PURPOSE OF THE STUDY.
Both national and international guidelines on the treatment of asthma emphasize the use of controller medications in persistent asthma and discuss the role of controller versus rescue medications. This study looked at 12 years of data to study the extent and trends of inappropriate or excessive use of SABAs.
The study used a health database in British Columbia (population 4.67 million). They created a cohort of patients with asthma, aged 15–55 years. Asthma was defined as meeting at least 1 of 3 criteria over 12 months: (1) use of 3 asthma-related medications, (2) two outpatient visits, or (3) one hospitalization with the primary code for asthma.
Data were collected from 2002–2013. Three metrics were defined: (1) inappropriate prescriptions of SABAs (>2 puffs of a SABA per week if no ICS was used and ≥9 canisters of SABA and no more than 100 μg [beclomethasone equivalent] per day of ICS), (2) excessive prescription of SABAs (filling prescriptions for ≥12 canisters during a year regardless of ICS use), and (3) the ratio of ICS to total asthma-related prescriptions. This ratio is negatively associated with adverse asthma outcomes. A cutoff of 50% each patient-year was selected as a satisfactory ratio.
A total of 343 520 individuals met the case definition of asthma. In 7.6% of patient-years, SABAs were prescribed inappropriately. When patient-years with no prescriptions filled were removed, this number increased to 11.9%. In 0.9% of patient years, SABAs were prescribed excessively. In 29.6% of patient-years, the ratio of ICS to total prescriptions was >50%.
Inappropriate prescriptions of SABAs are still prevalent but halved from 2002 to 2013, and excessive SABA prescriptions declined by more than 60%. Excessive SABA use declined over the study period but increased over the time course of asthma. Excessive SABA use was most notable in older patients and might explain higher mortality in this group.
Asthma guidelines have been around for over 2 decades and emphasize the use of ICS as first-line treatment to control chronic inflammation in persistent asthma. This study shows that inappropriate and excessive prescriptions of SABAs are still prevalent but appear to be decreasing in this population. The major limitation in this study is use of pharmacy data to reflect actual medication usage. Patients frequently want prescriptions for multiple SABAs to have in various locations or to replace lost medications. In addition, filling a prescription does not equate to medication use. So, the number of prescriptions for SABAs is likely higher than actual usage. Devices that measure the actual number of puffs accentuated from a device are available and may more acutely reflect patient medication usage. Preparation, distribution, and implementation of guidelines is no small task. It is refreshing to see data showing the benefits of guideline usage.
- Copyright © 2017 by the American Academy of Pediatrics