids (SCS) suggested as a final step if asthma is severe and/or difficult to treat. Yet, despite the effectiveness of SCS, they are also associated with potentially irreversible adverse outcomes such as type 2 diabetes, adrenal suppression, and cardiovascular disease. Based on recent data indicating that the risk of developing these conditions can increase after as few as 4 short-term (burst) courses of SCS, even patients with mild asthma who receive SCS occasionally for exacerbations are also at risk of these events. As a result, recent updates by GINA and the Latin American Thoracic Society recommend decreasing SCS use by optimizing administration of non-SCS therapies and/or increasing the use of alternatives, such as biologic agents. Recent and ongoing studies characterizing treatment patterns among patients with asthma have revealed alarming trends suggesting the widespread overuse of SCS around the world. In Latin America, asthma prevalence is approximately 17%, and data suggest that the majority of patients have uncontrolled disease. In this review, we summarize currently available data on asthma treatment patterns in Latin America, which indicate that SCS are prescribed to 20-40% of patients with asthma considered to be well controlled and over 50% of patients with uncontrolled disease. We also offer potential strategies to help reduce SCS use for asthma in everyday clinical practice.

Regional variation in prevalence of difficult-to-treat asthma and oral corticosteroid use for patients in Australia: heat map analysis

BACKGROUND

In Australia, the regional prevalence of difficult-to-treat asthma is unknown. We aimed to describe regional variation in difficult-to-treat asthma prevalence and oral corticosteroid (OCS) use.

METHODS

In this retrospective, observational, longitudinal study using data from March 2018-February 2019 in the NostraData longitudinal database, prescriptions dispensed for obstructive airway disease were processed through a high-level algorithm to identify patients with asthma. Difficult-to-treat asthma was defined by ≥2 high-dosage inhaled corticosteroids plus long-acting beta-agonist prescriptions over 6 months. Patients who additionally received OCS prescriptions sufficient to treat ≥2 exacerbations over 6 months were classified as having uncontrolled difficult-to-treat asthma. Patient-level data were analyzed across 340 geographic areas in Australia to determine regional prevalence of difficult-to-treat asthma, uncontrolled difficult-to-treat asthma, and OCS use.

RESULTS

Of 1 851 129 people defined as having asthma, 440 800 (24%) were classified as having difficult-to-treat disease. Of those difficult-to-treat asthma patients, 96 338 (22%) were considered to have uncontrolled disease. Between 29% and 48% of patients had difficult-to-treat asthma in 49 geographic areas, most frequently located in Western Australia. Between 26% and 67% of patients had uncontrolled difficult-to-treat asthma in 29 geographic areas (mostly in Eastern Australia). Overall, a wide variability of asthma severity and control was observed among regions.

CONCLUSIONS

Despite global and national guidelines, regional differences in the prevalence of difficult-to-treat asthma and uncontrolled difficult-to-treat asthma and OCS use exist in Australia. Understanding these regional variations should inform policy and target management in the areas with the greatest unmet need.

Oral Corticosteroids for Patients with Eosinophilic Diseases: An Expert Panel View on Use, Overuse, and Strategies to Reduce Use

Severe asthma (SA), chronic rhinosinusitis with nasal polyps (CRSwNP), and eosinophilic granulomatosis with polyangiitis (EGPA) are three conditions driven by IL-5 and eosinophilic inflammation. As these conditions have high use of healthcare services, as well as lifestyle and psychological burdens, safe treatment to achieve optimal control is key. In all three conditions, as for many other eosinophilic diseases (ED), oral corticosteroids (OCS) are often used for both acute and maintenance treatment where disease activity is high. While, in general, OCS are very effective, their use is limited by a well-recognised high potential for adverse effects (AE). Moreover, cumulative exposure to OCS may not be acknowledged in many patients, especially for those predominantly treated in primary care, exposing patients to potentially damaging long-term OCS-related AEs. To discuss the use of OCS for these eosinophilic diseases, as well as to provide guidance on how to help limit their use, a board of European experts within each field was gathered. The experts completed questionnaires regarding treatment and referral pathways for patients with SA, CRSwNP, or EGPA; then, in an online meeting, discussed a number of issues in regard to OCS use. Here, the authors present the key recommendations from the expert advisory panel alongside some background to these conditions regarding treatment with OCS.

