Usage Patterns of Short-Acting β2-Agonists and Inhaled Corticosteroids in Asthma: A Targeted Literature Review

Short-acting β2-agonists (SABA) overuse in asthma and patients' perceptions for this behavior

BACKGROUND

Short-acting β2-agonists (SABA) overuse is associated with poor asthma control. The Global Initiative for Asthma (GINA) 2019-updated guideline has therefore taken a paradigm shift in reliever therapy recommendations.

OBJECTIVES

(I) To investigate the status of SABA overuse and medication dispensing patters in asthma in the Netherlands (II) validate dispensing data for SABA overuse identification and (III) understand patients' perspectives towards this SABA-taking behavior to inform future improvement strategies.

METHODS

An annually repeated cross-sectional study was conducted from 2017-2021 using pharmacy dispensing data in a real-world setting, including asthma patients aged 18-45 with ≥ 1 inhaler. A following qualitative study was performed in identified SABA overusing patients with a questionnaire and semi-structured interviews, supported by theoretical frameworks.

RESULTS

Dispensing data was available from 87% of all community pharmacies (n=1,994) in 2017 and 95% (n=2,005) in 2021. SABA overuse prevalence was constant for the five study-years with 20.6% (±0.5%). Increased ICS-formoterol and decreased SABA dispenses were observed in starters of inhalation therapy in 2021. 53 asthma patients completed the questionnaire of whom 43 patients confirmed SABA overuse, generating a positive predictive value of 81%. Key behavioral drivers covered 7 themes regarding capability (knowledge; skills; memory, attention and decision process) motivation (emotion; beliefs about- capabilities; consequences) and opportunity (environmental context).

CONCLUSION

SABA overuse remains in one-fifth of asthma patients across the Netherlands, requiring careful attention from healthcare professionals. Dispensing data is a valid measure for SABA overuse in a clinical setting, facilitating patient selection. To meet patients' varied supporting needs, integration of tailored behavioral interventions is essential.

SABA prescriptions and asthma management practices in Singapore: results from a cross-sectional, observational SABINA III study

OBJECTIVES

To evaluate asthma characteristics and treatment patterns, including short-acting β2-agonist (SABA) prescriptions, in primary and specialist care in the Singapore cohort of the SABA use IN Asthma (SABINA III) study.

DESIGN

Cross-sectional, observational study.

SETTING

Multicentre study conducted at five sites across Singapore.

METHODS

In patients with asthma (aged ≥12 years), data on demographics, disease characteristics and asthma treatment prescriptions were collected using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by 2017 Global Initiative for Asthma recommendations) and practice type (primary/specialist care).

RESULTS

Of the 205 patients analysed (mean (SD) age, 53.6 (16.8) years; female, 62%), 55.9% were enrolled by specialists and 44.1% by primary care physicians. Most study patients (80.5%) had moderate-to-severe asthma (86.0% in specialist care and 74.4% in primary care). In the 12 months before study enrolment, 18.0% of patients experienced ≥1 severe exacerbation. Asthma was well or partly controlled in 78.0% of patients. Overall, 17.1% of all patients were overprescribed SABA (≥3 SABA canisters/year) in the preceding 12 months, and overprescription was greater in specialist versus primary care (26.3% vs 5.6%). Only 2.9% of patients were prescribed SABA monotherapy, while 41.0% received SABA in addition to maintenance therapy. Among the latter, 40.5% were overprescribed SABA. Overall, a higher percentage of patients prescribed ≥3 SABA canisters (vs 0-2 SABA canisters) were assessed as having uncontrolled asthma during the study visit (42.9% vs 17.6%). Maintenance therapy in the form of inhaled corticosteroids (ICS) or ICS/long-acting β2 agonist fixed-dose combinations were prescribed to 14.1% and 84.9% of patients, respectively, in the 12 months before enrolment.

CONCLUSIONS

In this Singapore cohort, ~17% of all patients and more than 40% of patients prescribed SABA in addition to maintenance therapy were overprescribed SABA. These findings emphasise the need to align clinical practices with the latest evidence-based treatment recommendations.

TRIAL REGISTRATION

NCT03857178.

The Wiser Strategy of Using Beta-Agonists in Asthma: Mechanisms and Rationales

Concerns regarding the safety of beta-2 agonists have led to revisions of the major asthma guidelines to better address these issues. Although these updates allow for a combination of previous and current strategies, they may confuse clinical practitioners. Beta-2 agonists are vital for alleviating asthma symptoms by relaxing smooth muscles; however, they also pose significant risks by inducing pro-inflammatory mediators both in vitro and in vivo. In addition to the risks of overuse and symptom masking, the use of beta-agonists alone at therapeutic doses can worsen airway inflammation and enhance virus-induced inflammation during asthma exacerbation. Inhaled corticosteroids (ICS) can effectively prevent these adverse effects. With new insights into the mechanisms of these adverse events, reserving short-acting beta-agonists for acute symptom relief during exacerbations and only for those who are already on ICS or oral steroids represents a careful approach to using beta-agonists with least adverse effects in patients with asthma. However, a major drawback of this approach is the potential non-compliance with ICS, leading to beta-agonist use without the necessary counteraction by ICS. An optimal strategy, both during and outside exacerbations, would integrate beta-agonists into an anti-inflammatory regimen that includes ICS, ideally combined with the same inhaler to ensure their concurrent use where finances allow. This would maintain the beneficial effects of beta-agonists, such as bronchodilation, while preventing the adverse effects from the induction of inflammatory mediators. This method is aligned with diverse clinical settings, maximizes the safe use of beta-agonists, and supports a comprehensive guideline-compliant management strategy.

