Oral Corticosteroid Prescriptions Research Articles

Poison Ivy Dermatitis Treatment Patterns and Utilization: A Retrospective Claims-based Analysis.

IntroductionPoison ivy (toxicodendron) dermatitis (TD) resulting from contact with poison ivy, oak, or sumac is a common form of allergic contact dermatitis that impacts millions of people in the United State every year and results in an estimated 43,000 emergency department (ED) visits annually. Our objective in this study was to evaluate whether healthcare utilization outcomes are impacted by prescription practices of systemic corticosteroids.MethodsWe used a health claims database from 2017–2018 of those treated for TD. Descriptive statistics and logistics regression models were used to characterize trends.ResultsWe included in this analysis 115,885 claims from 108,111 unique individuals (93.29%) with 7,774 (6.71%) return claims within 28 days. Of the return claims, 470 (6.05%) were to the ED. Emergency clinicians offered no oral corticosteroid prescription 5.27% (n = 3,194) of the time; 3276 (86.26%) prescriptions were for a duration of 1–13 days, 410 (10.80%) were for 14–20 days, and 112 (2.95%) were for >21 days. Further, we found that shorter duration oral corticosteroids (odds ratio [OR] 1.30; 95% confidence interval 1.17–1.44; P <0.001) and initial treatment for TD at the ED compared to primary care clinicians (OR 0.87 [0.80, 0.96]; P <0.001) and other non-dermatologists (OR 0.89 [0.80, 0.98]; P = 0.01) places patients at an increased risk for return visits with healthcare clinicians when controlling for drug group, duration of treatment, and initial treatment location.ConclusionDespite recommendations to treat TD with oral steroids for at least 14 days, most emergency clinicians offered this treatment for shorter durations and was associated with return visits. Emergency clinicians should consider treatment of two to three weeks when providing systemic steroid coverage when there are no limiting contraindications, especially as patients who present to the ED may do so with more severe disease. Additional education may be needed on appropriate treatment pathways for TD to reduce healthcare utilization associated with undertreatment.

Regional variation in prevalence of difficult-to-treat asthma and oral corticosteroid use for patients in Australia: heat map analysis

Background In Australia, the regional prevalence of difficult-to-treat asthma is unknown. We aimed to describe regional variation in difficult-to-treat asthma prevalence and oral corticosteroid (OCS) use. Methods In this retrospective, observational, longitudinal study using data from March 2018–February 2019 in the NostraData longitudinal database, prescriptions dispensed for obstructive airway disease were processed through a high-level algorithm to identify patients with asthma. Difficult-to-treat asthma was defined by ≥2 high-dosage inhaled corticosteroids plus long-acting beta-agonist prescriptions over 6 months. Patients who additionally received OCS prescriptions sufficient to treat ≥2 exacerbations over 6 months were classified as having uncontrolled difficult-to-treat asthma. Patient-level data were analyzed across 340 geographic areas in Australia to determine regional prevalence of difficult-to-treat asthma, uncontrolled difficult-to-treat asthma, and OCS use. Results Of 1 851 129 people defined as having asthma, 440 800 (24%) were classified as having difficult-to-treat disease. Of those difficult-to-treat asthma patients, 96 338 (22%) were considered to have uncontrolled disease. Between 29% and 48% of patients had difficult-to-treat asthma in 49 geographic areas, most frequently located in Western Australia. Between 26% and 67% of patients had uncontrolled difficult-to-treat asthma in 29 geographic areas (mostly in Eastern Australia). Overall, a wide variability of asthma severity and control was observed among regions. Conclusions Despite global and national guidelines, regional differences in the prevalence of difficult-to-treat asthma and uncontrolled difficult-to-treat asthma and OCS use exist in Australia. Understanding these regional variations should inform policy and target management in the areas with the greatest unmet need.

Trends and predictors of specialist assessments in oral corticosteroid treated asthma among young adults.

