Extent, trends, and determinants of controller/reliever balance in mild asthma: a 14-year population-based study

Amir Khakban,Mohsen Sadatsafavi,Hamid Tavakoli,Larry Lynd,J Mark Fitzgerald,Solmaz Ehteshami-Afshar

doi:10.1186/s12931-019-1007-0

Abstract

BackgroundThe majority of patients with asthma have the mild form of the disease. Whether mild asthma patients receive appropriate asthma medications has not received much attention in the literature. We examined the trends in indicators of controller/reliever balance.MethodsUsing administrative health databases of British Columbia, Canada (2000 to 2013), we created a population-based cohort of adolescents/adults with mild asthma using validated case definition algorithms. Each patient-year of follow-up was assessed based on two markers of inappropriate medication prescription: whether the ratio of controller medications (inhaled corticosteroids [ICS] and leukotriene receptor antagonists [LTRA]) to total asthma-related prescriptions was low (cut-off 0.5 according to previous validation studies), and whether short-acting beta agonists (SABA) were prescribed inappropriately according to previously published criteria that considers SABA in relation to ICS prescriptions. Generalized linear models were used to evaluate trends and to examine the association between patient-, disease-, and healthcare-related factors and medication use.ResultsThe final cohort consisted of 195,941 mild asthma patients (59.5% female; mean age at entry 29.6 years) contributing 1.83 million patient-years. In 48.8% of patient-years, controller medications were suboptimally prescribed, while in 7.2%, SABAs were inappropriately prescribed. There was a modest year-over-year decline in inappropriate SABA prescription (relative change − 1.3%/year, P < 0.001) and controller-to-total-medications (relative change − 0.5%/year, P < 0.001). Among the studied factors, the indices of type and quality of healthcare (namely respirologist consultation and receiving pulmonary function test) had the strongest associations with improvement in controller/reliever balance.ConclusionsLarge number of mild asthma patients continue to be exposed to suboptimal combinations of asthma medications, and it appears there are modifiable factors associated with such phenomenon.

Highlights

The majority of patients with asthma have the mild form of the disease
Patients who mainly rely on reliever medications are at increased risk of periods of intensified disease activity commonly known as exacerbations or attacks
We have demonstrated the adverse consequences associated with such inappropriate use in a cohort of largely mild asthma patients [10]

Summary

Introduction

The majority of patients with asthma have the mild form of the disease. Whether mild asthma patients receive appropriate asthma medications has not received much attention in the literature. Asthma is one of the most common chronic diseases worldwide. While it cannot be cured, achieving clinical and symptomatic control can substantially reduce the burden of asthma. Patients who mainly rely on reliever medications are at increased risk of periods of intensified disease activity commonly known as exacerbations or attacks. One postulated mechanism for such an increased risk is that through symptomatic relief, reliever medications facilitate inhalation of exacerbation triggers which, in the absence of anti-inflammatory therapy, make patients vulnerable to severe and potentially fatal attacks [3,4,5]. Landmark studies have demonstrated that monotherapy with SABAs is associated with an increased risk of severe exacerbations and mortality [6, 7]

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