Mild asthma: Conundrums, complexities and the need to customize care

Mild and moderate asthma cover a wide range of asthma presentations, phenotypes and symptom burden, and account for the majority of people with asthma worldwide. Mild asthma has been difficult to define because of its heterogeneity and wide spectrum of impact and outcomes, including being associated with severe exacerbations. Assessment of mild-moderate asthma is best made by combining asthma symptom control and exacerbation risk as the principle means by which to determine treatment needs. Incontrovertible evidence and guidelines support treatment initiation with anti-inflammatory medication, completely avoiding reliever-only treatment of mild asthma. Shared decision making with patients and a treatable traits approach will ensure that a holistic approach is taken to maximize patient outcomes. Most importantly, mild asthma should be regarded as a reversible, potentially curable condition, remaining in long-term remission through minimizing triggers and optimizing care.

Mild asthma is not mild: risk factors and predictive biomarkers for severe acute exacerbations and progression in mild asthma

INTRODUCTION

Asthma is a common chronic respiratory disease characterized by chronic airway inflammation, airway hyperresponsiveness, reversible airflow limitation, and airway remodeling. Mild asthma is the most common type of asthma, but it is the most neglected. Sometimes mild asthma can lead to acute severe exacerbations or even death.

AREAS COVERED

This article reviews the epidemiology, risk factors, and possible predictors of acute severe exacerbations and disease progression in mild asthma to improve the understanding of mild asthma and its severe acute exacerbations and progression.

EXPERT OPINION

There is a necessity to improve asthma patient categorization and redefine mild asthma's concept to heighten patient and physician attention. Identifying mild asthma patients that are highly vulnerable to severe acute exacerbations and researching the mechanisms are future prioritizations.

Expert Consensus on SABA Use for Asthma Clinical Decision-Making: A Delphi Approach

PURPOSE OF REVIEW

A modified Delphi process was undertaken to provide a US expert-led consensus to guide clinical action on short-acting beta2-agonist (SABA) use. This comprised an online survey (Phase 1), forum discussion and statement development (Phase 2), and statement adjudication (Phase 3).

RECENT FINDINGS

In Phase 1 (n = 100 clinicians), 12% routinely provided patients with ≥4 SABA prescriptions/year, 73% solicited SABA use frequency at every patient visit, and 21% did not consult asthma guidelines/expert reports. Phase 3 experts (n = 8) reached consensus (median Likert score, interquartile range) that use of ≥3 SABA canisters/year is associated with increased risk of exacerbation and asthma-related death (5, 4.75-5); SABA use history should be solicited at every patient visit (5, 4.75-5); usage patterns over time, not absolute thresholds, should guide response to SABA overuse (5, 4.5-5). Future asthma guidelines should include clear recommendations regarding SABA usage, using expert-led thresholds for action.

SABAs as Reliever Medications in Asthma Management: Evidence-Based Science

The role of as-needed inhaled short-acting β2-agonists (SABAs) in the management of asthma has become a subject of debate due to differing opinions in the professional community relating to the use of SABAs. In this article, we summarize the current position of SABAs when used as reliever medications and examine the challenges to appropriate use including a critique of the data that have led to the condemnation of SABA used as a reliever. We consider the evidence for the appropriate use of SABA as a reliever together with practical solutions to ensure such use, including identifying patients at risk of misusing their SABA relievers and managing issues of inhaler technique and treatment adherence. We conclude that inhaled corticosteroid (ICS)-based maintenance treatment with SABA used as-needed as a reliever is an effective and safe treatment for patients with asthma, with no scientific evidence of a causal link between SABA use as a reliever and mortality or serious adverse events (including exacerbations). Increased SABA use warns of a deterioration in asthma control, and patients at risk of misusing their ICS and SABA medication should be rapidly identified to ensure they are receiving adequate ICS-based controller therapy. Appropriate use of ICS-based controller therapy and as-needed SABA should be encouraged and promoted with educational activities.

Short-acting β2-agonists over-prescription in patients with asthma: an Indian subset analysis of international SABINA III study

OBJECTIVE

The SABINA (SABA use IN Asthma) program was initiated to describe short-acting β2-agonists (SABA) prescription patterns and assess the impact of its over-prescription on exacerbation risk and asthma control. We evaluated SABA prescription patterns in patients with asthma in the Indian cohort of SABINA III.

METHODS

This multi-centre, observational, cross-sectional study included retrospective and real-time electronic data collection. Data were extracted from medical records of patients with asthma (aged >12 years) having >3 consultations with the same healthcare practitioners between March 2019 and January 2020. The data included prescriptions of SABA and other asthma treatments and over-the-counter (OTC) purchases of SABA. SABA prescriptions were categorized by the number of SABA canisters prescribed in the 12 months preceding the study visit.

