Changes in prescribing of inhaled corticosteroids (1999-2002) in Scotland

Cost and appropriateness of treating asthma with fixed-combination drugs in local health care units in Italy

Background

Bronchial asthma is a chronic airways disease and is considered to be one of the major health problems in the Western world. During the last decade, a significant increase in the use of β2-agonists in combination with inhaled corticosteroids has been observed. The aim of this study was to assess the appropriateness of expenditure on these agents in an asthmatic population treated in a real practice setting.

Methods

This study used data for a resident population of 635,906 citizens in the integrated patient database (Banca Dati Assistito) of a local health care unit (Milano 2 Azienda Sanitaria Locale) in the Lombardy region over 3 years (2007–2009). The sample included 3787–4808 patients selected from all citizens aged ≥ 18 years entitled to social security benefits, having a prescription for a corticosteroid + β2-agonist combination, and an ATC code corresponding to R03AK, divided into three groups, ie, pressurized (spray) drugs, inhaled powders, and extrafine formulations. Patients with chronic obstructive lung disease were excluded. Indicators of appropriateness were 1–3 packs per year (underdosed, inappropriate), 4–12 packs per year (presumably appropriate), and ≥13 packs per year (overtreatment, inappropriate).

Results

The corticosteroid + β2-agonist combination per treated asthmatic patient increased from 37% in 2007 to 45% in 2009 for the total of prescribed antiasthma drugs, and 28%–32% of patients used the drugs in an appropriate manner (4–12 packs per years). The cost of inappropriately used packs increased combination drug expenditure by about 40%, leading to inefficient use of health care resources. This trend improved during the 3-year observation period. The mean annual cost per patient was higher for powders (€223.95) and sprays (€224.83) than for extrafine formulation (€142.71).

Conclusion

Based on this analysis, we suggest implementation of better health care planning and more appropriate prescription practices aimed at optimizing use of health care resources for the treatment of bronchial asthma. The results of our study should be extended to other regional/national reference local health care units, in order to define and compare average standard costs per pathology, and consolidated through the wide sample considered.

Measuring exacerbations in obstructive lung disease

PURPOSE

Using hospitalization always has been seen as a solid measurement for exacerbation in pharmacoepidemiology, but might lead to an underestimation of disease exacerbation because of a trend towards outpatient care. The aim of this study was to quantify the incidence of different exacerbation markers in obstructive lung disease and to identify predictors for these exacerbation markers.

METHODS

We conducted a cohort study using the PHARMO record linkage system, including demographic details and complete medication histories of more than two million community-dwelling residents in the Netherlands from 1985 onwards. Eligible patients were adult users of inhaled corticosteroids (ICS). Outcome parameters were hospitalization and short courses of systemic corticosteroids. Patients were allowed to have multiple exacerbations during follow-up.

RESULTS

We identified 5327 patients. During follow-up, 8635 exacerbations occurred in 2332 patients with a trend in time towards treating exacerbations out of the hospital (p-value 0.003). Of all patients with exacerbations, 73% was not hospitalized during follow-up. Exacerbations were associated with high-dose ICS use (adjusted RR 1.4; 95% CI 1.2-1.7) and chronic systemic corticosteroid use (adjusted RR 1.9; 95%CI 1.6-2.2).

CONCLUSIONS

Using hospitalization only as exacerbation marker leads to underestimating the exacerbation rate, because of exacerbation treatment out of the hospital. Patients with obstructive lung disease using chronic systemic corticosteroids or high-dose ICS use are more prone to exacerbations. This implies that these patients should be monitored carefully to prevent recurrent exacerbations which are detrimental for their prognosis and quality of life.

Identification of exacerbations in obstructive lung disease through biomarkers

Inflammation has been identified as an important factor for disease exacerbation in obstructive lung disease. In this study, we used neutrophil and eosinophil counts as biomarkers for exacerbation in obstructive lung disease. We conducted a case-control study within a cohort of patients frequenting an outpatient clinic of Respiratory Medicine using data from the Utrecht Patient Oriented Database (UPOD). Cases were patients with a hospital admission for obstructive lung disease in 2005. For each case, one control patient was sampled from the same study base. We identified 143 cases (118 patients with chronic obstructive pulmonary disease and 25 asthma patients) and 143 controls. Admission was associated with both neutrophilia (adjusted odds ratio (OR) 4.3; 95% confidence interval (CI) 2.2-8.5), and eosinophilia (adjusted OR 2.6; 95% CI 1.1-6.2). The association with eosinophilia was only seen in asthma patients. In conclusion, neutrophil and eosinophil counts seem to be useful biomarkers for identifying exacerbations in pharmacoepidemiological studies on obstructive lung disease.

Medication changes prior to hospitalization for obstructive lung disease: a case-crossover study

BACKGROUND

Hospitalizations have always been seen as a solid outcome parameter in pharmacoepidemiology. However, the period leading to hospitalization and prehospital management of the patient are equally important.

OBJECTIVE

To evaluate medication changes in the period prior to hospitalization for obstructive lung disease and to quantify the association between medication use and the risk of hospitalization.

METHODS

We conducted a case-crossover study using the PHARMO record linkage system, which contains drug dispensing data from community pharmacies and hospital admission data. Patients included in the study were adults hospitalized for obstructive lung disease between 2005 and 2007. The index date of the case period was the date of hospitalization, and control moments were set at 3, 6, 9, and 12 months before admission. For each patient, all prescriptions prior to the date of hospitalization were identified. Medication use was ascertained in a 90-day time window prior to each case or control moment.

