Short-acting Beta-agonist Inhalers Research Articles

Pharmacists' perspectives on school stock inhaler access for children.

Several states in the United States (U.S.) have laws permitting stock inhalers, including short-acting beta-agonist inhalers, such asalbuterol, and spacers to be prescribed to, dispensed to, and stocked in schools for use in students in respiratory distress, based on a protocol. This survey study assessed Arizona pharmacists' (1) levels of comfort for dispensing a short-acting beta-agonist inhaler to an individual child versus a stock inhaler to a school, and (2) awareness of the related Arizona state law. Researchers surveyed pharmacists licensed in Arizona who self-reported practicing in an outpatient pharmacy setting. Among 251 pharmacist participants, 62% practiced in a chain community pharmacy. About 80.8% felt comfortable filling a prescription for an albuterol inhaler in a pediatric patient case, whereas only 26.7% felt comfortable filling a prescription for albuterol inhalers to be used as stock inhalers for a given school. Among those who would not fill the stock inhaler prescription, only 5.5% reported awareness of the state law compared to 42.6% of those who would fill it (p < 0.0001). This survey identified a lack of pharmacist awareness of state laws pertaining to stock inhalers for schools.

Retrospective assessment of a collaborative digital asthma program for Medicaid-enrolled children in southwest Detroit: reductions in short-acting beta-agonist (SABA) medication use

BackgroundReal-world evidence for digitally-supported asthma programs among Medicaid-enrolled children remains limited. Using data from a collaborative quality improvement program, we evaluated the impact of a digital intervention on asthma inhaler use among children in southwest Detroit.MethodsChildren (6–13 years) enrolled with Kids Health Connection (KHC), a program involving home visits with an asthma educator, were invited to participate in a digital self-management asthma program (Propeller Health). Patients were provided with a sensor to capture short-acting beta-agonist (SABA) medication use, and given access to a paired mobile app to track usage. Patients’ healthcare providers and caregivers (“followers”) were invited to view data as well. Retrospective paired t-tests assessed change in mean SABA use and SABA-free days (SFD) over time, and regressions explored the relationship between followers and medication use.ResultsFifty-one patients were assessed. Mean program participation was nine months, and patients had on average 3 followers. From the first to last participation month, mean SABA use decreased from 0.68 to 0.25 puffs/day (p < 0.001), and mean SFD increased from 25.2 to 28.1 days/month (p < 0.001). 76% of patients had an increase in the number of SFD. There was a positive, but non-significant, relationship between the number of followers and reductions in SABA inhaler use.ConclusionsWe observed a significant reduction in SABA inhaler use and an increase in the number of SABA-free days among Medicaid-enrolled children enrolled in a multi-modal digital asthma program.

Characteristics of patients with asthma overprescribed short-acting beta-agonist (SABA) reliever inhalers stratified by blood eosinophil count in North East London: a cross-sectional observational study.

Overprescription of short-acting beta-agonist (SABA) inhalers and blood eosinophil count have strong associations with exacerbation risk in asthma. However, in the authors' recent publication only a minority of patients overprescribed SABA (≥6 inhalers in 12 months) were eosinophilic (≥0.3 x 109 cells/l). To compare the characteristics of eosinophilic and non-eosinophilic patients with asthma overprescribed SABA inhalers, and identify latent classes using clinical variables available in primary care. Cross-sectional analysis of patients with asthma in North East London, England, using primary care electronic health record data. Unadjusted and adjusted multi-variate regression models and latent class analysis. Eosinophilia was significantly less likely in female patients (P = 0.004), those with multiple mental health comorbidities (P<0.001), and those with SABA on repeat prescription (P<0.001). Latent class analysis identified the following three classes of patients overprescribed SABA: class 1, which represents classical uncontrolled asthma (oral steroids required for exacerbations, step 2-3 asthma medications, high probability of being eosinophilic); class 2, which represents mild asthma (low exacerbation frequency, low asthma medication step, low probability of being eosinophilic); and class 3, which represents difficult asthma (high exacerbation frequency despite high-strength preventer inhalers, low probability of being eosinophilic). The mild asthma class was the largest. Many patients being overprescribed SABA were non-eosinophilic with a low exacerbation frequency, suggesting disproportionately high SABA prescription compared with other asthma control markers. Potential reasons for high SABA prescription in these patients included repeat prescription (being dispensed but not taken) and use of SABA for non-asthma breathlessness (for example, breathing pattern disorders with anxiety). Further research is needed into management of SABA overuse in patients without other markers of uncontrolled asthma.