RESULTS

A total of 510 patients with asthma were included from specialist care (mean age 49.1 years; 57.65 females), with 8.2% classified with mild asthma and 91.8% with moderate-to-severe asthma. SABA as monotherapy and add-on to maintenance therapy was prescribed to 4.5% (n = 23) and 44.9% (n = 229) of patients, respectively. While ICS monotherapy and ICS/LABA were prescribed to 5.1% (n = 26) and 93.3% (n = 476) of patients, respectively. SABA was found to be over-prescribed (≥3 SABA canisters/year) among 23.9% of patients (n = 122). Additionally, 8% of patients (n = 41) purchased SABA OTC without prescription.

CONCLUSIONS

Nearly one-fourth of patients with asthma in India were over-prescribed SABA. Educational programmes targeted at national and regional levels should be expanded to raise greater asthma awareness and encourage the adoption of guideline-directed asthma treatment plans among healthcare practitioners.

A Predictive Machine Learning Tool for Asthma Exacerbations: Results from a 12-Week, Open-Label Study Using an Electronic Multi-Dose Dry Powder Inhaler with Integrated Sensors

PURPOSE

Machine learning models informed by sensor data inputs have the potential to provide individualized predictions of asthma deterioration. This study aimed to determine if data from an integrated digital inhaler could be used to develop a machine learning model capable of predicting impending exacerbations.

PATIENTS AND METHODS

Adult patients with poorly controlled asthma were enrolled in a 12-week, open-label study using ProAir® Digihaler®, an electronic multi-dose dry powder inhaler (eMDPI) with integrated sensors, as reliever medication (albuterol, 90 µg/dose; 1-2 inhalations every 4 hours, as needed). Throughout the study, the eMDPI recorded inhaler use, peak inspiratory flow (PIF), inhalation volume, inhalation duration, and time to PIF. A model predictive of impending exacerbations was generated by applying machine learning techniques to data downloaded from the inhalers, together with clinical and demographic information. The generated model was evaluated by receiver operating characteristic area under curve (ROC AUC) analysis.

RESULTS

Of 360 patients included in the predictive analysis, 64 experienced a total of 78 exacerbations. Increased albuterol use preceded exacerbations; the mean number of inhalations in the 24-hours preceding an exacerbation was 7.3 (standard deviation 17.3). The machine learning model, using gradient-boosting trees with data from the eMDPI and baseline patient characteristics, predicted an impending exacerbation over the following 5 days with an ROC AUC of 0.83 (95% confidence interval: 0.77-0.90). The feature of the model with the highest weight was the mean number of daily inhalations during the 4 days prior to the day the prediction was made.

CONCLUSION

A machine learning model to predict impending asthma exacerbations using data from the eMDPI was successfully developed. This approach may support a shift from reactive care to proactive, preventative, and personalized management of chronic respiratory diseases.

Long-Term Use of Short-Acting β2-Agonists in Patients With Adult-Onset Asthma

BACKGROUND

Short-term studies have associated high use of short-acting β₂-agonists (SABA) with increased risk of exacerbations, emergency visits, and asthma-related costs. However, no studies exist on long-term SABA use, and previous studies on the topic have not included information about adherence to inhaled corticosteroids (ICS) nor disease control, both affecting the need of SABA.

OBJECTIVE

To evaluate the clinical characteristics of SABA and ICS usage in newly diagnosed adult-onset asthma patients during a 12-year follow-up period.

METHODS

In the Seinäjoki Adult Asthma Study, 203 patients with adult-onset asthma were followed for 12 years. Information on dispensed SABA and ICS during the follow-up was obtained from the Finnish Social Insurance Institution. High SABA use was defined as ≥36 canisters in 12 years, corresponding to an average of ≥3 dispensed canisters/y.

RESULTS

Patients were dispensed median 6 (interquartile range: 3-16) SABA canisters and 48 (18-67) ICS canisters over 12 years, corresponding to 2 (1-4) and 11 (5-16) puffs/week, respectively. Only 10% of the patients were classified as high SABA users during this period. Obesity (body mass index ≥30) and high Airways Questionnaire 20 symptom scores at baseline predicted high long-term SABA use (incidence rate ratio: 1.53 [1.01-2.30] and 1.04 [1.00-1.08], respectively). High SABA users had higher ICS adherence, higher blood neutrophil counts, more comorbidities, and used more oral corticosteroid and antibiotic courses versus low SABA users.

CONCLUSION

High SABA use was infrequent in patients with confirmed adult-onset asthma. However, as high SABA use is associated with more severe asthma, these patients should be recognized in clinical practice.

Over-prescription of short-acting β2-agonists and asthma management in the Gulf region: a multicountry observational study

Background

The overuse of short-acting β₂-agonists (SABA) is associated with poor asthma control. However, data on SABA use in the Gulf region are limited. Herein, we describe SABA prescription practices and clinical outcomes in patients with asthma from the Gulf cohort of the SABA use IN Asthma (SABINA) III study.

Methods

In this cross-sectional study conducted at 16 sites across Kuwait, Oman, and the United Arab Emirates, eligible patients (aged ≥ 12 years) with asthma were classified based on investigator-defined disease severity guided by the 2017 Global Initiative for Asthma report and by practice type, i.e., respiratory specialist or primary care physician. Data on demographics, disease characteristics, and prescribed asthma treatments, including SABA, in the 12 months prior to a single, prospective, study visit were transcribed onto electronic case report forms (eCRFs). All analyses were descriptive in nature. Continuous variables were summarized by the number of non-missing values, given as mean (standard deviation [SD]) and median (range). Categorical variables were summarized by frequency counts and percentages.