Application of an algorithm to analyze patterns of intermittent oral corticosteroid use in asthma

An algorithm to describe patterns of intermittent oral corticosteroid use in the UK (n = 476,167) found that one-third of patients receiving intermittent oral corticosteroids for asthma only had short gaps (<90 days) between oral corticosteroid prescriptions sometime during follow-up. The increasing frequency pattern was more likely in patients with greater asthma severity and with more short-acting β₂-agonist use at baseline. Our approach may provide a clinically relevant representation of intermittent oral corticosteroid use in asthma.

Addressing sex and gender to improve asthma management

Sex (whether one is 'male' or 'female', based on biological characteristics) and gender (defined by socially constructed roles and behaviors) influence asthma diagnosis and management. For example, women generally report more severe asthma symptoms than men; men and women are exposed to different asthma-causing triggers; men tend to be more physically active than women. Furthermore, implicit, often unintended gender bias by healthcare professionals (HCPs) is widespread, and may result in delayed asthma diagnosis, which can be greater in women than men. The sex and gender of the HCP can also impact asthma management. Pregnancy, menstruation, and menopause can all affect asthma in several ways and may be associated with poor asthma control. This review provides guidance for considering sex- and gender-associated impacts on asthma diagnosis and management and offers possible approaches to support HCPs in providing personalized asthma care for all patients, regardless of their sex or gender.

Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group

Systemic corticosteroids (SCS) are a highly effective treatment for acute exacerbations and long-term symptom control in asthma. Long-term SCS use is highly prevalent across all asthma severities, occurring in over 20% of patients with severe or uncontrolled disease globally. It is now well known that exposure to both long-term and repeated acute courses of SCS is associated with a high risk of serious adverse effects (AEs), such as osteoporosis, and metabolic and cardiovascular complications, especially when prescribed onto a background of other corticosteroids. The aim of this call-to-action article, endorsed by the World Allergy Organization and the Respiratory Effectiveness Group, is to review the accumulating evidence on the burden of SCS on patients with asthma and provide an overview of potential strategies for implementing SCS Stewardship. Primary prevention of exacerbations and improvement of asthma control is a key first step in achieving SCS Stewardship, by optimizing maintenance asthma medications and addressing modifiable risk factors, such as adherence and inhaler technique. Other key elements of SCS Stewardship include increasing appropriate specialist referrals for multidisciplinary review, assessment of biomarkers, and consideration of oral corticosteroid-sparing add-on therapies (eg, biologics). In cases where SCS use is deemed clinically justified, it should be tapered to the lowest possible dose. In addition, patients receiving long-term SCS or frequent acute courses should be closely monitored for emergence of SCS-related AEs. Because of the extensive data available on the costly and burdensome AEs associated with SCS use, as well as the range of treatment options now available, there is a need for healthcare providers (HCPs) to carefully evaluate whether the benefits of SCS outweigh the potential harms, to adopt SCS-sparing and Stewardship strategies, and to consider alternative therapies where possible. Development of a structured and collaborative SCS Stewardship approach is urgently required to protect patients from the potential harm of SCS use.

Salivary Steroid Collection in Children Under Conditions Replicating Home Sampling

CONTEXT

Measurement of salivary glucocorticoids is an accepted method for testing adrenal function but there are few data on stability during home collection. Current salivary collection techniques require active participation or present a choking hazard and are unsuitable for young children.

OBJECTIVE

We sought to compare different salivary collection methods; assess the stability of salivary glucocorticoids under conditions replicating home collection; and assess patient tolerability and caregiver acceptability of a salivary collection device for young children, a swab encased in an infant pacifier (SaliPac).

METHODS

Six healthy adults collected salivary samples using a Salivette Cortisol, passive drool, and SalivaBio at night, waking, and 3 Pm for five days. Time to collect 1-mL saliva using the SalivaBio and SaliPac and caregiver acceptability were assessed in 30 children younger than 6 years. Saliva was stored at 4 °C, room temperature (RT), and 50 °C for 24, 48, 72 hours and 1 week to replicate potential postage conditions. Salivary cortisol and cortisone concentrations were measured by mass spectrometry.

RESULTS

There was no difference in salivary glucocorticoid concentrations using the 3 collection methods. Salivary cortisol and cortisone were stable for 72 hours at RT and 4 °C, and repeated freeze-thaw cycles did not cause significant degradation. In children younger than 6 years the SalivaBio and SaliPac were well tolerated and collected sufficient saliva for salivary steroid analysis in less than 4 minutes.

CONCLUSION

Salivette, passive drool, and SalivaBio collect samples with comparable salivary cortisol and cortisone concentrations, which are stable under conditions replicating home collection. SaliPac is an acceptable device for salivary sampling in young children.

