Asthma management and mode of acquisition of inhaled bronchodilators

Over-the-counter use of short-acting beta-2 agonists: a systematic review

BACKGROUND

The widespread use of short-acting beta-2 agonists (SABA) as an as-needed treatment for asthma is well-established. However, excessive use of SABA has been linked to undesirable outcomes such as increased risk of asthma attacks, exacerbations, and even death. The availability of SABA as an over-the-counter (OTC) medication has contributed to their overuse, leading to undertreated asthma and reduced access to asthma education.

OBJECTIVE

This systematic review aimed to summarize the prevalence, characteristic features of, and factors contributing to over-the-counter SABA purchase or overuse.

METHODS

The databases searched included PubMed, Scopus, Springer Link, Google Scholar, CINAHL, and APA PsycArticles. Original research articles reporting the prevalence, characteristics features, and factors regarding over-the-counter SABA use, available as full text, published in English language between the year 2000 and April 2023 were included in this review. Commentaries, letters to editor, review articles, qualitative studies, clinical trials, and conference proceedings were excluded. Data extraction was followed by a review of the quality of studies included and data were then synthesized for meaningful findings. This systematic review had been registered in the PROSPERO with registration number CRD42023421007.

RESULTS

A total of 18 articles were included. The prevalence range of OTC SABA users in populations were 1.4% to 39.6% and SABA over-users among OTC users were 14% to 66.4%. Factors mostly associated with this behavior were moderate-severe asthma, and less use of preventers. On top of that, not understanding the risk of SABA overuse was clear in many studies that explored this factor.

CONCLUSION

Over-the-counter purchase and overuse of SABA medication is a common problem, leading to adverse consequences such as uncontrolled asthma and increased healthcare utilization. Addressing these issues requires improved patient education about their conditions and adequate information regarding the potential long-term effects of SABA use by the healthcare providers. Management and education of asthma patients, including regular monitoring and follow-up, can help reduce overuse of SABA medication and prevent negative consequences.

Asthma medications should be available for over-the-counter use: con

The United States Food and Drug Administration recently considered a policy to transfer inhaled short-acting bronchodilators to over-the-counter status if conditions of safe use can be established. The American Thoracic Society filed a comment in opposition to the proposal. This article examines the negative consequences that might result from allowing nonprescription access to bronchodilators and other inhaled asthma medications. Such a proposed policy change conflicts directly with current guidelines for asthma management and would undermine efforts to achieve adequate asthma control in patients. In addition, a policy change to convert asthma medications to over-the-counter status could result in increased costs to patients as well as increased health care costs to society overall due to a worsening of asthma control in the population.

Over-the-counter β2-agonist purchase versus script: a cross-sectional study

BACKGROUND

Purchase of short-acting β(2)-agonist (SABA), but not anti-inflammatory asthma medication, is permitted in Australia without a doctor's prescription. This has been associated with worse asthma outcomes. We sought to compare the asthma outcomes between those purchasing SABA with and without a doctor's prescription.

METHODS

DESIGN

Cross-sectional study, using stratified randomisation of pharmacies.

SETTING

43 pharmacies in Victoria, Australia.

PARTICIPANTS

Up to 10 consecutive adults purchasing β(2)-agonists were recruited from each pharmacy, with 316 adults in total.

OUTCOME MEASURES

Participants underwent spirometry and questionnaires on respiratory health, asthma control, Quality of Life and medication adherence. Asthma severity was determined by GINA medication step. Regression analyses were performed that allowed for clustering by pharmacy.

RESULTS

Of 316 individuals recruited (65% participation rate), 191 (60%) purchased a β(2)-agonist with a prescription. Purchase of SABA without prescription was not associated with worse asthma outcomes or lung function. Mean (±SD) asthma control score (ACQ) was 1.65 ± 1.03; only 63 (20%) had well-controlled asthma (ACQ < 0.75). Anti-inflammatory asthma medication was owned by 188 (60%) of participants, of whom 157 (83%) reported using this in the last 7 days. There was no correlation between medication adherence scores and asthma control. Forty-seven participants (15%) had an FEV(1) below 80% predicted and did not own an anti-inflammatory asthma medication.

CONCLUSION

Purchase of SABA without prescription was not associated with worse asthma outcomes in Australia. Although many patients reported symptoms of asthma, this did not appear to be associated with reported adherence to anti-inflammatory asthma medication.