BackgroundRepeated oral corticosteroid use indicates uncontrolled disease among asthma patients, and referral for asthma specialist assessment is recommended. We aimed to describe trends and predictors associated with specialist contacts among young adults with asthma and repeated oral corticosteroid use.MethodsIndividuals aged 18–45 years with two or more dispensed asthma medication prescriptions and two dispended oral corticosteroid prescriptions (including short-term and long-term treatments) within 12 months during 1999–2018 were identified by use of Danish healthcare registers. The frequency of specialist contacts within 1 year of follow-up was assessed among individuals without previous specialist contacts within 5 years of inclusion. Factors associated with specialist contact were identified using logistic regression models. Furthermore, oral corticosteroid prescriber sources were assessed.ResultsFor the 11 223 individuals included, 2444 (22%) had previous specialist-contact care within 5 years prior of inclusion, and additionally 926 (8.3%) within 1 year of follow-up. Among those without previous specialist contacts (n=8779), the frequency of incident specialist contacts within 1 year of follow-up increased from 6.3% in 1999 to 18% in 2017. Factors associated with incident specialist contacts included dispensing ≥12 short-acting β-agonist canisters and previous asthma-related emergency department visits and hospitalisations. The majority of oral corticosteroid prescriptions at baseline (71%) were prescribed by general practitioners, although with decreasing proportions from 1999 to 2018.ConclusionsThe majority (70%) of young adults with asthma and repeated oral corticosteroid use do not seem to receive specialist assessment in Denmark. This highlights a potential room for improvement in the patient referral pathway for at-risk asthma patients.

Overuse of Oral Corticosteroids in Asthma Is Often Underdiagnosed and Inadequately Addressed

Overuse of oral corticosteroids (OCS) is associated with serious adverse effects. It is currently unknown what proportion of patients with asthma regularly use these drugs, or whether they are optimally treated by specialists to minimize the use of these drugs. To investigate (1) the prevalence of patients requiring ≥2 courses or maintenance use of OCS (ie, frequent users), (2) their use of inhaled corticosteroids, and (3) who prescribed their asthma medications. We analyzed OCS prescription data (Dutch IQVIA Prescription Database) focusing on adult patients receiving asthma medication between March 2017 and March 2018 (focus year). An OCS course was defined as ≥20 mg prednisolone equivalent for 3 to 28 days; maintenance OCS as 2.5 to 17.5 mg/day for >28 days. Prescribers were classified as specialist or general practitioners. Of 182,849 adults taking asthma medications, 77.8% had not received a prescription for OCS and 7.2% of patients were frequent OCS users: 2.6% received ≥2 OCS courses and 4.6% were on maintenance OCS. Of the frequent OCS users, 45.8% received only low or medium doses (<500 μg/day) of inhaled corticosteroids. Within the preceding 3 years (2014-2017), 51.1% and 34.3% of patients prescribed ≥2 OCS courses or maintenance OCS, respectively, had received prescriptions from a general practitioner without medication adjustments by a specialist. This prescription-fill study shows that 7.2% of Dutch patients with asthma were overexposed to OCS, of whom only about half used adequate doses of inhaled corticosteroids, and 40.3% had not received specialist intervention within the previous 3 years. This suggests that OCS overuse is often underdiagnosed and inadequately addressed.

Risk of serious COVID-19 outcomes among adults with asthma in Scotland: a national incident cohort study