Characteristics of Oral Corticosteroid Users Among Persons with Asthma on GINA Step 3 Therapy and Above: A Cross-Sectional Study in Portuguese Community Pharmacies

PURPOSE

Oral corticosteroids (OCS) are frequently used in asthma management but have an important risk-profile. The aim of the study is to characterize and compare the sociodemographic and clinical characteristics, treatment regimen and asthma control between OCS users and non-users among the population of asthma patients (≥18 years) at GINA step 3 and above treated with a fixed combination of an inhaled corticosteroid and a long-acting beta-agonist (ICS/LABA).

METHODS

Cross-sectional study in Portuguese community pharmacies. Data was collected via paper-based interview delivered at the pharmacy (sociodemographic characteristics and asthma treatment regimen, namely ICS/LABA and OCS utilization), followed by a telephonic interview collecting smoking history, comorbidities, body mass index (BMI), history of exacerbations and asthma-related healthcare resource utilization (HCRU) in the previous 12 months, as well as asthma control using the Control of Allergic Rhinitis and Asthma Test (CARAT®).

RESULTS

A total of 347 patients recruited in 98 pharmacies were included in the analysis. Of those, 328 had completed both questionnaires. A quarter of the individuals reported OCS use in the previous 12 months (OCS users), either as add-on therapy (6%) or exacerbation treatment (19%). Patients were mostly females (72%), with an average age of 59.5 years (SD=15.4). OCS users were significantly older and reported more frequently having conjunctivitis (25.9% vs 15.0%), osteoporosis (25.9% vs 13.4%), arthritis (14.6% vs 6.9%), and gastrointestinal disease (16.1% vs 8.1%). OCS users also reported greater urgent HCRU: unscheduled consultations (33.3% vs 9.3%) and emergency department (ED) visits (32.1% vs 12.1%). Both groups presented poor disease control (85.2% of OCS users vs 72.9% of non-OCS users).

CONCLUSION

These results highlight the burden of OCS therapy to asthma patients and the need to improve asthma management, by adopting OCS sparing strategies in this subgroup of patients.

Characterization of Patients in the International Severe Asthma Registry with High Steroid Exposure Who Did or Did Not Initiate Biologic Therapy

Background

Many severe asthma patients with high oral corticosteroid exposure (HOCS) often do not initiate biologics despite being eligible. This study aimed to compare the characteristics of severe asthma patients with HOCS who did and did not initiate biologics.

Methods

Baseline characteristics of patients with HOCS (long-term maintenance OCS therapy for at least 1 year, or ≥4 courses of steroid bursts in a year) from the International Severe Asthma Registry (ISAR; https://isaregistries.org/), who initiated or did not initiate biologics (anti-lgE, anti-IL5/5R or anti-IL4R), were described at the time of biologic initiation or registry enrolment. Statistical relationships were tested using Pearson’s chi-squared tests for categorical variables, and t-tests for continuous variables, adjusting for potential errors in multiple comparisons.

Results

Between January 2015 and February 2021, we identified 1412 adult patients with severe asthma from 19 countries that met our inclusion criteria of HOCS, of whom 996 (70.5%) initiated a biologic and 416 (29.5%) did not. The frequency of biologic initiation varied across geographical regions. Those who initiated a biologic were more likely to have higher blood eosinophil count (483 vs 399 cells/µL, p=0.003), serious infections (49.0% vs 13.3%, p<0.001), nasal polyps (35.2% vs 23.6%, p<0.001), airflow limitation (56.8% vs 51.8%, p=0.013), and uncontrolled asthma (80.8% vs 73.2%, p=0.004) despite greater conventional treatment adherence than those who did not start a biologic. Both groups had similar annual asthma exacerbation rates in the previous 12 months (5.7 vs 5.3, p=0.147).

Conclusion

Around one third of severe HOCS asthma patients did not receive biologics despite a similar high burden of asthma exacerbations as those who initiated a biologic therapy. Other disease characteristics such as eosinophilic phenotype, serious infectious events, nasal polyps, airflow limitation and lack of asthma control appear to dictate biologic use.

Overuse of Oral Corticosteroids in Asthma Is Often Underdiagnosed and Inadequately Addressed

BACKGROUND

Overuse of oral corticosteroids (OCS) is associated with serious adverse effects. It is currently unknown what proportion of patients with asthma regularly use these drugs, or whether they are optimally treated by specialists to minimize the use of these drugs.