Results

This study analyzed data from 301 patients with asthma, 54.5% of whom were treated by respiratory specialists. Most patients were female (61.8%), with a mean age of 43.9 years, and 84.4% were classified with moderate-to-severe disease, with a mean (SD) asthma duration of 14.8 (10.8) years. Asthma was partly controlled or uncontrolled in 51.2% of patients, with 41.9% experiencing ≥ 1 severe exacerbation in the 12 months preceding their study visit. Overall, 58.5% of patients were prescribed ≥ 3 SABA canisters, 19.3% were prescribed ≥ 10 canisters, and 13.3% purchased SABA over-the-counter (OTC) in the 12 months before the study visit. Most patients who purchased OTC SABA (92.5%) also received SABA prescriptions. Inhaled corticosteroid/long-acting β₂-agonist combinations and oral corticosteroid bursts were prescribed to 87.7% and 22.6% of patients, respectively.

Conclusions

SABA over-prescription was highly prevalent in the Gulf region, compounded by purchases of nonprescription SABA and suboptimal asthma-related outcomes. Increased awareness among policymakers and healthcare practitioners is needed to ensure implementation of current, evidence-based, treatment recommendations to optimize asthma management in this region.

Trial registration

NCT03857178 (ClinicalTrials.gov).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40733-022-00085-5.

Disease Control, Not Severity, Drives Job Absenteeism in Young Adults with Asthma - A Nationwide Cohort Study

Introduction

The impact of asthma and disease control on job absenteeism in young adults is sparsely investigated and conflicting evidence exist. Based on a nationwide cohort, the present study aims to describe the overall job absenteeism across asthma severities and describe the possible influence of asthma control.

Methods

REASSESS is a nationwide cohort of Danish asthma patients aged 18–45 using controller medication between 2014 and 2018, followed retrospectively for up to 15 years using national databases. Impact of asthma was investigated using negative binomial regression adjusted for age, sex, Charlson score and level of education and presented as adjusted incidence rate ratios with 95% confidence intervals.

Results

A total of 60,534 patients with asthma (median age 33 (25, 39), 55% female, 19% uncontrolled disease and 5.7% possible severe asthma) were followed for 12.7 (6.5–14.8) years. The prevalence of any absenteeism was more common in both mild-to-moderate and possible severe asthma compared to the background population (67%, 80% and 62%, respectively; p < 0.0001). Compared to the background population, mild-to-moderate and possible severe asthma were more likely to have temporary sick leave (1.37 (1.33–1.42); 1.78 (1.62–1.96)), unemployment (1.11 (1.07–1.14); 1.26 (1.15–1.38)) and obtain disability benefits (1.67 (1.66–1.67); 2.64 (2.63–2.65)). Uncontrolled asthma had increased temporary sick leave (1.42 (1.34–1.50)), unemployment (1.40 (1.32–1.48)) and disability (1.26 (1.26–1.27)) when compared to controlled disease. Significant increases in absenteeism could be measured already at ≥100 annual doses of rescue medication (1.09 (1.04–0.1.14)), patients’ first moderate or severe exacerbation (1.31 (1.15–1.49) and 1.31 (1.24–1.39), respectively). Further increases in absenteeism were observed with increasing rescue medication use and severe exacerbations.

Conclusion

Across severities, job absenteeism is increased among patients with asthma compared to the background population. Increases in absenteeism was seen already at ≥100 annual doses of rescue medication, representing a substantial, and probably preventable, reduction in productivity among young adults.

SABA use as an indicator for asthma exacerbation risk: an observational cohort study (SABINA Canada)

Background

Patients with asthma use short-acting β-agonists (SABA) to relieve symptoms but SABA alone does not treat underlying inflammation. Thus, over-reliance on SABA may result in poor asthma control and negative health outcomes.

Objective

To describe use of SABA and characterise the relationship with severe exacerbations in the Canadian provinces of Nova Scotia (NS) and Alberta (AB).

Methods

In this longitudinal Canadian SABA In Asthma (SABINA) study, patients with an asthma diagnosis were identified between 2016 and 2020 within two provincial administrative datasets (Health Data Nova Scotia and Alberta Health Services). All patients were followed for ≥24 months, with the first 12 months used to measure baseline asthma severity. Medication use and the relationship of SABA overuse (three or more canisters per year) with severe asthma exacerbations were characterised descriptively and via regression analysis.

Results

A total of 115 478 patients were identified (NS: n=8034; AB: n=107 444). SABA overuse was substantial across both provinces (NS: 39.4%; AB: 28.0%) and across all baseline disease severity categories. Patients in NS with SABA overuse had a mean±sd annual rate of 0.46±1.11 exacerbations, compared to 0.30±1.36 for those using fewer than three canisters of SABA. Patients in AB had mean±sd exacerbation rates of 0.31±0.86 and 0.17±0.62, respectively. The adjusted risk of severe exacerbation was associated with SABA overuse (NS: incidence ratio rate 1.36, 95% CI 1.18–1.56; AB: incidence ratio rate 1.32, 95% CI 1.27–1.38).

Conclusion

This study supports recent updates to Canadian Thoracic Society and Global Initiative for Asthma guidelines for asthma care. SABA overuse is associated with increased risk of severe exacerbations and can be used to identify patients at a higher risk for severe exacerbations.