SummaryBackgroundThere is considerable uncertainty over whether adults with asthma should be offered booster vaccines against SARS-CoV-2 and, if so, who should be prioritised for booster vaccination. We were asked by the UK's Joint Commission on Vaccination and Immunisation to undertake an urgent analysis to identify which adults with asthma were at an increased risk of serious COVID-19 outcomes to inform deliberations on booster COVID-19 vaccines.MethodsThis national incident cohort study was done in all adults in Scotland aged 18 years and older who were included in the linked dataset of Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II). We used data from EAVE II to investigate the risk of COVID-19 hospitalisation and the composite outcome of intensive care unit (ICU) admission or death from COVID-19 among adults with asthma. A Cox proportional hazard model was used to derive adjusted hazard ratios (HRs) and 95% CIs for the association between asthma and COVID-19 hospital admission and ICU admission or death, stratified by markers of history of an asthma attack defined by either oral corticosteroid prescription (prednisolone, prednisone, and dexamethasone) in the 2 years before March 1, 2020, or hospitalisation for asthma before March 1, 2020. Analyses were adjusted for age, sex, socioeconomic status, comorbidity, previous hospitalisation, and vaccine status.FindingsBetween March 1, 2020, and July 27, 2021, 561 279 (12·7%) of 4 421 663 adults in Scotland had clinician-diagnosed-and-recorded-asthma. Among adults with asthma, 39 253 (7·0%) had confirmed SARS-CoV-2 infections, of whom 4828 (12·3%) were admitted to hospital for COVID-19 (among them, an estimated 600 [12·4%] might have been due to nosocomial infections). Adults with asthma were found to be at an increased risk of COVID-19 hospital admission (adjusted HR 1·27, 95% CI 1·23–1·32) compared with those without asthma. When using oral corticosteroid prescribing in the preceding 2 years as a marker for history of an asthma attack, the adjusted HR was 1·54 (95% CI 1·46–1·61) for those with three or more prescribed courses of oral corticosteroids, 1·37 (1·26–1·48) for those with two prescribed courses, 1·30 (1·23–1·37) for those with one prescribed course, and 1·15 (1·11–1·21) for those without any courses, compared with those aged 18 years or older without asthma. Adults with asthma were found to be at an increased risk of COVID-19 ICU admission or death compared with those without asthma (adjusted HR 1·13, 95 % CI 1·05–1·22). The adjusted HR was 1·44 (95% CI 1·31–1·58) for those with three or more prescribed courses of oral corticosteroids, 1·27 (1·09–1·48) for those with two prescribed courses, 1·04 (0·93–1·16) for those with one prescribed course, and 1·06 (0·97–1·17) for those without any course, compared with adults without asthma.InterpretationAdults with asthma who have required two or more courses of oral corticosteroids in the previous 2 years or a hospital admission for asthma before March 1, 2020, are at increased risk of both COVID-19 hospitalisation and ICU admission or death. Patients with a recent asthma attack should be considered a priority group for booster COVID-19 vaccines.FundingUK Research and Innovation (Medical Research Council), Research and Innovation Industrial Strategy Challenge Fund, Health Data Research UK, and Scottish Government.

Real-world Treatment Patterns, Outcomes, and Healthcare Resource Utilization in Newly Treated Korean Patients With Asthma: A Retrospective Cohort Study.

PurposeAlthough asthma treatment guidelines recommend regular inhaled medication, real-world treatment patterns and outcomes in South Korea have not been examined. We examined real-world treatment patterns and outcomes among patients treated for asthma in South Korea.MethodsThis retrospective cohort study utilized data from the South Korean National Health Insurance database (2013–2016). Newly treated patients with asthma aged ≥18 years without history of chronic obstructive pulmonary disease were included. Initial and maintenance medication prescriptions were examined. Treatment discontinuation and switch were described. Asthma exacerbation rates, poor asthma control, and healthcare resource utilization (HRU) were compared between maintenance treatment groups (inhaled versus oral) using adjusted incidence rate ratios (aIRR) and hazard ratios (aHR).ResultsOverall, 1,054,707 patients initiated any asthma medication; 37,868 patients initiated inhaled (n = 9,983, 26.4%) or oral (n = 27,885, 73.6%) maintenance medication. More patients initiating inhaled versus oral asthma medication discontinued treatment within 12 months (94.4% vs. 86.3%; P < 0.0001). Patients treated with inhaled and oral medication switched treatment (2.5% and 2.3%; P = 0.4160, respectively). Patients initiating inhaled medication had significantly lower rates of asthma exacerbation (aIRR, 0.52; 95% CI, 0.39–0.69), lack of asthma control (aHR, 0.55; 95% CI, 0.48–0.62; P < 0.0001), all-cause and asthma-related HRU versus oral medication.ConclusionsDespite current asthma guidelines, more patients in South Korea were prescribed oral than inhaled medications, resulting in suboptimal asthma management and increased HRU. This study highlights the need to reduce oral corticosteroid prescriptions for optimized treatment in asthma management.

Prescription Patterns of Oral Corticosteroids for Asthma Treatment and Related Asthma Phenotypes in University Hospitals in Korea.

