Why and how to step down chronic asthma drugs

Gionfriddo, Michael R.; Hagan, John B.; Rank, Matthew A.

doi:10.1136/bmj.j4438

Cited by 22 publications

(18 citation statements)

References 51 publications

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“…Poor adherence to medication is a common reason for loss of asthma control [5, 6]. Clinical guidelines advise to adjust medication according to symptom severity [6-8]. At the population level, outcome of asthma improves if diagnosis is made early, treatment is started effectively, and patients are guided to proactively stop symptom increase [9, 10].…”

Section: Introductionmentioning

confidence: 99%

Multimorbidity in Asthma, Allergic Conditions and COPD Increase Disease Severity, Drug Use and Costs: The Finnish Pharmacy Survey

Jantunen

Haahtela

Salimäki³

et al. 2019

Int Arch Allergy Immunol

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Background: Asthma, allergic conditions, and COPD overlap, but the effect of them and their combinations on disease severity, need for drugs, use of healthcare, and costs is poorly known. Objective: To study how different allergic diseases co-occur in asthma and allergy patients and evaluate the use of medication well as drug and healthcare costs. Methods: Nationwide Allergy Barometer Survey was carried out in the Finnish pharmacies during 1 week in September 2016. Altogether, 956 patients (5–75 years) who purchased asthma or allergy drugs with prescription participated in 351 pharmacies. Results: Of the participants, 78% reported physician-diagnosed asthma, 57% allergic rhinitis, 24% atopic eczema, 21% food allergy, 20% allergic conjunctivitis, 8% anaphylaxis, and 8% COPD. One-third of the patients had at least three conditions, and multimorbidity was common across all age groups. Disease severity increased with the number of coexisting conditions, and asthma severity also with age. Patients with asthma alone used on average 3.8 drugs with the annual costs of EUR 661. This increased to 4.9 drugs and EUR 847 in asthmatics with multimorbidity. For all participants, costs of drugs and healthcare services together during the preceding year were on average EUR 1,214, of which 56% were drug costs. The costs doubled to EUR 2,714 in 65 subjects (7%) who had both asthma and COPD. Conclusions: In asthma and allergy, multimorbidity and polypharmacy are major concerns. Disease severity, drug use, and costs increased with multimorbid conditions. To reduce the burden, allergy management should be better integrated and more comprehensive.

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Section: Introductionmentioning

confidence: 99%

Multimorbidity in Asthma, Allergic Conditions and COPD Increase Disease Severity, Drug Use and Costs: The Finnish Pharmacy Survey

Jantunen

Haahtela

Salimäki³

et al. 2019

Int Arch Allergy Immunol

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“…SQ ® -HDM tablets treatment of respiratory allergy to mites is associated with measurable changes in the immune response to allergens, reduction of the risk of exacerbations, improvement of disease control, reduction of symptomatic pharmacotherapy, favorable impact on the quality of life of patients [16,32,38]. Last but not least, immunotherapy has the potential to provide a long-term clinical benefit even after cessation of treatment [39].…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, the Guidelines highlight the possibility of a step-down of the therapy after a prolonged exacerbation-free period. In this context, AIT con be considered to facilitate step-down in patients with HDM sensitization in therapy with medium dose inhaled corticosteroids [38].…”

Section: Gina Guidelinesmentioning

confidence: 99%

New perspectives in allergen specific immunotherapy driven by big trials with house dust mite sublingual SQ® tablets