This longitudinal study supports the recent updates to the CTS and GINA guidelines for asthma care. SABA utilisation can be used to identify patients at higher risk of severe exacerbation, regardless of disease severity.https://bit.ly/3Nd3USz

Medication adherence in Medicare-enrolled older adults with asthma before and during the coronavirus disease 2019 pandemic

BACKGROUND

Data regarding medication adherence in older adults with asthma before and during the coronavirus disease 2019 (COVID-19) pandemic are lacking.

OBJECTIVE

To evaluate medication adherence and determine factors associated with adherence in Medicare-enrolled older adults with asthma before and during the COVID-19 pandemic.

METHODS

This was a retrospective cohort analysis of Medicare-enrolled patients with asthma. Medication adherence was measured using rates of proportion of days covered for dates January to July 2019 and January to July 2020. Patients less than 65 years of age, with chronic obstructive pulmonary disease, or with cystic fibrosis were excluded. Paired t tests assessed change in adherence between 2019 and 2020. Logistic regression evaluated association of age, sex, depression, moderate or severe asthma, use of a 90-day supply, having 3 or more albuterol fills, number of medications, medication-related problems, prescribers, pharmacies, controller medication classes, and systemic corticosteroid fills with high adherence (proportion of days covered ≥ 80%).

RESULTS

Mean adherence to asthma controller medications ranged from 75% to 90%, in 2019. Adherence significantly decreased (P < .001) from 51% to 70% for all controller medications, except theophylline in 2020. Similar results were observed among patients with moderate or severe asthma. In 2019 and 2020, number of controller medications, 3 or more albuterol fills, and having a 90-day supply were associated with high adherence (P < .001).

CONCLUSION

Adherence to asthma controller medications decreased considerably during the COVID-19 pandemic among Medicare-enrolled patients with asthma. Patients with markers for more severe asthma, overuse of albuterol, and a 90-day supply of controller medications were more likely to have high adherence. These findings can be used to identify opportunities to improve adherence and prescribing among adult patients with asthma.

Bronchodilatory effect of higenamine as antiallergic asthma treatment

Asthma is a complex airway disease that affects more than 350 million humans worldwide. Allergic asthma symptoms are induced by Th2 immune response with the release of cytokines and allegro-inflammatory mediators that amplify the inflammatory response, airway hyper-responsiveness (AHR) and hyperproduction of mucus. Higenamine, as a chemical compound, is a β₂ adrenoreceptor agonist and can be used as bronchodilator in allergic asthma.BALB/c mice were allocated in four groups and then allergic asthma was induced in three groups. One of the asthmatic groups was treated with albuterol and other one was treated with higenamine. At least, methacholine challenge to determine the AHR, measurement of cytokines, total immunoglobulin E (IgE), LTB4 and LTC4 levels, evaluation of gene expression of Muc5ac, Muc5b, Agr2 and Arg1, and histopathological study were done.Higenamine treatment reduced AHR, interleukin (IL)-4, IL-13 levels, mRNA expression of MUC5ac, MUC5b, Arg1 and Agr2, goblet cell hyperplasia and mucus hypersecretion. Higenamine had no significant effect on IL-5, interferon-γ (INF-γ), IgE, LTB4, LTC4 levels and eosinophilic inflammation in lung tissue.Higenamine treatment controls asthma acute attack and breathlessness and can be used as asthma treatment with control of AHR and decrease of airflow obstruction and mucus hypersecretion and had allegro-immune-regulatory effect. But higenamine treatment had no notable effect on the inflammation and inflammatory factors.

Integrating Pharmacy and Registry Data Strengthens Clinical Assessments of Patient Adherence

Background: Accurate clinical assessment of patient adherence using reliable and valid measures is essential in establishing the presence of adherence issues and support practices for pharmacists.

Objective: This investigation aims to conduct a novel assessment of patient adherence to asthma controller therapy by combining 1) patient-specific dosage data found in pharmacy dispensing data with 2) centrally collected administrative claims records, to determine the added value of using both sources of data.

Methods: A total of 381 clinically uncontrolled asthma patients, from 95 community pharmacies across three Australian States were recruited and provided consent for the retrieval of their claims records and pharmacy dispensing data. Patients were stratified as multiple or single pharmacy users and adherence scores were calculated via the proportion of days covered (PDC) method using 1) patient claims records, 2) patient pharmacy dispensing data, and 3) combined claims records and pharmacy dispensing data. Cohort and subgroup adherence estimates were then compared.

Results: Low levels of adherence were evident amongst the cohort irrespective of the data source used. PDC estimates based on claims records alone or combined claims records and pharmacy dispensing data were significantly higher than estimates based on pharmacy dispensing data for the total cohort (56%, 52%, 42% respectively, p &lt; 0.001) and more noticeably for multiple pharmacy users (67%, 64%, 35% respectively, p &lt; 0.001). PDC estimates based on combined claims records and pharmacy dispensing data were significantly lower than estimates based on claims records alone, indicating that perhaps standard daily dose is not a robust proxy for prescribed dosage to inhaled respiratory devices in adherence approximations. Poorer adherence was found amongst single pharmacy users than multiple pharmacy users when combined claims records and pharmacy dispensing data (46% compared to 64% respectively, p &lt; 0.001) or claims records alone (51% compared to 67% respectively, p &lt; 0.001) were compared.