OBJECTIVE

To investigate (1) the prevalence of patients requiring ≥2 courses or maintenance use of OCS (ie, frequent users), (2) their use of inhaled corticosteroids, and (3) who prescribed their asthma medications.

METHODS

We analyzed OCS prescription data (Dutch IQVIA Prescription Database) focusing on adult patients receiving asthma medication between March 2017 and March 2018 (focus year). An OCS course was defined as ≥20 mg prednisolone equivalent for 3 to 28 days; maintenance OCS as 2.5 to 17.5 mg/day for >28 days. Prescribers were classified as specialist or general practitioners.

RESULTS

Of 182,849 adults taking asthma medications, 77.8% had not received a prescription for OCS and 7.2% of patients were frequent OCS users: 2.6% received ≥2 OCS courses and 4.6% were on maintenance OCS. Of the frequent OCS users, 45.8% received only low or medium doses (<500 μg/day) of inhaled corticosteroids. Within the preceding 3 years (2014-2017), 51.1% and 34.3% of patients prescribed ≥2 OCS courses or maintenance OCS, respectively, had received prescriptions from a general practitioner without medication adjustments by a specialist.

CONCLUSION

This prescription-fill study shows that 7.2% of Dutch patients with asthma were overexposed to OCS, of whom only about half used adequate doses of inhaled corticosteroids, and 40.3% had not received specialist intervention within the previous 3 years. This suggests that OCS overuse is often underdiagnosed and inadequately addressed.

Clinical burden related to oral corticosteroid treatment of severe asthma in Spain: LEVANTE study

Background: Severe asthma treatment with oral corticosteroids (OCS) added to inhaled corticosteroids and a long-acting β2-agonist (ICS-LABA) may result in more treatment burden and increased adverse effects.Objective and Methods: This ambispective multicenter observational study aimed at describing the clinical burden in patients with severe asthma on stable high-dose ICS-LABA who received OCS during ≥6 months (maintenance group) or ≥2 cycles in the previous 12 months (bursts group). Data collection comprised a retrospective 12-month baseline period and 2 follow-up visits at 3 and 6 months. Results: Eighty-nine patients were evaluable (30 on maintenance, 59 on bursts). At baseline, mean (SD) daily prednisone equivalent exposure in the total population was 24.6 (14.7) mg: 13.8 (9.4) mg on maintenance and 29.9 (14.3) mg on bursts. During the 6-month follow-up period, mean (SD) daily dose in the total cohort was 22.5 (18.8) mg: 17.2 (18.6) mg on maintenance and 28.4 (20.6) mg on bursts. The overall annual severe exacerbations rate during the 12-month baseline period was 2.05 per patient-year and 1.5 per patient-year over the 6-month follow-up, and frequency of hospitalizations and emergency department visits were similar on both maintenance and bursts use. Conclusions: Results show a suboptimal control of severe asthma despite such high doses of OCS and persistence of disease burden regardless of the prescribing pattern in maintenance or bursts. There is therapeutic inertia to continue using OCS despite the increased risk of adverse effects and the availability of biologics.

The carbon footprint of respiratory treatments in Europe and Canada: An observational study from the CARBON programme

Climate change represents a global challenge and nations are increasingly looking to decarbonise their economies by developing roadmaps for reducing greenhouse gas (GHG) emissions in accordance with international treaties, such as the Paris Agreement [1]. As the healthcare sector remains a key contributor to GHG emissions [2], an examination of the global carbon footprint of its operations and treatment pathways is essential to identify targets for decarbonisation.

Relievers account for the majority of inhaler use and associated GHG emissions. Implementing treatment guidelines can reduce the unmet need in respiratory care by improving disease control and reducing reliever overuse and the overall carbon footprint.https://bit.ly/3zh3c2B

Personalized Treatment of Asthma: The Importance of Sex and Gender Differences

An individual's sex (nominally male or female, based on biological attributes) and gender (a complex term referring to socially constructed roles, behaviors, and expressions of identity) influence the clinical course of asthma in several ways. The physiologic development of the lungs and effects of sex hormones may explain why more boys than girls have asthma, and after puberty, more women than men have asthma. Female sex hormones have an impact throughout the life span and are associated with poor asthma control. Gender may influence exposure to asthma triggers, and sex and gender can influence the prevalence of comorbidities and interactions with health care professionals. Despite widely reported sex- and gender-based differences in asthma and asthma management, these issues frequently are not considered by health care professionals. There is also inconsistency regarding the use of "sex" and "gender" in scientific discourse; research is needed to define sex- and gender-based differences better and how they might interact to influence asthma outcomes. This review outlines the impact an individual's sex and gender can have on the pathogenesis, clinical course, diagnosis, treatment, and management of asthma.