PurposeOral corticosteroids (OCSs) are frequently prescribed for asthma management despite their adverse effects. An understanding of the pattern of OCS treatment is required to optimize asthma treatment and reduce OCS usage. This study evaluated the prescription patterns of OCSs in patients with asthma.MethodsThis is a retrospective multicenter observational study. We enrolled adult (≥18 years) patients with asthma who had been followed up by asthma specialists in 13 university hospitals for ≥3 years. Lung function tests, the number of asthma exacerbations, and prescription data, including the days of supply and OCS dosage, were collected. The clinical characteristics of OCS-dependent and exacerbation-prone asthmatic patients were evaluated.ResultsOf the 2,386 enrolled patients with asthma, 27.7% (n = 660) were OCS users (the median daily dose of OCS was 20 mg/day prednisolone equivalent to a median of 14 days/year). OCS users were more likely to be female, to be treated at higher asthma treatment steps, and to show poorer lung function and more frequent exacerbations in the previous year than non-OCS users. A total of 88.0% of OCS users were treated with OCS burst with a mean dose of 21.6 ± 10.2 mg per day prednisolone equivalent to 7.8 ± 3.2 days per event and 2.4 times per year. There were 2.1% (51/2,386) of patients with OCS-dependent asthma and 9.5% (227/2,386) with exacerbation-prone asthma. These asthma phenotypes were consistent over the 3 consecutive years in 47.1% of OCS-dependent asthmatic patients and 34.4% of exacerbation-prone asthmatic patients when assessed annually over the 3-year study period.ConclusionsWe used real-world data from university hospitals in Korea to describe the OCS prescription patterns and relievers in asthma. Novel strategies are required to reduce the burden of OCS use in patients with asthma.

Sensor-Based Electronic Monitoring for Asthma: A Randomized Controlled Trial

To assess whether sensor-based monitoring of daily inhaled corticosteroids and short-acting b-agonist medications can improve asthma outcomes in diverse populationsA socioeconomically and racially diverse population of caregiver and children dyads were randomly assigned to control (n = 127) or sensor-based electronic monitoring (n = 125) for asthma.This was a randomized controlled multicenter trial of socioeconomically and racially diverse caregiver and children pairs from 5 Chicago medical clinics. The primary outcomes measured were the Asthma Control Test (ACT) (≥19 score equivalent to controlled asthma) and health care use (emergency department visits, hospitalizations, and oral corticosteroid prescriptions). Caregiver quality of life (QoL) and adherence to inhaled corticosteroids were also evaluated with multitiered models to ascertain changes.The intervention group had a significant increase in adjusted mean ACT scores (19.1 [n = 123; SE = 0.3] to 21.8 [n = 102; SE = 0.4]). The control group also had an increase in adjusted mean ACT scores (19.4 [n = 126; SE = 0.3] to 19.9 [n = 118; SE = 0.4]), the change was less than that of the intervention group at all time points (P < .01 for all comparisons). There was no difference in terms of the reported number of asthma attacks, missed school days, and steroid prescriptions in the ED and/or hospital. However, more children in the intervention group were prescribed steroids for asthma attacks during the 12 month study than controls were (72.5% intervention versus 34.6% control; P < .01). Improved QoL was reported by caregivers of the intervention group; this change was greater that of seen in the control group at 1 month follow-up, but there was no difference at 12 months.The outcomes of the study reveal that sensor-based inhaler monitoring with clinical participant–provider feedback may enhance asthma control and caregiver QoL in racially and socioeconomically diverse populations. However this improvement in outcomes for child and caregiver comes at the price of higher health care use, so further improvement in the sensor and participant–provider feedback system is needed.The authors should be recognized for demonstrating that use of sensor monitoring for asthma medications in children can improve asthma control and caregiver QoL in diverse populations. However, these improvements may come at a price of increasing health care use (steroid prescriptions). The limitations of the study include that data had to be manually entered because the blue chip device did not fit the inhaler and the absence of documentation or quantification of participant–provider phone feedback and adherence in both study groups as well as cost-effectiveness analysis.