Conclusion: Access to routine collected data increases clinical acuity over patient adherence to asthma controller medications and is a valuable resource for health care professionals. A policy of secure accessibility of such data at the patient-pharmacist or patient-GP interface may allow real-time intervention and assist in decision making across numerous therapeutic areas.

High Use of Antidepressant Medication in Both Mild-to-Modelate and Possible Severe Asthma - A Nationwide Cohort Study

PURPOSE

In asthma, increased severity has been linked to depression assessed as assessed by patient-reported outcomes. However, little is known about predictors of antidepressant use in asthma compared to the background population.

METHODS

The study consists of 60,534 asthma patients aged 18-45 and a 1:1 age- and sex-matched control group. Using national registries and prescription data, the prevalence of and risk factors for antidepressant use were investigated by logistic regression adjusted for age, sex, workforce and civil status, income- and education-level and comorbidity. Results presented as odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

A total of 16% and 22%, respectively, among patients with mild-to-moderate and possible severe asthma redeemed antidepressant drugs, compared to 10% of controls. Antidepressant use was more prevalent amongst patients with high rescue medication use (>600 annual doses) and those with a history of moderate or severe exacerbation(s). Both mild-to-moderate and possible severe asthma were independent risk factors for antidepressant use (OR 1.40 (95% CI 1.35, 1.46) and OR 1.55 (95% CI 1.41, 1.70), respectively). Female sex, age, being divorced or never married, having only primary education or currently being under education, as well as being on welfare/transfer income increased odds of antidepressant use. Completing higher education and having high income were associated with lower odds.

CONCLUSION

In asthma, antidepressant use is significantly higher than in the background population. Even after adjusting for known risk factors, asthma remains a predictor of antidepressant use, signalling a psychologic burden related to living with asthma.

Socioeconomic status is associated with healthcare seeking behaviour and disease burden in young adults with asthma - A nationwide cohort study

Introduction

Specialist management of asthma has been shown to associate with socioeconomic status (SES). However, little is known about the influence of SES on care burden in universal healthcare settings.

Methods

Patients aged 18–45 years using inhaled corticosteroids (ICS) were followed in national databases. Impact of asthma was investigated using negative binomial regression adjusted for age, sex, comorbidity, and GINA 2020 Step. Uncontrolled asthma was defined as >600 annual SABA puffs, ≥2 prednisolone courses and/or ≥1 hospitalization.

Results

A total of 60,534 (55% female, median age 33 (IQR 25–39)) patients were followed for 10.1 years (IQR 5.2–14.3)). Uncontrolled asthma resulted in 6.5 and 0.51 additional annual contacts to primary care and pulmonologists, respectively.

Unscheduled and primary care burden was dependent on SES, increasing with rural residence, lower education, income and receiving welfare. Differences in planned respiratory care were slight, only seen among divorced, low income- or welfare recipients. Lower SES was consistently associated with an increased utilization of SABA and prednisolone. No dose–response relationship between ICS use and SES could be identified.

Conclusion

Lower SES in asthma is a risk factor for a predominance of unscheduled care and adverse outcomes, warranting further attention to patients’ background when assessing asthma care.

Short-acting β2-agonist prescriptions are associated with poor clinical outcomes of asthma: the multi-country, cross-sectional SABINA III study

Background

To gain a global perspective on short-acting β₂-agonist (SABA) prescriptions and associated asthma-related clinical outcomes in patients with asthma, we assessed primary health data across 24 countries in five continents.

Methods

SABINA III was a cross-sectional study that employed electronic case report forms at a study visit (in primary or specialist care) to record prescribed medication(s), over-the-counter (OTC) SABA purchases and clinical outcomes in asthma patients (≥12 years old) during the past 12 months. In patients with ≥1 SABA prescriptions, associations of SABA with asthma symptom control and severe exacerbations were analysed using multivariable regression models.

Results

Of 8351 patients recruited (n=6872, specialists; n=1440, primary care), 76.5% had moderate-to-severe asthma and 45.4% experienced ≥1 severe exacerbations in the past 12 months. 38% of patients were prescribed ≥3 SABA canisters; 18.0% purchased OTC SABA, of whom 76.8% also received SABA prescriptions. Prescriptions of 3–5, 6–9, 10–12 and ≥13 SABA canisters (versus 1–2) were associated with increasingly lower odds of controlled or partly controlled asthma (adjusted OR 0.64 (95% CI 0.53–0.78), 0.49 (95% CI 0.39–0.61), 0.42 (95% CI 0.34–0.51) and 0.33 (95% CI 0.25–0.45), respectively; n=4597) and higher severe exacerbation rates (adjusted incidence rate ratio 1.40 (95% CI 1.24–1.58), 1.52 (95% CI 1.33–1.74), 1.78 (95% CI 1.57–2.02) and 1.92 (95% CI 1.61–2.29), respectively; n=4612).

Conclusions

This study indicates an association between high SABA prescriptions and poor clinical outcomes across a broad range of countries, healthcare settings and asthma severities, providing support for initiatives to improve asthma morbidity by reducing SABA overreliance.