Real-world Treatment Patterns, Outcomes, and Healthcare Resource Utilization in Newly Treated Korean Patients With Asthma: A Retrospective Cohort Study

Purpose

Although asthma treatment guidelines recommend regular inhaled medication, real-world treatment patterns and outcomes in South Korea have not been examined. We examined real-world treatment patterns and outcomes among patients treated for asthma in South Korea.

Methods

This retrospective cohort study utilized data from the South Korean National Health Insurance database (2013–2016). Newly treated patients with asthma aged ≥18 years without history of chronic obstructive pulmonary disease were included. Initial and maintenance medication prescriptions were examined. Treatment discontinuation and switch were described. Asthma exacerbation rates, poor asthma control, and healthcare resource utilization (HRU) were compared between maintenance treatment groups (inhaled versus oral) using adjusted incidence rate ratios (aIRR) and hazard ratios (aHR).

Results

Overall, 1,054,707 patients initiated any asthma medication; 37,868 patients initiated inhaled (n = 9,983, 26.4%) or oral (n = 27,885, 73.6%) maintenance medication. More patients initiating inhaled versus oral asthma medication discontinued treatment within 12 months (94.4% vs. 86.3%; P < 0.0001). Patients treated with inhaled and oral medication switched treatment (2.5% and 2.3%; P = 0.4160, respectively). Patients initiating inhaled medication had significantly lower rates of asthma exacerbation (aIRR, 0.52; 95% CI, 0.39–0.69), lack of asthma control (aHR, 0.55; 95% CI, 0.48–0.62; P < 0.0001), all-cause and asthma-related HRU versus oral medication.

Conclusions

Despite current asthma guidelines, more patients in South Korea were prescribed oral than inhaled medications, resulting in suboptimal asthma management and increased HRU. This study highlights the need to reduce oral corticosteroid prescriptions for optimized treatment in asthma management.

Low dose oral corticosteroids in asthma associates with increased morbidity and mortality

Long-term oral corticosteroid (OCS) treatment for severe asthma is known to cause significant adverse effects, but knowledge on effects of lower exposures in general asthma populations is limited. We aimed to explore this in a nationwide Danish asthma population.Users of asthma medication aged 18-45 were identified in the Danish nationwide registers during 1999-2018 and followed prospectively in an open cohort design. Incident OCS-users were matched 1:4 to non-users by propensity scores with replacement. Associations between OCS use and incident comorbidities were examined by Cox regression. Mortality rates, causes of death, and rates of unscheduled hospital visits were assessed.OCS-users (n 30,352) had, compared to non-users (n 121,408), an increased risk of all outcomes with evident dose-response relationships starting at cumulative doses of ≤500 mg (prednisolone equivalents). Hazard ratios ranged from 1.24 (95% CI 1.18-1.30) for fractures to 8.53 (95% CI 3.97-18.33) for adrenal insufficiency. Depression/anxiety had the highest incidence rate difference at 4.3 (95% CI 3.6-5.0) per 1000 person years. Asthma-specific mortality rates were generally low at 0.15 (95% CI 0.11-0.20) and 0.04 (95% CI 0.02-0.06) per 1000 person years for OCS-users and non-users, respectively. Mortality rates and unscheduled hospital visits increased with increasing OCS exposure.The study findings should be interpreted with their observational nature in mind. However, we found that even at low cumulative exposure, OCS use in asthma management was associated with increased risk of comorbidities, mortality, and unscheduled hospital visits. Effective strategies for optimising asthma control and reducing OCS use are pivotal in asthma management.

Prescription Patterns of Oral Corticosteroids for Asthma Treatment and Related Asthma Phenotypes in University Hospitals in Korea

Purpose

Oral corticosteroids (OCSs) are frequently prescribed for asthma management despite their adverse effects. An understanding of the pattern of OCS treatment is required to optimize asthma treatment and reduce OCS usage. This study evaluated the prescription patterns of OCSs in patients with asthma.

Methods

This is a retrospective multicenter observational study. We enrolled adult (≥18 years) patients with asthma who had been followed up by asthma specialists in 13 university hospitals for ≥3 years. Lung function tests, the number of asthma exacerbations, and prescription data, including the days of supply and OCS dosage, were collected. The clinical characteristics of OCS-dependent and exacerbation-prone asthmatic patients were evaluated.

