Overuse of Oral Corticosteroids, Underuse of Inhaled Corticosteroids, and Implications for Biologic Therapy in Asthma

Abstract

<b><i>Background:</i></b> Asthma patients using high cumulative doses of oral corticosteroids (OCSs) are at risk of serious adverse events and are increasingly being treated with steroid-sparing asthma biologics. However, it is unknown whether prescribing these expensive biologics is always justified. <b><i>Objectives:</i></b> This study aimed to (1) assess the prevalence of asthma patients using high cumulative doses of OCSs, (2) explore the role of suboptimal inhaler therapy, and (3) estimate the proportion of patients to whom asthma biologics might be prescribed unnecessarily. <b><i>Methods:</i></b> All adults (<i>n</i> = 5,002) with at least 1 prescription of high-dose inhaled corticosteroids (≥500–1,000 mcg/day fluticasone-equivalent) and/or OCSs (GINA step 4–5) in 2010 were selected from a pharmacy database including 500,500 Dutch inhabitants, and sent questionnaires. Of 2,312 patients who returned questionnaires, 929 had asthma. We calculated the annual cumulative OCS dose and prescription fillings and checked inhaler technique in a sample of 60 patients. Patients estimated to have good adherence and inhaler proficiency who still required high doses of OCSs (≥420 mg/year) were considered candidates for initiating biologic treatment. <b><i>Results:</i></b> 29.5% of asthma patients on GINA 4–5 therapy used high doses of OCSs, of which 78.1% were likely to have poor therapy adherence or inadequate inhaler technique. Only 21.9% were considered definitive candidates for biologic therapy. <b><i>Conclusion:</i></b> High OCS use in Dutch GINA 4–5 asthma patients was common. However, in 4 out of 5 patients adherence to inhaled corticosteroid therapy and/or inhalation technique was considered suboptimal. Since optimizing inhaler therapy may reduce the need for OCSs, this should be mandatory before prescribing expensive steroid-sparing drugs.

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

“…The proportion of individuals not using any ICS was largest in the group with no OCS use, but a smaller, albeit slightly decreasing, proportion of individuals not using ICS also persisted among the high OCS users. This may be due to poor adherence to maintenance ICS treatment, which is unfortunately common in asthma treatment 5,34 . Individual‐level estimates of adherence were, however, beyond the capability of this study, as it would acquire date on individual asthma treatment plans.…”

“…This may be due to poor adherence to maintenance ICS treatment, which is unfortunately common in asthma treatment. 5,34 Individual-level estimates of adherence were, however, beyond the capability of this study, as it would acquire date on individual asthma treatment plans. Still, these results indicate a persistent group of undertreated patients, which emphasises the importance of frequent asthma control visits including evaluation of adherence to maintenance treatment.…”

Clinical inertia in asthma

“…According to previous reports, almost three-quarters of patients with asthma have an imperfect inhalation technique 29 , 30 . In a survey of Dutch residents, 29.5% of patients treated equivalent to GINA steps 4–5 required high-dose oral corticosteroids, of whom 78% had problems with inhalation technique or medication adherence 31 , suggesting the possibility of inappropriate inhalation device selection by healthcare providers.…”

A Prospective Study On Corticosteroids Utilization Pattern In Dermatology Department Of A Tertiary Care Teaching Hospital, Bangalore, India

“…This practice has led to quite often overprescribing of these drugs and, thereby, increasing adverse drug reactions. [4,5] Ironically, the mechanisms of the same useful anti-inflammatory properties are also the reason for their adverse effects. [6] The topical application disadvantages are adrenal suppression, epidermal, and dermal thinning, purpura, striae, steroid induced rosacea, perioral dermatitis, and hypertrichosis.…”