An audit to review high risk asthma patients with over-use of short-acting beta-agonist inhalers

Abstract Introduction The UK National Review of Asthma deaths (NRAD)1 has shown that the over-prescribing of Short Acting Beta Agonist’s (SABA) inhalers is a risk factor for exacerbation and death in asthmatic patients. A quality improvement audit was identified as a priority to review practice performance in line with national guidelines.2,3 Aim The aim was to identify patients on the asthma register who were prescribed 12 or more SABA inhalers within the preceding 12 months and investigate any reasons for overuse. Additionally, patients were highlighted for review to optimise management in line with national recommendations2,3. Methods A search run in a GP practice highlighted high-risk patients on the asthma register prescribed 12 or more SABAs in the preceding 12 months. Audit criteria were defined to assess if 100% of patients had a completed annual asthma review. Patients who were not asthmatics or undergoing investigations for a potential diagnosis of chronic obstructive pulmonary disease (COPD) were excluded. Phase 1 of the audit was notes-based data-collection on recent asthma reviews and reasons for potential overuse. In Phase 2, patients were contacted prioritising those overdue a review. During contact, the Asthma Control Test, checking inhaler technique, discussing any reasons for SABA over-use and patient education on their inhalers were all discussed. Patients requiring treatment optimisation or a follow-up review were highlighted for referral to various members of the multidisciplinary team. This audit did not require ethical approval. Results 42 out of 988 patients with asthma were identified as being issued more than 12 SABA’s in the preceding 12 months. 1 patient was excluded due to having a diagnosis of COPD. Out of the remaining 41 patients, 16 patients had already had an up to date annual asthma review prior to the search. 13 patients were contacted and referred to the pharmacist or asthma nurse for a review. As a result of the audit, a total of 29 patients had an asthma review conducted. 12 patients were unable to be contacted and follow-up remains outstanding. A number of themes were highlighted during the audit such as patients using the incorrect dose or inhaler, lack of understanding on how the inhaler worked, requests for spare inhalers, absence/lack of using an inhaled corticosteroid (ICS) and worsening asthma. Discussion/Conclusion The audit successfully identified reasons for SABA overuse and using the multidisciplinary team to educate patients and optimise medication where needed. Following this audit, the practice has reviewed cohorts of patients that are at high risk of exacerbations and implemented quarterly safety searches to highlight these for review on a regular basis. Two further audits were also identified to improve practice in line with updated national guidance; patients prescribed a SABA alone without an ICS and patients prescribed a Long-acting beta-agonist (LABA) alone without an ICS.

Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London.

BackgroundExcess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission.AimTo quantify the prevalence and identify the predictors of SABA overprescribing.Design and settingA cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous East London boroughs.MethodPrimary care medical record data for patients aged 5–80 years, with ‘active’ asthma were extracted in February 2020. Explanatory variables included demography, asthma management, comorbidities, and prescriptions for asthma medications.ResultsIn the study population of 30 694 people with asthma, >25% (1995/7980), were prescribed ≥6 SABA inhalers in the previous year. A 10-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABAs and inhaled corticosteroids (ICSs) to standard units the accuracy of comparisons was improved across different preparations. In total, >25% of those taking ≥6 SABAs/year were underusing ICSs, this rose to >80% (18 170/22 713), for those prescribed <6 SABAs/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (odds ratio 6.52, 95% confidence interval = 4.64 to 9.41). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing.ConclusionIn this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA ≥12 group to reduce to 4–12 a year could potentially save up to 70% of asthma admissions a year within that group.

Asthma Control and Medication Reliance Among Asthmatics in a General Practice Setting - A Questionnaire Based Study.

The main goal of asthma treatment is to obtain and maintain reasonable control of symptoms with current evidence-based protocols. Asthma is one of the chronic diseases, that, if not well controlled, can lead to the development of serious complications involving not only the respiratory, but the cardiovascular system. In this study, we aimed to determine how well intermittent asthma and mild persistent asthma are controlled among patients aged 15 years and above in a general practice setting using Asthma Control Test (ACT) questionnaire. Furthermore, we used a SABA Reliance Questionnaire (SRQ) to understand whether these patients rely heavily on their prescribed short-acting beta agonist (SABA) medication. This is an audit questionnaire-based study conducted in our primary health care setting in New Zealand from February to May 2021. Forty-three physician-diagnosed intermittent asthma and mild persistent asthma patients aged 15 years and above volunteered to take part in this study. They completed two questionnaires - the ACT to assess asthma control and the SRQ to assess patients’ reliance on SABA reliever inhalers. Overall, 43 patients responded; asthma was well-controlled in 23 patients (53.5%), partially controlled in 15 (34.9%), and uncontrolled in five (11.6%). The total of patients who showed a high reliance on SABA was 31 (72.1%). When comparing SABA reliance with asthma control, 23 (53.5%) patients reported well-controlled asthma; however, 13 (56.5%) of these patients showed a high reliance on SABA. Furthermore, 15 (34.9%) of the patients had partially controlled asthma, and 14 (93.3%) of them also relied highly on their SABA inhalers. We concluded that intermittent asthma and mild persistent asthma remains inadequately controlled in general practice, with the majority of patients showing a high reliance on SABA.