RESULTS

We identified 1481 patients who were hospitalized for obstructive lung disease. It appeared that respiratory medication use increased in the 90 days prior to hospitalization. Hospitalization was associated with the use of 3 or more respiratory drugs (OR 2.2; 95% CI 1.8 to 2.8), systemic glucocorticoids (OR 4.5; 95% CI 3.8 to 5.4), and antibiotics (OR 3.1; 95% CI 2.7 to 3.6).

CONCLUSIONS

The use of systemic glucocorticoids, antibiotics, and other respiratory drugs increased prior to hospitalization for obstructive lung disease. These results could be indicative of the development and/or treatment of an exacerbation. There is a need for markers to detect exacerbations in an early phase in order to start treatment as early as possible and possibly prevent hospitalizations for obstructive lung disease.

Trends in medication use for asthma in school-entry children in the Australian Capital Territory, 2000-2005

OBJECTIVE

To analyse trends in asthma medications used by school-entry children whose parents report they have asthma.

DESIGN AND SETTING

Annual cross-sectional study of all school-entry children (about 4400 each year) in the Australian Capital Territory in 2000-2005, by means of a questionnaire for parents on child health status and medication use; and a cross-sectional study of asthma prescriptions for children aged 5 years obtained from the Medicare Australia database for 2002-2005.

PARTICIPANTS

All school-entry children in the ACT with parent-reported asthma (numbers in the years 2000-2005 ranged between 435 and 589).

MAIN OUTCOME MEASURES

Changes in the use of different medications; changes in delivery devices for asthma; changes in the potency of inhaled fluticasone.

RESULTS

Response rates to kindergarten health screening were in the range 85%-89% for 2000-2005. Parent-reported asthma prevalence ranged from 11% to 15%. Each year, around 35% of children with asthma (age range, 4-6 years) used inhaled corticosteroids. An increase in the use of fluticasone (from 11% to 33% of children with asthma) was offset by decreases in beclomethasone use (from 14% to 3%) and budesonide (from 14% to 4%). Use of cromoglycate and nedocromil fell from 46% to 16%. Nebuliser use decreased (from 45% to 20%), while the use of spacer devices increased (from 70% to 83%). Use of combined salmeterol/fluticasone increased from 8% (in 2002) to 20% (in 2005) of children with parent-reported asthma. These trends were mirrored in Medicare Australia data for 5-year-old children in the ACT.

CONCLUSIONS

There was marked volatility in the types of asthma medication used over the 6 years. Reciprocal trends leading to increased use of spacers and decreased use of nebulisers are in accord with national guidelines for better asthma management. The increasing use of products containing a combination of salmeterol and fluticasone requires ongoing monitoring.

[Drug prescription for chronic obstructive pulmonary disease and asthma by primary care physicians in the Spanish autonomous community of Madrid, 1996-2002]

OBJECTIVE

To identify trends in the drug prescription used to treat chronic obstructive pulmonary disease (COPD) and asthma at the primary care level in Madrid between 1996 and 2002, and to assess the repercussion of new treatments.

PATIENTS AND METHODS

We analyzed information on primary care general practitioners' and pediatricians drug prescription from the R03 group (drugs for obstructive airway diseases) of the Anatomical Therapeutic Chemical Classification System. Drug consumption was measured by recording the number of packages charged to the Spanish National Health Service and dispensed in pharmacies in the Spanish autonomous community of Madrid between 1999 and 2002. Consumption was expressed as defined daily dose per 1000 inhabitants per day.

RESULTS

Drug use expressed as defined daily dose per 1000 inhabitants per day for COPD and asthma in Madrid increased by 18.48% between 1996 and 2002. The use of inhalants increased by 33.5% over the same period. The most marked differences were the increase in the number of patients treated with selective beta2 adrenergic agonists, anticholinergics, and combinations of fixed doses of long acting beta2 agonists with corticosteroids. The most-used drugs in 2002 were selective beta2 adrenergic agonist inhalants (37.7%), anticholinergics (22.5%), corticosteroids (19.5%), combinations of fixed doses of long acting beta2 adrenergic agonists with corticosteroids (10.5%) band xanthines (5.03%). In 2002, the prescription of 5 new treatments amounted to 15.76% of total use of COPD and asthma drugs (R03 group).

CONCLUSIONS

Drug use for obstructive diseases of the airways showed a sharp increase between 1996 and 2002. Changes in patterns of use were observed, new treatments being quickly adopted, modifying the profile of drug prescription for the management of COPD and asthma.

Corticosteroids and adrenoceptor agonists: the compliments for combination therapy in chronic airways diseases

The combination of inhaled corticosteroids and long-acting beta2-adrenoceptor agonists is increasingly used as maintenance therapy in patients with moderate to severe asthma or chronic obstructive pulmonary disease (COPD). The main effect of inhaled corticosteroids is thought to be mediated through suppression of airway inflammation, while long-acting beta2-adrenoceptor agonists are thought to work by inducing bronchodilation. However, there is emerging data to indicate that these two classes of drugs interact positively with each other, leading to added or perhaps synergistic benefits for patients. Corticosteroids enhance the expression of beta2-adrenoceptor, thus providing protection against desensitization and development of tolerance to beta2-adrenoceptor agonists, which may occur with prolonged use of these medications. Long-acting beta2-adrenoceptor agonists, on the other hand, may amplify the anti-inflammatory effects of corticosteroids by accelerating nuclear translocation of the glucocorticoid receptor complex, and enhancing transcription and expression of steroid-inducible genes in pro-inflammatory cells. In clinical trials, corticosteroids in combination with long-acting beta2-adrenoceptor agonists reduce exacerbation rates, and improve lung function and health status of patients with moderate to severe asthma or COPD beyond that achieved by individual component therapy. Their effects on mortality are unknown. There is a large clinical trial currently underway, which will provide mortality data by the year 2006. On balance, clinical evidence supports the use of combination therapy in moderate to severe asthma and COPD.