Results

Of the 2,386 enrolled patients with asthma, 27.7% (n = 660) were OCS users (the median daily dose of OCS was 20 mg/day prednisolone equivalent to a median of 14 days/year). OCS users were more likely to be female, to be treated at higher asthma treatment steps, and to show poorer lung function and more frequent exacerbations in the previous year than non-OCS users. A total of 88.0% of OCS users were treated with OCS burst with a mean dose of 21.6 ± 10.2 mg per day prednisolone equivalent to 7.8 ± 3.2 days per event and 2.4 times per year. There were 2.1% (51/2,386) of patients with OCS-dependent asthma and 9.5% (227/2,386) with exacerbation-prone asthma. These asthma phenotypes were consistent over the 3 consecutive years in 47.1% of OCS-dependent asthmatic patients and 34.4% of exacerbation-prone asthmatic patients when assessed annually over the 3-year study period.

Conclusions

We used real-world data from university hospitals in Korea to describe the OCS prescription patterns and relievers in asthma. Novel strategies are required to reduce the burden of OCS use in patients with asthma.

Changes in oral corticosteroid use in asthma treatment-A 20-year Danish nationwide drug utilisation study

Oral corticosteroids (OCS) are used in asthma management but can cause serious adverse effects. We aimed to investigate the usage trends in a nationwide asthma cohort in Denmark from 1999 to 2018. Using national registers, we identified young adults (18-45 years) with two or more asthma drug collections within 12 months since the age of 15 years as indicative of active asthma. OCS exposure level was stratified as high use (≥5 mg prednisolone/day/year) and low use (<5 mg/day/year). Lorenz curves were computed to illustrate potential skewness of consumption among the OCS users. We identified 318 950 individuals with a median age of 29 years (IQR 20-38 years) whereof 57% were women. The 1-year prevalence of OCS users was stable at 4.8% (median, IQR 4.7%-4.8%), but with nearly 40% decrease in high-users from 0.54% in 1999 to 0.33% in 2018. The median annual exposure decreased from 500 mg/year (1999) to 250 mg/year (2018). We found a substantial skewness in the distribution of OCS usage with 10% of users accounting for almost 50% of all OCS use. The prevalence of OCS users among young adults with active asthma has been relatively stable from 1999 to 2018, but with a decreasing prevalence of high-users and annual consumption.

Use of Systemic Corticosteroids for Reasons Other than Asthma in Subjects with Asthma

BACKGROUNDS

Recent studies have reported increased risks of adverse events from systemic corticosteroids even with only low-dose or short-term use. Some patients with asthma experience complications requiring systemic corticosteroids. However, few studies have examined issues associated with administration of systemic corticosteroids for reasons other than asthma among subjects with asthma.

OBJECTIVES

We investigated patterns of systemic corticosteroid exposure for reasons other than asthma in subjects with asthma.

METHOD

We retrospectively reviewed the records of adult subjects with asthma followed up for >1 year at Yokohama City University Hospital from January 1, 2010, to December 31, 2019. We investigated patterns and reasons for systemic corticosteroid use during follow-up. In addition, factors related to systemic corticosteroid use for reasons likely other than asthma were investigated.

RESULTS

Among the 568 subjects with asthma analyzed, 326 (57.4%) had received systemic corticosteroids for some reason. Among those 326 patients, 120 (36.8%) had received systemic corticosteroids for reasons likely other than asthma. Multivariable analysis revealed rheumatoid arthritis, eosinophilic granulomatosis with polyangiitis, other collagen vascular diseases, chronic rhinosinusitis, and malignancy as positively associated with systemic corticosteroid exposure for reasons likely other than asthma in subjects with asthma.

CONCLUSIONS

About 40% of systemic corticosteroid use in subjects with asthma was for reasons likely other than asthma. Clinicians should be aware of their asthma patients' exposures to systemic corticosteroids for nonasthma reasons, to avoid missing adverse events or underestimating the severity of asthma, and to reduce systemic corticosteroid use.