Concurrent Improvement Observed in Patient-Reported Burden and Sensor-Collected Medication Use Among Patients Enrolled in a COPD Digital Health Program.

Background: The COPD assessment test (CAT) is an 8-item questionnaire widely used in clinical practice to assess patient burden of disease. Digital health platforms that leverage electronic medication monitors (EMMs) are used to track the time and date of maintenance and short-acting beta-agonist (SABA) inhaler medication use and record patient-reported outcomes. The study examined changes in CAT and SABA inhaler use in COPD to determine whether passively collected SABA and CAT scores changed in a parallel manner.Methods: Patients with self-reported COPD enrolled in a digital health program, which provided EMMs to track SABA and maintenance inhaler use, and a companion smartphone application (“app”) to provide medication feedback and reminders. Patients completing the CAT questionnaire in the app at enrollment and at 6 months were included in the analysis. Changes in CAT burden category [by the minimally important difference (MID)] and changes in EMM-recorded mean SABA inhaler use per day were quantified at baseline and 6 months.Results: The analysis included 611 patients. At 6 months, mean CAT improved by −0.9 (95% CI: −1.4, −0.4; p < 0.001) points, and mean SABA use decreased by −0.6 (−0.8, −0.4; p < 0.001) puffs/day. Among patients with higher burden (CAT ≥ 21) at enrollment, CAT improved by −2.0 (−2.6, −1.4; p < 0.001) points, and SABA use decreased by −0.8 (−1.1, −0.6; p < 0.001) puffs/day.Conclusion: Significant and parallel improvement in CAT scores and SABA use at 6 months were noted among patients enrolled in a digital health program, with greater improvement for patients with higher disease burden.

Asthma and COVID-19: In Defense of Evidence-Based SABA.

There have recently been major objections to the use of short-acting beta-agonist (SABA) in episodic acute asthma culminating in a call for replacing SABA with combination of inhaled corticosteroids and long-acting beta-agonists despite little evidence supporting this point of view. It is regrettable to note that this attack on SABA occurs in the midst of an unprecedented demand for, and shortage of, SABA inhalers during the current COVID-19 pandemic, and the worldwide efforts to increase SABA supplies. In this commentary, we defend the well-established role of SABA and argue that the call for the phase out of SABA is inappropriate, since it is not solidly evidence based.

ASTHMA CONTROL EVALUATED WITH ELECTRONIC MEDICATION MONITOR (EMM)-DEFINED OCCASIONS OF SHORT-ACTING BETA-AGONIST INHALER USE

Introduction The Global Initiative for Asthma (GINA) and National Heart Lung and Blood Institute Expert Panel-3 (EPR-3) guidelines quantify short-acting beta-agonist (SABA) use in their assessment of asthma control. Both define control by the number of SABA uses/week, but neither defines the duration for each “occasion” of use. Utilizing EMMs, we compared estimates of asthma control using GINA and EPR-3 criteria based on 3 potential occasion definitions of SABA. Methods Data were collected from 5,067 adults from 2015-2017 with self-reported asthma and an EMM-equipped SABA inhaler to passively collect time and date of SABA actuations. For GINA, partly controlled (PC) asthma was use >2 times/week. For EPR-3, not well-controlled (NWC) was use >2 days/week, and very poorly controlled (VPC) was use several (≥3) times a day. Using EMMs, 3 occasions of SABA use were studied as ≥1 puff of SABA within 2-, 4- or 6- hour durations. This study was exempted from IRB approval. Results Both GINA and EPR-3 criteria identified 34-37% of patients as PC or NWC irrespective of occasion definition. Among those NWC based on EPR-3 criteria, the prevalence of VPC was 50%, 44% and 32% with 2-, 4- or 6-hour occasions, respectively. Conclusions The prevalence of very poorly controlled asthma varied by the duration of an occasion. Standardized definitions of an occasion and collection of SABA data with EMMs should be harmonized to more accurately assess asthma control and identify patients who may need modifications in controller therapy to achieve optimal control.