Risk of COVID-19 hospital admission among children aged 5–17 years with asthma in Scotland: a national incident cohort study

SummaryBackgroundThere is an urgent need to inform policy deliberations about whether children with asthma should be vaccinated against SARS-CoV-2 and, if so, which subset of children with asthma should be prioritised. We were asked by the UK's Joint Commission on Vaccination and Immunisation to undertake an urgent analysis to identify which children with asthma were at increased risk of serious COVID-19 outcomes.MethodsThis national incident cohort study was done in all children in Scotland aged 5–17 years who were included in the linked dataset of Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II). We used data from EAVE II to investigate the risk of COVID-19 hospitalisation among children with markers of uncontrolled asthma defined by either previous asthma hospital admission or oral corticosteroid prescription in the previous 2 years. A Cox proportional hazard model was used to derive hazard ratios (HRs) and 95% CIs for the association between asthma and COVID-19 hospital admission, stratified by markers of asthma control (previous asthma hospital admission and number of previous prescriptions for oral corticosteroids within 2 years of the study start date). Analyses were adjusted for age, sex, socioeconomic status, comorbidity, and previous hospital admission.FindingsBetween March 1, 2020, and July 27, 2021, 752 867 children were included in the EAVE II dataset, 63 463 (8·4%) of whom had clinician-diagnosed-and-recorded asthma. Of these, 4339 (6·8%) had RT-PCR confirmed SARS-CoV-2 infection. In those with confirmed infection, 67 (1·5%) were admitted to hospital with COVID-19. Among the 689 404 children without asthma, 40 231 (5·8%) had confirmed SARS-CoV-2 infections, of whom 382 (0·9%) were admitted to hospital with COVID-19. The rate of COVID-19 hospital admission was higher in children with poorly controlled asthma than in those with well controlled asthma or without asthma. When using previous hospital admission for asthma as the marker of uncontrolled asthma, the adjusted HR was 6·40 (95% CI 3·27–12·53) for those with poorly controlled asthma and 1·36 (1·02–1·80) for those with well controlled asthma, compared with those with no asthma. When using oral corticosteroid prescriptions as the marker of uncontrolled asthma, the adjusted HR was 3·38 (1·84–6·21) for those with three or more prescribed courses of corticosteroids, 3·53 (1·87–6·67) for those with two prescribed courses of corticosteroids, 1·52 (0·90–2·57) for those with one prescribed course of corticosteroids, and 1·34 (0·98–1·82) for those with no prescribed course, compared with those with no asthma.InterpretationSchool-aged children with asthma with previous recent hospital admission or two or more courses of oral corticosteroids are at markedly increased risk of COVID-19 hospital admission and should be considered a priority for vaccinations. This would translate into 9124 children across Scotland and an estimated 109 448 children across the UK.FundingUK Research and Innovation (Medical Research Council), Research and Innovation Industrial Strategy Challenge Fund, Health Data Research UK, and Scottish Government.

Healthcare Resource Utilization and Costs of Medicare Fee for Service Beneficiaries Newly Diagnosed with Moderate to Severe Non-Advanced Systemic Mastocytosis

Healthcare Resource Utilization and Costs of Medicare Fee for Service Beneficiaries Newly Diagnosed with Moderate to Severe Non-Advanced Systemic Mastocytosis

A multidisciplinary team clinic for vocal cord dysfunction reduces corticosteroid burst therapy

Multidisciplinary team (MDT) care is a model that enables individualized management of complex conditions.1 Using this approach in vocal cord dysfunction (VCD) assists diagnosis and treatment, leading to reduced general practice (GP) visits and emergency hospital attendance.2 However, benefits on another key outcome, oral corticosteroid (OCS) prescriptions, have not been reported. We now detail findings in a new cohort demonstrating for the first time that OCS burden in patients with VCD is also significantly reduced by using this MDT approach to guide management.

Long-term predictors of loss of asthma control in school-aged well-controlled children with mild to moderate asthma: A 5-year follow-up.