Beliefs that support the behavior of people with asthma: a qualitative investigation

Differences between patients' knowledge and behavior in relation to asthma may account for continuing morbidity in theface of professional and public asthma education campaigns. We conducted a qualitative study of beliefs that support asthma-related behavior, obtaining data from interviews with 70 adult patients. Analysis identified four clear subgroups, or "streams," of adults with asthma: an "anonymous" stream, who doubt that they have asthma and manage symptoms outside the organized health system; an "isolated" stream, who feel dependent on bronchodilators and do not understand the potential of preventive therapy; a "suboptimal" stream, who are confident that they are managing their asthma effectively but who are excessively reliant on bronchodilators; and an "optimal stream," who have high expectations of outcomes and participate actively in a partnership with a doctor. Characteristics of the doctor and the doctor-patient relationship are important elements in altering asthma-related behavior in ways that may facilitate the best health outcomes.

Use of "preventer" medications and written asthma management plans among adults with asthma in New South Wales. NSW Health Department Asthma Data Working Group

OBJECTIVES

(1) To measure the extent of use of preventer medications (ie, inhaled corticosteroids or cromones) and possession of written asthma management plans (AMPs) among people with asthma in New South Wales in 1997. (2) To assess factors associated with underuse of preventer medications and AMPs.

DESIGN AND SETTING

A cross-sectional survey by computer-assisted telephone interviews of a stratified random sample of the adult population of New South Wales, Australia.

PARTICIPANTS

People aged 16 to 54 years with asthma diagnosed by a doctor and causing symptoms or requiring treatment in the preceding year (n = 1,372).

RESULTS

Although 55.2% of survey participants had used preventer medications in the preceding year, only 27.8% had used them regularly. Only 34.7% had a written AMP. Preventer medications were judged to be indicated for 54% of the study population, but only 42.5% of this group had used them regularly (43.1% had a written AMP). Younger adults were less likely to use preventer medications regularly, but there was no difference in use of preventer medications by sex, urban/rural residence, or manner of purchasing reliever medications (either on prescription or "over the counter"). Past smokers used preventers more commonly than current smokers, with never smokers having an intermediate prevalence of regular preventer use. Age, sex, urban/rural residence, and manner of purchasing reliever medications were not related to the possession of an AMP.

CONCLUSION

Despite the trend towards increased use of preventer medications and written AMPs during the 1990s, undertreated asthma remains a major public health problem in Australia.

Safety of over-the-counter inhalers for asthma: report of the council on scientific affairs

The occasional use of over-the-counter (OTC) epinephrine inhalers appears to be safe and effective when used according to labeled instruction by individuals with mild, intermittent asthma. However, gross misuse of these products can cause severe adverse reactions, including death. Limited survey data suggest that approximately 20% of individuals using OTC epinephrine inhalers have mild-to-moderate persistent asthma. According to recent consensus guidelines, these individuals should be under a physician's care and receiving corticosteroid therapy. If these products continue to be marketed, labeling should be strengthened to better educate users about appropriate and inappropriate use of OTC epinephrine inhalers intended for patients with mild, intermittent asthma.

Nonprescription bronchodilator medication use in asthma

STUDY OBJECTIVE

Many persons with asthma self-medicate with widely available and potentially hazardous nonprescription medicines. This study assessed the demographic and clinical covariates of self-treatment with over-the-counter asthma medications (OTCs).

DESIGN AND SETTING

We conducted an analytical investigation using questionnaires and measures of lung function, comparing OTC and prescription medication users. We recruited adults with asthma by public advertisement.

SUBJECTS

We studied 22 exclusive prescription asthma medication users, 15 exclusive OTC users, and 13 other subjects who combined prescription medication use with self-treatment with asthma OTCs. All but one OTC user self-medicated with a nonselective, sympathomimetic metered-dose inhaler.

RESULTS

Taking income, access to care, and self-assessed disease severity into account, male gender was strongly associated with exclusive OTC use alone (odds ratio [OR]=8.9, 95% confidence interval [CI]= 1.3 to 61) and mixed OTC-prescription medication use (OR=9.7, 95% CI=1.1 to 83). The covariates of income, access to care, and self-assessed disease severity provided significant additional explanatory power to the model of exclusive OTC use (model chi2 difference 11.3, 5 df, p<0.05). Pulmonary function was similar among OTC and prescription medication users. However, prescription medication users' self-assessed asthma severity (mild compared to more severe) was associated with postbronchodilator reversibility of FEV1 obstruction (6% vs 18% reversibility, p<0.05) while exclusive OTC users' self-assessed severity showed the reverse pattern (19% vs 8%, p=0.2).

CONCLUSION

Asthma education programs attempting to discourage unregulated bronchodilator use should give consideration to this profile of the "asthmatic-at-risk."