Findings from SABINA III, which included 8351 patients from 24 countries, indicate that across treatment steps and clinical care settings, high SABA prescriptions were associated with higher rates of severe exacerbations and poorer asthma controlhttps://bit.ly/2VHBISg

Asthma diagnosis: into the fourth dimension

Asthma is the most common chronic respiratory disease in the UK; however, the misdiagnosis rate is substantial. The lack of consistency in national guidelines and the paucity of data on the performance of diagnostic algorithms compound the challenges in asthma diagnosis. Asthma is a highly rhythmic disease, characterised by diurnal variability in clinical symptoms and pathogenesis. Asthma also varies day to day, seasonally and from year to year. As much as it is a hallmark for asthma, this variability also poses significant challenges to asthma diagnosis. Almost all established asthma diagnostic tools demonstrate diurnal variation, yet few are performed with standardised timing of measurements. The dichotomous interpretation of diagnostic outcomes using fixed cut-off values may further limit the accuracy of the tests, particularly when diurnal variability straddles cut-off values within a day, and careful interpretation beyond the 'positive' and 'negative' outcome is needed. The day-to-day and more long-term variations are less predictable and it is unclear whether performing asthma diagnostic tests during asymptomatic periods may influence diagnostic sensitivities. With the evolution of asthma diagnostic tools, home monitoring and digital apps, novel strategies are needed to bridge these gaps in knowledge, and circadian variability should be considered during the standardisation process. This review summarises the biological mechanisms of circadian rhythms in asthma and highlights novel data on the significance of time (the fourth dimension) in asthma diagnosis.

Medical care and treatment of children with asthmatic or wheezing health outcomes and urban-rural differences in Bavaria - a cross-sectional study

Introduction: Asthma is among the most common chronic conditions in children. The aim of this publication is to describe prevalence rates and factors associated with asthmatic or wheezing preschoolers and to evaluate medical care and treatment with regard to urban-rural differences.Methods: Data for this cross-sectional study were collected through a questionnaire, which was distributed to parents within the Health Monitoring Units in Bavaria (HMU), Germany. Data from 4767 children were available (2016/17). Those children were classified into four diagnostic groups: Unremitting Wheeze, International Study of Asthma and Allergies in Children (ISAAC) Asthma, Physician-diagnosed Asthma, and healthy control group. Urban-rural differences were tested by Pearson's chi-squared test or by Fisher's exact test. Independent variables were factors associated with health outcomes, for example, residency or migrant status. To examine associations between independent and outcome variables multivariate logistic regression analysis was performed.Results: Prevalence rates were 6.3% for 'Unremitting Wheeze', 5.2% for 'ISAAC Asthma', and 1.2% for 'Physician-diagnosed Asthma'. Factors associated with health outcomes were the occurrence of asthma in first-degree relatives, male sex, and migrant status. Generally, higher rates of doctor's visits, positive allergy tests, and corticosteroids intake in the diagnostic groups in rural compared to urban areas were observed. Rates of performed allergy tests were 55.6% for 'ISAAC Asthma' and 74.6% for 'Physician-diagnosed Asthma'.Conclusions: Prevalence rates of the diagnostic groups decreased compared to the HMU 2014/15. According to previous studies, factors associated with asthmatic or wheezing health outcomes could be confirmed. Children in rural areas generally received more medical care.Key pointsChildren's prevalence rates of asthma or wheezing disorders decreased in the past 2 years within Bavaria.This study is consistent with risk factors for asthma from the literature: asthma in the family, male gender, and migrant status.Children in rural areas receive more medical care than children in urban areas.There should me more allergy tests among children with medical diagnosis in Bavaria as low rates indicate gaps in care.

Socioeconomic biases in asthma control and specialist referral of possible severe asthma

BACKGROUND

Although socioeconomic impact on asthma control has been investigated, little is known about its relation to specialist referral of patients with possible severe asthma, especially in a public healthcare setting. The present study aims to identify socioeconomic patterns in disease control and referral of patients with asthma in a nationwide cohort of adult patients treated with inhaled corticosteroid (ICS).

METHODS

Asthma patients fulfilling the following: aged 18-45 and redeeming ≥2 prescriptions of ICS during 2014-18 based on data from Danish national registers were included. Possible severe asthma was defined as GINA 2020 Step 4 (with either ≥2 courses of systemic steroids or ≥1 hospitalisation) or Step 5 treatment. Findings presented as odds ratio (OR) (95% confidence intervals).

RESULTS

Of 60 534 patients (median age 34, 55% female), 3275 (5.7%) were deemed as having possible severe asthma, of whom 61% were managed in primary care alone.Odds of specialist management for possible severe asthma decreased with age (OR 0.66 (0.51-0.85)), 36-45 versus 18-25 years), male sex (OR 0.75 (0.64-0.87)), residence outside the Capital Region (OR 0.70 (0.59-0.82)) and with receiving unemployment or disability benefits OR 0.75 (0.59-0.95)).Having completed higher education increased odds of specialist referral (OR 1.28 (1.03-1.59)), when compared to patients with basic education.

CONCLUSION

Even in settings with nationally available free access to specialist care, the majority of patients with possible severe asthma are managed in primary care. Referral of at-risk asthma patients differs across socioeconomic parameters, calling for initiatives to identify and actively refer these patients.