Long-term follow-up studies establishing risk factors for loss of asthma control in well-controlled children with mild to moderate disease are lacking and are of importance for improving patient quality of life and utilization of health-care resources. Loss of asthma control was assessed in 146 school-aged children with well-controlled mild to moderate asthma from a Danish pediatric asthma outpatient clinic based on hospital admissions, emergency department (ED), or outpatient management of exacerbations, oral corticosteroid (OCS) use, or step-up of regular asthma treatment according to Global Initiative for Asthma (GINA) guidelines through a 5-year follow-up period. Risk factors included sex, ethnicity, age, body mass index (BMI), atopic comorbidity and predisposition, lung function, fractional exhaled nitric oxide (FeNO) level, exercise challenge test results, regular physical activity, GINA treatment step at baseline, and adherence to controller therapy. A total of 27 (18%) children experienced 56 acute events defined by hospital admission, ED, or outpatient management. Risk of experiencing any acute event was increased with female sex (adjusted odds ratio, aOR = 2.4 (1.0-5.9), p = 0.047) and higher baseline GINA treatment step (aOR = 1.6 (1.1-2.5), p = 0.03). Furthermore, female sex (aOR = 6.1 (1.4-42.2), p = 0.01) and higher FeNO (aOR = 1.8 (1.0-3.2), p = 0.04) were associated with OCS prescriptions, whereas no risk factors were identified for GINA treatment step-up during the 5-year follow-up. Female sex, higher FeNO, and higher baseline GINA treatment step increase the risk of long-term loss of control including acute events and OCS use in well-controlled children with mild to moderate asthma. These findings are important for primary physicians and clinicians in asthma outpatient clinics to identify seemingly well-controlled children at risk to plan more frequent follow-ups.

OVERLAP OF ASTHMA WITH ABPA AND EGPA BY DISEASE SEVERITY, EOSINOPHIL LEVELS, HEALTH CARE RESOURCE UTILIZATION, AND COSTS

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: Eosinophilic immune dysfunction (EID) is the dysregulation of mechanisms of eosinophil recruitment and activation, which may be a key mediator of many eosinophilic-driven diseases (EDDs). The overlap of asthma and other respiratory EDDs is not well understood.We aimed to quantify the overlap of asthma and allergic bronchopulmonary aspergillosis (ABPA) and eosinophilic granulomatosis with polyangiitis (EGPA) according to asthma severity. We also examined eosinophil levels, health care resource utilization (HCRU), and total costs in patients with and without disease overlap. METHODS: REal-world inVestigation of Eosinophilic-Associated disease overLap (REVEAL) is a retrospective study using Optum Clinformatics claims data. Diagnoses and disease severity were determined from International Classification of Diseases (ICD) codes. REVEAL included data from patients with ≥2 years of continuous health plan enrollment and at least one diagnostic code for selected respiratory and eosinophilic diseases of interest. This analysis included 406,573 patients with asthma, 702 with EGPA, and 881 with ABPA during the period from January 1, 2015 to June 30, 2019. Descriptive statistics were used to analyze disease overlap. RESULTS: Of 406,573 patients with asthma, 588 (0.14%) had comorbid ABPA and 310 (0.08%) had comorbid EGPA. Disease overlap rates were greater for severe asthma than for mild to moderate asthma. (Severe asthma was defined as patients with a prescription for oral corticosteroids, an emergency room [ER] visit or inpatient hospitalization with a primary diagnosis code for asthma, or use of biologic therapy for asthma.) Of patients with mild to moderate asthma, 430 (0.13%) had ABPA and 192 (0.06%) had EGPA; of patients with severe asthma, 158 (0.23%) had ABPA and 118 (0.17%) had EGPA. High eosinophil levels (≥500 cells/µL) were more frequent in patients with asthma and ABPA (24.7%) or EGPA (24.8%) than in those with asthma alone (8.4%). All-cause HCRU per patient per month (including hospitalizations, inpatient length of stay [LOS], ER visits, and outpatient visits) and total all-cause costs (2020 US$) were higher in patients with asthma and ABPA or asthma and EGPA than in those with asthma alone (hospitalizations [mean]: 0.5 and 0.6 vs. 0.2; LOS [days]: 0.9 and 1.2 vs. 0.5; ER visits: 0.2 and 0.2 vs. 0.1; outpatient visits: 2.6 and 2.9 vs. 1.2; and costs: $8499.10 and $10,047.90 vs. $2628.80, respectively). CONCLUSIONS: We observed that asthma patients with comorbid ABPA or EGPA had more severe disease, greater levels of eosinophilia, and increased HCRU and costs, suggesting a central role of EID in disease severity. CLINICAL IMPLICATIONS: These findings have implications for quantifying unmet need, informing diagnostic and treatment approaches, and raising awareness about the role of EID in driving the development of multiple related conditions. DISCLOSURES: Employee relationship with AstraZeneca Please note: Aug 2020 to present Added 04/27/2021 by Anamaria Brailean, source=Web Response, value=Salary Employee relationship with AstraZeneca Please note: Aug 2020 to present Added 04/27/2021 by Anamaria Brailean, source=Web Response, value=Ownership interest Employee relationship with astrazeneca Please note: current Added 04/30/2021 by Rohit Katial, source=Web Response, value=Salary Employee relationship with AstraZeneca Please note: 2019 Added 05/10/2021 by Danuta Kielar, source=Web Response, value=Salary Employee relationship with Evidera Please note: Oct 2020 Onward Added 04/27/2021 by Yong Jin Kim, source=Web Response, value=Salary Consultant relationship with AstraZeneca Please note: October 2020 Onward Added 04/27/2021 by Yong Jin Kim, source=Web Response, value=Consulting fee Employee relationship with AstraZeneca Please note: 2014-current Added 04/27/2021 by Justin Kwiatek, source=Web Response, value=Salary No relevant relationships by Sharon MacLachlan, source=Web Response Employee relationship with AstraZeneca Please note: full time employee Added 04/28/2021 by Heide Stirnadel-Farrant, source=Web Response, value=Salary No relevant relationships by Michael Stokes, source=Web Response Employee relationship with AstraZeneca Please note: 2008 - now Added 04/27/2021 by Xiao Xu, source=Web Response, value=Salary

Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand.

Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over‐reliance on OCS for asthma and that doses >1000 mg prednisolone‐equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS‐related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add‐on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk–benefits of OCS medications, side effects, effective add‐on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.

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

Background: 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. Objectives: 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. Methods: All adults (n = 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. Results: 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. Conclusion: 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.

Factors Associated with Asthma Exacerbations During Pregnancy

Asthma exacerbations during pregnancy are associated with adverse pregnancy outcomes. The aim of this study was to establish factors associated with asthma exacerbations during pregnancy. We obtained data from three cohorts of pregnant women with asthma recruited in eastern Australia (2004-2019; n= 1461). Severe exacerbations were defined as episodes of asthma requiring hospitalization, an emergency department visit, or prescription of oral corticosteroids after enrollment. Baseline information on potential risk factors included demographic characteristics, asthma characteristics (eg, lung function, asthma triggers, asthma control, medication use), pregnancy factors (eg, fetal sex, parity, antenatal care type), and other maternal factors (body mass index, smoking status, mental health). Backward stepwise logistic regression and Akaike information criterion were used to determine the best-fitting model. A total of 135 participants experienced a severe exacerbation during pregnancy (9.2%). Medium to high ICS dose was most strongly associated with severe asthma exacerbations (adjusted odds ratio= 3.20; 95% confidence interval, 1.85-5.53). Worse asthma control, possession of a written action plan, and a history of asthma exacerbations in the year preceding pregnancy were associated with an increased rate of exacerbations. Asthma exacerbations before pregnancy and more severe asthma at the beginning of pregnancy were associated with an increased rate of exacerbations during pregnancy. Despite Global Initiative for Asthma step 3 and 4 treatment and optimal management including a written asthma action plan, there is still a significant asthma burden in a group of women at high risk for severe exacerbations in pregnancy.

Impact of COVID-19 lockdown on emergency asthma admissions and deaths: national interrupted time series analyses for Scotland and Wales

BackgroundThe COVID-19 pandemic’s impact on people with asthma is poorly understood. We hypothesised that lockdown restrictions were associated with reductions in severe asthma exacerbations requiring emergency asthma admissions and/or leading...

Sex differences in excessive oral corticosteroid exposure in poor adherent adult asthmatics overusing short-acting β-2 agonists.