2020

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House-dust mites (HDM) allergy is the prevailing condition in subjects allergic to inhalants. Clinical studies with HDM extracts-either subcutaneous (SCIT) or sublingual (SLIT) have long been characterized by small sample size, varying allergen doses, and poorly defined endpoints assessing disease severity. In the last decade, well-designed, randomized, controlled studies recruiting thousands of patients have been conducted with newly developed HDM sublingual tablets (SQ ®-HDM tablets). This drug is easily dispersible in the oral cavity due to the patented Zydis ® technology and its allergen composition is balanced in terms of group I and group II major mite allergen content, reflecting the equal contribution of the two components to HDM sensitization. HDM is the most common allergen associated with asthma. Clinical efficacy of the SQ ® HDM SLIT-tablet in HDM allergic asthma has been evaluated in randomized, double-blind, placebo-controlled trials. Both endpoints related to "present" asthma control (inhaled corticosteroid-ICS) as well as endpoints related to "future" asthma control (occurrence of asthma exacerbations) were included in these studies, in agreement with GINA (Global Initiative for Asthma) guidelines. Based on the positive results of these studies, SQ ®-HDM SLIT-tablets were approved Europe-wide as registered drug for treating moderate-to-severe allergic rhinitis with or without allergic asthma and not well controlled HDM allergic asthma, associated with allergic rhinitis of any severity. GINA guidelines in 2017 included SLIT-tablet-based immunotherapy as an "add-on" treatment for asthmatic patients sensitized to HDM; indeed, allergen immunotherapy (AIT) is considered to be a complementary treatment option that targets the immunological of allergic diseases, representing the only treatment potentially disease-modifier or, at least, with a long-term efficacy. The availability of a safe, standardized, registered treatment for HDM respiratory allergies is pivotal in the immunotherapy field, pushing it out of a century-long limbo of amatorial interest towards the full dignity deserved by the only casual treatment of respiratory allergies.

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“…For example, they may be reluctant to step-up therapy due to awareness of safety issues with high-dose steroids, or reluctant to step-down therapy due to concerns about leaving patients inadequately controlled or at risk of exacerbations. 16,17 It is also possible that clinicians are conducting asthma reviews without properly considering whether patients are adequately controlled on the current therapy, or if they should be stepped up or down. It is difficult to speculate on this point, given the descriptive nature of our study, however, the lack of recorded review is suggestive of at least sub-optimal data recording, if not a lack of sufficient asthma review in the real world.…”

Section: Discussionmentioning

confidence: 99%

Real-life prescribing of asthmatic treatments in UK general practice over time using 2014 BTS/SIGN steps

Gayle

Tebboth

Pang

et al. 2019

npj Prim. Care Respir. Med.

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The 2014 British Thoracic Society (BTS) and Scottish Intercollegiate Guideline Network (SIGN) guidelines recommend a stepwise approach to asthma management. We investigated the management of asthma in primary care in the UK to understand how real-world practice compares with BTS/SIGN guidelines. Asthma patients were identified from the UK Clinical Practice Research Datalink from September 2006 to August 2016. Aims were to classify patients according to BTS/SIGN steps, describe the proportion of patients transitioning between steps and describe patient demographics and clinical characteristics per group. Overall, 647,308 patients with asthma were identified (40,096 aged 5–11 years; 607,212 aged 12–80 years). Most treated patients were in step 1 or 2 (88.3% of children/67.5% of adults in December 2007; 83.0% of children/67.0% of adults in June 2016). Most patients remained within their treatment step within a 6-month interval (>78% of children and adults throughout the study duration). The proportion of patients stepping up and down reduced from the beginning of the study, although stepping down to step 1 was relatively common in both adults and children. Few patients had a recorded asthma review in the year before reference date (18.8% of children and 14.8% of adults). Although prescribing patterns meant that most patients remained within their treatment step throughout the study, we cannot be sure that this was because their disease was truly stable. The small proportion of patients stepping up/down and the lack of recorded asthma review suggest that patients may not be treated in accordance with BTS/SIGN guidelines.

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Why and how to step down chronic asthma drugs

Cited by 22 publications

References 51 publications

Multimorbidity in Asthma, Allergic Conditions and COPD Increase Disease Severity, Drug Use and Costs: The Finnish Pharmacy Survey

Multimorbidity in Asthma, Allergic Conditions and COPD Increase Disease Severity, Drug Use and Costs: The Finnish Pharmacy Survey

New perspectives in allergen specific immunotherapy driven by big trials with house dust mite sublingual SQ® tablets

Real-life prescribing of asthmatic treatments in UK general practice over time using 2014 BTS/SIGN steps

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