The prevalence and outcome of short-acting β2-agonists overuse in asthma patients in Taiwan

This study aims to investigate the prevalence of short-acting β2-agonist (SABA) overuse in asthma and the associated risk of acute exacerbation and mortality in Taiwan. We used the Taiwanese pay-for-performance asthma program database, which included patients aged between 12 and 100 years who were enrolled in the program between 2001 and 2015. Among a total of 218,039 patients, 34,641 (15.9%) patients are classified as SABA over-users. Compared with patients who did not receive inhaled corticosteroids (ICS) and collected ≤2 canisters, SABA over-users had a higher risk of severe exacerbations. SABA over-users had a higher risk of all-cause mortality compared with patients who did not receive ICS and collected ≤2 canisters. The overall prevalence of SABA overuse in Taiwan is 15.9%, and this is even higher in concomitant ICS users. In addition, the overuse of SABA is associated with an increased risk of severe exacerbation and death.

Prevalence of overuse of short-acting beta-2 agonists (SABA) and associated factors among patients with asthma in Germany

BACKGROUND

Overuse of short-acting beta-2 agonists (SABA), which do not treat the underlying inflammation of asthma, is linked to poor clinical outcomes such as increased exacerbation risk. This study, as part of the SABINA program, estimated the prevalence of SABA overuse and associated variables in outpatients in Germany.

METHODS

This retrospective study used anonymized electronic healthcare data from the Disease Analyzer database (IQVIA). A total of 15,640 patients aged ≥ 12 years with asthma who received ≥ 1 SABA prescription(s) between July 2017 and June 2018 in 924 general physician and 22 pneumologist (PN) practices were included. SABA overuse was defined as ≥ 3 prescribed inhalers (~ 200 puffs each) during the study period. The associations between SABA overuse and physician specialty, Global Initiative for Asthma (GINA) steps (based on asthma medications), age, sex, and inhaled corticosteroid (ICS)/long-acting beta agonist (LABA) use were estimated using multivariable regression for patients with probable moderate (GINA step 2) and probable severe (GINA steps 3-5) asthma.

RESULTS

Annually, 36% of all patients (GINA steps 1-5) in general and 38% in PN practices received ≥ 3 SABA inhalers. The risk of SABA overuse was 14% higher in patients treated by a general practitioner vs. a PN; 34% and 85% higher in GINA steps 4 and 5, respectively, vs. GINA step 3; and 40% higher in male vs. female patients.

CONCLUSIONS

SABA overuse is prevalent among patients with asthma across all GINA steps in Germany, which may indicate suboptimal asthma control. Further studies are needed to investigate the reasons behind SABA overuse.

Evaluating the impact of coronavirus disease 2019 on asthma morbidity: A comprehensive analysis of potential influencing factors

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic period is experiencing better asthma control, fewer exacerbations, and health care utilization, with limited data on factors that could explain this phenomenon.

OBJECTIVE

To confirm these improved asthma outcomes during COVID-19 and evaluate potential contributing factors.

METHODS

In 18,912 pediatric patients with asthma treated in the Children's Hospital of Orange County network from 2017 to 2020, monthly asthma-related encounters and medication summaries were extracted from electronic health records, particulate matter 2.5 (PM_2.5) air pollution from the California Air Resources Board, and influenza-like illness from Illness Surveillance Network for the first 6 months of each year. Changes in outcomes between January to March and April to June (post-COVID-19 shutdown in 2020) were compared with historical data using generalized estimating equations analyses for patient outcomes and generalized linear models for pollution exceedance, influenza-positive, and telehealth visit rates.

RESULTS

During COVID-19, we found 78%, 90%, 68% reductions in hospitalization, emergency department visits, and exacerbations, respectively, compared with pre-COVID-19 2020, with significantly greater changes than the same time period of 2017 to 2019 and significant reductions in albuterol and inhaled corticosteroid use (P < .05). Emergency department visit reduction was not seen for African Americans. The PM_2.5 and influenza rates were also significantly reduced during COVID-19 (P < .05). Increased rates in telehealth visits were greater in the publicly insured group when compared with commercially insured.

CONCLUSION

Our data confirm reduced health care utilization and suggest better asthma control during COVID-19, except for African Americans. This was associated with a significant increase in telehealth visits and reductions in PM_2.5 and influenza infections, but not better asthma controller adherence.

Medication Adherence in a Community Population with Uncontrolled Asthma

It is well documented that the use of medications in asthma and allergic rhinitis is often suboptimal, and consequently, patients remain symptomatic. This study aimed to determine the extent and type of medication-related issues contributing to poor asthma control by profiling medication management in those most at risk—a population with clinically uncontrolled asthma. Participants (n = 363) were recruited from Australian community pharmacies, and a dispensed medication history report for the previous 12 months was collected to examine medication adherence and factors affecting adherence. Information was also collected regarding participant asthma control and asthma/allergic rhinitis (if applicable) management. The participants’ mean asthma control score was 2.49 (± 0.89 SD, IQR = 1.20) (score ≥ 1.5 indicative of poorly controlled asthma), and 72% were either non-adherent or yet to initiate preventer therapy. Almost half had been prescribed high doses of inhaled corticosteroid and 24% reported use of oral corticosteroids. Only 22% of participants with concomitant allergic rhinitis were using first line treatment. A logistic regression model highlighted that participant health care concession status and hospital admissions were associated with better adherence. Suboptimal medication management is evident in this at-risk population.