Step-up and step-down approaches in the treatment of asthma

Introduction: Significant intraindividual and temporal variability in symptom control is a feature of asthma that requires careful monitoring and the need to periodically review and adjust therapy. Both NHLBI/NAEPP and GINA offer helpful algorithms for a stepping approach to asthma.Areas covered: The problems arisen in applying the stepwise approach to the treatment of asthma proposed by NHLBI/NAEPP and GINA algorithms and their possible alternatives.Expert opinion: The current therapeutic stepping approach to asthma, which takes into account lung function, symptoms and quality of life, is certainly useful, but it does not consider the underlying mechanisms. Furthermore, patient's overestimation or underestimation of the severity of the disease and differences in the opinions on the level of asthma control required between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks. A reassessment of the conventional stepping approach to management of asthma is now needed. A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma which, when therapeutically targeted, will in many cases help to achieve the goals, seems more reasonable than the present stepping approach.

Uncontrolled Asthma: Unmet Needs in the Management of Patients

The recent scientific research has provided clinicians with the tools for substantially upgrading the standard of care in the field of bronchial asthma. Nevertheless, satisfactory asthma control still remains an unmet need worldwide. Identifying the major determinants of poor control in different asthma severity levels represents the first step towards the improvement of the overall patients' management. The present review aims to provide an overview of the main unmet needs in asthma control and of the potential tools for overcoming the issue. Implementing a personalized medicine approach is essential, not only in terms of pharmacological treatments, biologic drugs or sophisticated biomarkers. In fact, exploring the complex profile of each patient, from his inflammation phenotype to his preferences and expectations, may help in filling the gap between the big potential of currently available treatments and the overall unsatisfactory asthma control. Telemedicine and e-health technologies may provide a strategy to both optimize disease assessment on a regular basis and enhance patients' empowerment in managing their asthma. Increasing patients' awareness as well as the physicians' knowledge about asthma phenotypes and treatment options besides corticosteroid probably represent the key and more difficult goals of all the players involved in asthma management at every level.

German regional variation of acute and high oral corticosteroid use for asthma

OBJECTIVE: 

To improve understanding of real-world asthma treatment and inform physician education, we evaluated regional variation in asthma prevalence and oral corticosteroid (OCS) use across Germany.

METHODS: 

We developed a machine learning gradient-boosted tree model with IMS® Disease Analyzer electronic medical records, which cover 3% of German patients. This model had a 91% accuracy in predicting the presence of asthma and chronic obstructive pulmonary disease. We applied the model to the IMS^® Longitudinal Prescription database, with 82% national coverage, to classify patients receiving treatment for airflow obstruction from October 2017-September 2018 in 63 regions in Germany.

RESULTS: 

Of 2.4 million individuals under statutory health insurance predicted to have asthma, 13.7%, 18.7%, 36.5%, 29.4%, and 1.7% received treatment classified as Global Initiative for Asthma (GINA) Steps 1, 2, 3, 4, and 5, respectively. Approximately 7-15% of those at GINA Steps 1-4 and 35% at Step 5 treatment received ≥1 acute OCS prescription (duration <10 days). Of patients receiving GINA Steps 1-4 and Step 5 treatments, 1-3% and 86%, respectively, received ≥1 high-dosage OCS prescription. Cumulative OCS dosage and percentages of patients receiving OCS differed substantially across regions, and regions with lower OCS use had greater use of biologic therapies.

CONCLUSIONS: 

Both acute and high OCS use varied regionally across Germany, with overall use suggesting patients are considerable risk of adverse effects and long-term health consequences.

Supplemental data for this article can be accessed at publisher's website.

Oral corticosteroid prescription for asthma by general practitioners: A three-year analysis in Germany

BACKGROUND

Regular treatment of patients with asthma with oral corticosteroids (OCS) remains common despite potential severe side effects and alternative treatment options. However, there is limited data on the prevalence of OCS prescriptions for patients with asthma in Germany.

METHODS

Records from 1039 General practitioners for the years 2015-2017 in the German IMS® Disease Analyzer database were retrospectively analysed for patients with at least two confirmed asthma diagnoses (ICD-10) per observed year, representing approximately 30,000 patients per year. Asthma treatment steps (1-5) were assigned according to the German national guideline, based on prescribed therapies.

RESULTS

In the years 2015-2017, 20.3-21.3% of patients were classified as being in treatment step 1, 4.7-5.2% in step 2, 38.8-40.1% in step 3, 31.7-32.1% in step 4 and 2.7-3.2% in step 5. Proportions of patients treated with OCS >30 days/year were 9.4% (2015), 9.6% (2016) and 8.9% (2017), reducing to 8.1%, 8.2% and 7.4%, respectively, when patients with other inflammatory diseases possibly requiring OCS treatment were excluded. Use of OCS >30 days/year was more prevalent in patients aged >65 years (14.1-15.0%) than those aged 18-65 years (6.8-7.8%). Median daily prednisolone dose was 10-15 mg/day. Approximately 30% of patients treated with OCS >30 days/year were not in step 5 (based on their prescribed inhaled therapies).