Dose counting and use of short-acting beta-agonist inhalers in emergency department patients with asthma exacerbation

Dose counting and use of short-acting beta-agonist inhalers in emergency department patients with asthma exacerbation

Comparing Ran-Out Status of Inhaled Short-Acting Beta-Agonists in Emergency Department Patients with Acute Asthma: 1996-1998 versus 2015-2017

Medication nonadherence, including running out of inhaled asthma medications, is an important problem. The objective of this study was to examine the changes in the proportion of adults with acute asthma who ran out of their short-acting beta-agonist (SABA) inhalers before presenting to the emergency department (ED) between 1996--1998 and 2015-2017. We analyzed data from prospective multicenter observational cohort studies of ED adult patients (aged 18-54 years) with acute asthma. Within the same 3 EDs, we performed a structured interview during 2 time periods: 1996-1998 and 2015-2017. We fitted multivariable models to compare ran-out status between the 2 periods, adjusting for the baseline patient demographics, socioeconomic status, chronic asthma factors, and health care utilization factors. We further adjusted for the presence of a written action plan-an intervenable factor. The analytic cohort comprised 353 patients (150 from the 1996-1998 studies and 203 from the 2015-2017 study). Over the approximately 20-year period, the proportion of patients who ran out of SABA inhalers increased (18% in 1996-1998 vs 26% in 2015-2017). In the multivariable model, compared with patients in 1996-1998, those in 2015-2017 had a significantly higher risk of running out of their SABA inhalers (adjusted odds ratio [OR] 2.01; 95% confidence interval [CI] 1.06-3.81; P= .03). With further adjustment for the presence of a written action plan, this difference attenuated (adjusted OR 1.66; 95% CI 0.75-3.68; P= .21). Between 1996 and 2017, the proportion of ED patients with asthma who ran out of SABA inhalers significantly increased. The increase was explained, at least partially, by a lack of a written action plan.

P235 Budgetary impact model on a medicare plan adopting short-acting beta-agonist inhalers with integrated dose counters

P235 Budgetary impact model on a medicare plan adopting short-acting beta-agonist inhalers with integrated dose counters

P236 Comorbidities associated with poor short-acting beta-agonist inhaler handling among united states respiratory patients

P236 Comorbidities associated with poor short-acting beta-agonist inhaler handling among united states respiratory patients

Determination of asthma control using administrative data regarding short-acting beta-agonist inhaler purchase

ABSTRACTBackground: Symptom control is a primary goal in asthma. We hypothesized that administrative data regarding rescue inhaler purchases may correlate with asthma symptom control. Methods: We identified all patients who purchased short-acting beta-agonist (SABA) inhalers during the course of one year in the database of a Health Maintenance Organization (HMO). Primary physicians identified asthma patients and classified their asthma symptom control into three groups according to the Global Initiative for Asthma (GINA) guidelines. Asthma patients were asked to answer symptom questionnaires and grade their asthma control. SABA inhaler purchases were compared between asthma control groups as classified by the guidelines, the physicians and the patients. We also compared the agreement on asthma control between the three methods of classification. Results: Of 241 asthma patients, 83 completed the questionnaires. Using the GINA guidelines criteria, 26 were symptom controlled, 46 were partially controlled and 11 were uncontrolled. SABA inhaler purchases were not significantly lower in the controlled group. Using patients' overall impression of their asthma control, the mean numbers of SABA inhalers purchased were 1.5, 4.4 and 6.4 per year in the controlled, partially controlled and uncontrolled groups, respectively (p = 0.03). Patients' classification of asthma control had better agreement (kappa = 0.34) with GINA guidelines than physician's' agreement (kappa = 0.05). Conclusion: When using administrative data for asthma patients, 2 or more SABA inhaler purchases in one year should alert the physician for the need for asthma control evaluation. Purchase of at least 4 SABA inhalers a year may be regarded as a marker for asthma that is not controlled.

