Health and cost impact of stepping down asthma medication for UK patients, 2001–2017: A population-based observational study

Abstract

Background Guidelines recommend stepping down asthma treatment to the minimum effective dose to achieve symptom control, prevent adverse side effects, and reduce costs. Limited data exist on asthma prescription patterns in a real-world setting. We aimed to evaluate the appropriateness of doses prescribed to a UK general asthma population and assess whether stepping down medication increased exacerbations or reliever use, as well as its impact on costs. Methods and findings We used nationwide UK primary care medical records, 2001-2017, to identify 508,459 adult asthma patients managed with preventer medication. Prescriptions of higher-level medication: medium/high-dose inhaled corticosteroids (ICSs) or ICSs + add-on medication (longacting β2-agonist [LABA], leukotriene receptor antagonist [LTRA], theophylline, or long-acting muscarinic antagonist [LAMA]) steadily increased over time (2001 = 49.8%, 2017 = 68.3%). Of those prescribed their first preventer, one-third were prescribed a higher-level medication, of whom half had no reliever prescription or exacerbation in the year prior. Of patients first prescribed ICSs + 1 add-on, 70.4% remained on the same medication during a mean follow-up of 6.6 years. Of those prescribed medium/high-dose ICSs as their first preventer, 13.0% already had documented diabetes, cataracts, glaucoma, or osteopenia/osteoporosis. A cohort of 125,341 patients were drawn to assess the impact of stepping down medication: mean age 50.4 years, 39.4% males, 39,881 stepped down. Exposed patients were stepped down by dropping their LABAs or another add-on or by halving their ICS dose (halving their mean-daily dose or their inhaler dose). The primary and secondary outcomes were, respectively, exacerbations and an increase in reliever prescriptions. Multivariable regression was used to assess outcomes and determine the prognostic factors for initiating stepdown. There was no increased exacerbation risk for each possible medication stepdown

<p>Qualitative Study of Practices and Challenges of Stepping Down Asthma Medication in Primary Care Across the UK</p>

“…In the UK, around two-thirds of asthma patients, that are managed with a preventer, use medium or high dose ICS. 1 It is unclear whose role it is to step down, arguably it is everyone's role, but many doctors and some nurses did not feel it was their responsibility. This may be a major contributing factor, for example doctors often suggested it should be assessed during a nurse-led asthma review, whereas some nurses reported feeling hesitant to step-down medication prescribed by a doctor.…”

“…21 We feel our data was adequate in this respect and complementary to recent UK observational data. 1 However, it is possible there was some selection bias, such that those with an interest in asthma were more likely to participate. If this bias occurs, you may expect the health professionals that did not wish to participate were more likely to perceive the barriers we found.…”

“…Around 7% of UK adults have active asthma, with an increasing proportion receiving preventer medication. 1 The predominant UK asthma guidelines, the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN), the National Institute for Health and Care Excellence (NICE), and the international Global Initiative for Asthma (GINA) report, recommend a stepwise approach to pharmacological management. [2][3][4] For each progressive step, medication can be increased.…”

“…7 In the UK, there has been an increase in the proportion receiving higher level medication (medium or high dose inhaled corticosteroids, ICS). 1 Of those prescribed a medium/high dose combination inhaler as their first ever preventer, 70% remained on the same inhaler for several years. 1 However, the literature on barriers to stepping down asthma medication is sparse.…”

“…1 Of those prescribed a medium/high dose combination inhaler as their first ever preventer, 70% remained on the same inhaler for several years. 1 However, the literature on barriers to stepping down asthma medication is sparse. As nearly all (96%) of asthma patients are managed in primary care, 8 we sought to understand the perceptions of practitioners managing asthma patients in that setting.…”