CONCLUSION

These data suggest that a substantial proportion of patients with asthma in non-specialised care in Germany receive OCS prescriptions regularly, despite the availability of less harmful alternative treatment options.

Oral CorticoSteroid sparing with biologics in severe asthma: A remark of the Severe Asthma Network in Italy (SANI)

According to the data derived from several national and international registries, including SANI (Severe Asthma Network Italy), and considering the strong impact that frequent or regular use of oral corticosteroid has on quality of life (QoL) of severe asthmatics, as well as on the costs for managing corticosteroid-related diseases, oral corticosteroid sparing up to withdrawal should be considered a primary outcome in the management of severe asthma. New biologics have clearly demonstrated that this effect is possible, with concomitant reduction in the rate of exacerbations and in symptom control. Then, there is no reason for using so frequently oral corticosteroid before having explored all alternatives currently available for a large part of severe asthmatics.

Global Quality Standard for Identification and Management of Severe Asthma

INTRODUCTION

Severe asthma is a debilitating, life-threatening disease associated with substantial global morbidity, mortality, and health care resource utilization. Patients may not receive guideline-directed medical care for severe asthma. Moreover, viable precision-based assessment tools and newer preventive therapies that can reduce the frequency of exacerbations and associated functional impact are underused. As a result, high rates of poorly controlled severe asthma persist, and patient health-related quality of life suffers.

METHODS

In 2019, the Improve Access to Better Care Task Force of the PRECISION Steering Committee set out to develop a global template on quality standards for severe asthma care to support improved access to and delivery of quality care. This Quality Standard is grounded in the vast body of published evidence available for severe asthma care, published clinical guidelines (i.e., from the Global Initiative for Asthma in 2019 and the European Respiratory Society/American Thoracic Society in 2014), and the 2018 PRECISION-supported Charter to Improve Patient Care in Severe Asthma.

RESULTS

The Quality Standard developed emphasizes four key elements aimed at optimizing clinical care and outcomes in severe asthma: (1) organization of services, (2) timely identification and referral for suspected severe asthma, (3) specialized assessment and management of severe asthma to optimize outcomes, and (4) patient-centric care and shared decision-making that is reflective of the patient's expectations, priorities, and values. Four key Quality Statements are provided, along with quality metrics and strategies for local adaptation to optimize implementation.

CONCLUSION

This Global Quality Standard is intended to mobilize policymakers, health care providers, and patient advocacy groups to build consensus on the definition and expectations of quality care in severe asthma, to promote patient-centric care, to identify gaps in care and areas for improvement, and systematically implement improvement measures and outcomes and to reduce the burden of illness for patients with severe asthma.

Oral Corticosteroid Treatment Patterns of Patients in the United States with Persistent Asthma

BACKGROUND

Patients with poor asthma control may receive oral corticosteroid (OCS) therapy despite the risk for adverse effects.

OBJECTIVE

We assessed OCS use frequency and treatment patterns in patients with persistent asthma in the United States (US).

METHODS

We used the IBM MarketScan Commercial Claims and Encounters, Medicare Supplemental, and Medicaid Multistate Claims research databases to identify patients from January 1, 2012, to December 31, 2017, who were ≥12 years old, met the 2-year Healthcare Effectiveness Data and Information Set criteria for persistent asthma, and were continuously enrolled ≥6 months before (baseline) and ≥24 months after (follow-up) the persistent asthma index date. Patients were classified as high OCS use (defined as ≥450 mg of OCS prescribed within a 90-day period during follow-up), low use (use OCS but not meeting high use criteria), or no OCS use.

RESULTS

We identified 435,675 patients, of whom 65% used OCS and 19% were classified as high OCS users at some point during follow-up. The annual prevalence of high OCS use ranged from 5.3% in 2013 to 7.6% in 2017. During the entire follow-up, high and low OCS users filled an average of 2.2 and 0.8 OCS prescriptions and received an average daily dosage of 2.2 and 0.3 mg, respectively. Once the patients became high OCS users, the average daily OCS dosage was relatively stable (5.1-7.1 mg) over 3 years.

CONCLUSIONS

Patients with persistent asthma in the US have substantial exposure to OCS. OCS therapy should be considered carefully to avoid associated adverse effects.