Concomitant Asthma Medication Use by Patients Receiving Omalizumab 2003–2008

Objective. To examine patterns of omalizumab use in the first 5 years of its availability. Methods. Our study comprised a series of descriptive retrospective cohort analyses using healthcare claims data. The study population comprised patients of any age who had omalizumab claims in the 5 years after 1 July 2003, and we created five 1-year cohorts from this population. Each cohort included patients continuously enrolled for at least 12 months with ≥2 omalizumab claims during the year. Cohorts contained between 302 and 1382 unique omalizumab users, and over 99% of patients with an omalizumab claim had at least one asthma diagnosis. Results. In all years, the specialty most commonly seen in conjunction with the initial omalizumab prescription was allergy/immunology. In all years, omalizumab was used in conjunction with three or more additional classes of asthma medications at least 70% of the time and with five or more classes at least 33% of the time; the proportion of patients filling omalizumab prescriptions who had no other concomitant classes of asthma medications varied from 4% to 8%. The most common pattern of asthma medication treatment in all years was omalizumab with combination steroids/long-acting beta-agonist inhaler, a leukotriene receptor antagonist, a short-acting beta-agonist inhaler, and at least one course of oral corticosteroids. Conclusions. In this study of a large sample of commercial health insurance claims covering the first 5 years after approval of omalizumab, we found that omalizumab was infrequently used as a single agent or without concomitant inhaled corticosteroids, and most omalizumab prescriptions came from specialist physicians.

Severe dyspnoea during late pregnancy in a woman with history of asthma

Sirs: Dyspnoea is a common complaint of about 75% of healthy women during late pregnancy [1] which in many cases is not clinically relevant. However, asthma is the most common medical condition to complicate pregnancy, with episodes of severe exacerbation reported in about 10% of the women with history of asthma [2]. Moreover, 0.5–2% of all pregnancies in Western countries are also complicated by cardiovascular disease and clinical differentiation might be challenging. Cardiomyopathies are rare diseases but are thought to be the main cardiac cause for maternal mortality during pregnancy [3]. A 31-year-old woman who was regularly attending our pneumology outpatient clinic for asthma underwent routine cardiac evaluation in summer 2010 with normal findings on echocardiography examination and a NT-pro-BNP concentration of 76 pg/ml. In February 2011, the now pregnant woman (34th week of pregnancy) was introduced for pneumological consultancy with suspected exacerbation of the known asthma. The asthma was well controlled during the pregnancy so far with rare application of the quickrelief inhaler. For the preceding 10 days the patient reported progressive dyspnoea and coughing during day and night times corresponding to NYHA functional class III–IV with severe trouble sleeping and no effect of the short-acting beta agonist inhaler. Additional application of a steroid inhaler for 3 days did not improve symptoms substantially. On physical examination there was no evidence of wheezing, but bilaterally decreased breathing sound throughout basilar lung fields consistent with high diaphragm due to advanced pregnancy. Spirometry showed reduced vital capacity (2.1 l, 54% of predicted) and normal FEV1/VC ratio of 80%. Laboratory tests showed a minor proteinuria (0.8 g/24 h), normal liver enzymes and platelet count, no signs of haemolysis, Troponin T \ 0.1 lg/l and a NT-pro-BNP concentration of 1,519 pg/ml. An exacerbation of a hypereosinophilic syndrome by pregnancy was unlikely given a peripheral-blood eosinophilia rate of 0.2%. On echocardiography, the left ventricle was dilated (end-diastolic diameter 61 mm) and left-ventricular systolic function was reduced (ejection fraction 40%) with a moderate mitral-valve regurgitation, increased systolic pulmonary-arterial pressure (55–60 mmHg) and large bilateral pleural effusion (Fig. 1). The pleural effusion was drained subsequently and heart failure treatment was started with furosemide (2 9 40 mg/ day) and metoprolol (1 9 23.75 mg/day). Due to refractory heart failure symptoms and increasing evidence of placenta insufficiency after 3 days of heart failure treatment, a Caesarean section was decided which was well tolerated by the patient and the baby. Six days post section echocardiography showed further decrease of the leftventricular function (EF 25%). Relapsing pleural effusion was drained again and heart failure medication was carefully up-titrated to bisoprolol (1 9 5 mg/day), ramipril (1 9 5 mg/day), torasemide (1 9 20 mg/day) which was paralleled by symptomatic improvement (NYHA II-III). In addition, bromocriptine (2 9 2.5 mg/day) was given to stop lactation. An echocardiography examination 2 months after delivery showed an improvement of left-ventricular function (EF 39%) with only mild mitral-valve regurgitation and no evidence for pulmonary hypertension. Peripartum cardiomyopathy is an idiopathic form of dilated cardiomyopathy characterized by depressed R. Pfister (&) K. F. Frank S. Rosenkranz G. Michels Medizinische Klinik III fur Innere Medizin, Herzzentrum der Universitat zu Koln, Kerpener Str. 62, 50924 Cologne, Germany e-mail: roman.pfister@uk-koeln.de