We know that excessive short-acting β2-agonists (SABA) use in asthma may be associated to high exacerbation risks. We studied whether such excessive SABA consumption is connected with different higher oral corticosteroid (OC) prescriptions in the two sexes. In our prescribing database, we searched subjects aged 18-40 years that were prescribed at least one SABA package/year and/or at least two ICS or two ICS/LABA boxes/year to identify asthmatics. Their OC prescriptions/year were also examined. Subjects were divided into 4 groups according to SABA packages/year prescribed (0, 1-2,3-6 and ≥7), considering sexes separately. Individuals recruited were 9,102. Subjects with at least one OC prescription were higher in each group and were females (p<0.001). The OC packages/year number was also more elevated in women especially those with >7 SABA prescriptions/year (0.96 in males vs 2.64 in females, p<0.001). 94.7%/93.6% males/females, who never used SABA, took at least one ICS/LABA (mean 5.84/5.48 packages/year), while the subject percentage adhering to ICS/LABA dropped to 28-47% (mean 0.94-3.82 packages/year) in those who used SABA (p<0.001). Higher SABA prescriptions were associated with an increasing OC dispensation (β=0.057,p<0.0001). We observed also a greater risk of using >3 OC packages/year in subjects with 3-6 (OR:2.98[95%CI:2.19-4.06],p<0.001) and ≥7 (OR:3.49[95%CI:2.39-5.10],p<0.001) SABA prescriptions compared to those that never used SABA. Besides, we found that using ICS (OR:0.51[95%CI:0.35-0.75], p<0.001) or ICS/LABA (OR:0.07[95%CI:0.05-0.09],p<0.001) may significantly reduce SABA prescriptions. Poor adherence to maintenance treatment appears to associated with excessive SABA prescriptions that may lead to a higher OC consumption particularly noticeable in women.

The Asthma Toolkit Bootcamp to Improve Rural Primary Care for Pediatric Asthma

Children with asthma living in rural areas receive most of their care from primary care providers who have variable knowledge of evidence-based guideline management. To test the capacity of the Asthma Toolkit Bootcamp program to improve primary care provider guidelines adherence and reduce health care utilization in rural children with asthma. The Asthma Toolkit Bootcamp program provided intensive training in National Heart, Lung, and Blood Institute guidelines-based asthma care, evaluated within a RE-AIM implementation science framework. All primary care practices serving pediatric patients in rural La Plata County, Colorado, received (1) online instruction, (2) full-day training, and (3) follow-up, in-practice training 1 month later. Training focused on spirometry use, severity and control assessment, medication management, asthma action plan utilization, and adoption of a standardized visit protocol. RE-AIM evaluation determined successful enrollment of practices in La Plata County (Reach) and provider uptake of evidence-based practices including spirometry (Adoption). Pediatric asthma patients receiving spirometry increased from 22% pretraining to 86% posttraining; severity assessment from 47% to 88%; and action plans from 40% to 86%. Significant improvements in health care utilization were observed among trained practices including a 10% decrease in emergency department visits, 35% decrease in hospital admissions, and 29% decrease in oral corticosteroid prescriptions (Effectiveness). Comparison practices showed no significant reductions in health care utilization. Participating providers reported that having the training in their own community, intense practice, a team-based approach, and cost-free materials including the spirometer and patient education materials were particularly helpful. The Asthma Toolkit Bootcamp improved pediatric asthma care given by rural providers and reduced health care utilization among their patients.

Geographic variations in rheumatoid arthritis treatment in Japan: A nationwide retrospective study using the national database of health insurance claims and specific health checkups of Japan.

To characterize the treatments for rheumatoid arthritis (RA) among institution types and prefectures in Japan. Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan in the 2017 fiscal year, we investigated disease-modifying antirheumatic drug (DMARD) and oral corticosteroid prescription trends across 825 thousand RA patients. These data were compared between specialized and non-specialized institutions and by prefecture. RA specialized institutions (SIs) were defined as either institutions registered in the rheumatology training program at the Japan College of Rheumatology or institutions where board-certified rheumatologists were employed. The overall percentage of patients who never visited an SI was 31.8% and increased with age (16-29 years old = 15.6%; ≥80 years = 42.8%). In twelve prefectures (25.5%), the proportions of patients who never visited an SI were at least 10% higher than the overall average. The proportions of patients who only visited SIs and were prescribed methotrexate and biological DMARDs were ranged from 51.9-72.9% and 19.5-33.2%, respectively. However, those of patients who had never visited an SI and were prescribed those medications were 44.0-71.6% and 7.2-28.0%, respectively. This is the first study evaluating the trends in RA treatments by prefecture and institution specialty by using the NDB Japan. Opportunities of patients with RA for visiting SI was unevenly distributed in Japan, affecting some aspects of treatment provided.