Characterization of long-acting beta₂-adrenergic agonists utilization in asthma patients

The US Food and Drug Administration's drug safety recommendations and long-acting beta2-agonist dispensing pattern changes in adult asthma patients: 2003-2012

Background

Emerging safety issues associated with long-acting beta₂-agonist (LABA) have led to multiple regulatory activities by the US Food and Drug Administration (FDA) since 2003, including Drug Safety Communications (DSCs) in 2010. These DSCs had three specific recommendations for the safe use of LABA products in adult asthma treatment.

Methods

We examined the initiation of LABA-containing products for adult asthma treatment using an intermittent time series approach in a claims database from 2003 to 2012. We assessed the alignment of dispensing patterns with the following 2010 FDA recommendations: 1) contraindicated use of single-ingredient (SI)-LABA without an asthma controller medication (ACM); 2) a LABA should only be used when asthma is not adequately controlled on inhaled corticosteroids (ICSs) or ACM; and 3) step-down asthma therapy (e.g., discontinue LABA) when asthma control is achieved.

Results

There were 477,922 adults (18–64 years old) dispensed a new LABA during 2003–2012. Among LABA initiators, patients who initiated an SI-LABA and who did “not” have an ACM dispensed on the same date decreased from >9% in 2003 (the initial labeling change) to <2% post 2010 DSCs (p-value <0.0001 in the segmented regression model). The proportion of asthma patients dispensed an ICS in 6 months prior to initiating LABA treatment did not increase. The proportion of patients with longer than 4 months of continuous treatment did not decrease over the study period.

Conclusion

Although the decrease in SI-LABA initiation is consistent with FDA’s recommendations, low ICS dispensing before initiating a LABA and LABA continuation practices require further efforts to move toward the recommended safe practices.

Analysis of prescription pattern and guideline adherence in the management of asthma among medical institutions and physician specialties in Taiwan between 2000 and 2010

PURPOSE

The aim of this study was to evaluate prescription patterns of antiasthmatic medications in ambulatory care, guideline adherence by physician specialties and medical institutions, and the rate of hospitalization and emergency department visits due to asthma exacerbation.

METHODS

The ambulatory visits between 2000 and 2010 from the Taiwan Longitudinal Health Insurance Database 2000 were analyzed for prescription trends. Seven classes of antiasthmatic medications were identified for prescription trend analysis. Prescription patterns of different medical institutions and physician specialties were further evaluated.

FINDINGS

We studied 4495 patients with newly diagnosed asthma in 2000. Estimates indicated an increased use in fixed-dose combination of inhaled corticosteroids and long-acting β2-agonists (3.6% in 2002 to 28.8% in 2010) with decreased use of inhaled corticosteroids (14.5% in 2001 to 7.3% in 2010). Xanthine was still the most frequently used medication for asthmatic patients (60.2% in 2001 and 45.2% in 2010). Another marked increase was the use of leukotriene receptor antagonists (2.6% in 2001 to 6.0% in 2010). In the studied population, the rate of hospital admission or emergency department visit moderately decreased from 1.42% to 0.59% during 10 years. Physicians in medical centers and regional hospitals, as well as asthma specialists, dominated the increased use of fixed-dose combinations of inhaled corticosteroids and long-acting β2-agonists and leukotriene receptor antagonists.

IMPLICATIONS

Physicians in academic medical centers and asthma specialists achieved better adherence to the core recommendations of the international guidelines for asthma management. The reasons for guideline nonadherence among physicians in district hospitals and primary care clinics deserve health care professionals' attention and require further investigation.

Changes in long-acting β-agonist utilization after the FDA's 2010 drug safety communication

PURPOSE

In February 2010, the US Food and Drug Administration (FDA) issued new recommendations for the safe use of long-acting β-agonists (LABAs) in patients with asthma. The objective of this study was to determine the impact of the FDA's 2010 safety advisory on LABA utilization.

METHODS

Using administrative data from the Oregon Medicaid program, we performed an interrupted time series regression to evaluate changes in the trend in new LABA prescriptions before and after the FDA's 2010 advisory. Trends in incident fills were examined among those with and without an asthma diagnosis code and previous respiratory controller medication use; trends were also assessed according to patient age.

FINDINGS

The average age of the 8646 study patients was 37 years, 53% had a diagnosis of asthma, 21% had no respiratory diagnosis, and 32% had not used a respiratory controller medication in the recent past. The trend in new LABA prescriptions declined by 0.09 new start per 10,000 patients per month (95% CI, -0.19 to -0.01) after the FDA's advisory. Among those with a diagnosis of asthma, there was an immediate drop of 0.48 (95% CI, -0.93 to -0.03) and a 0.10 (95% CI, -0.13 to -0.06) decline in the monthly rate of new starts per 10,000 patients. Immediately after the FDA's advisory, we observed a statistically significant 4.7% increase (95% CI, 0.8 to 8.7) in the proportion of new LABA starts with history of previous respiratory controller medication use. Utilization of LABAs did not change in those without a diagnosis of asthma.

IMPLICATIONS

The FDA's 2010 advisory was associated with modest reductions in LABA utilization overall and in ways highlighted in their recommendations.

Long-acting beta2-adrenergic agonist in pediatric and adolescent asthma patients, 2003-2011

OBJECTIVES

To evaluate changes in the dispensing patterns of long-acting beta2-adrenergic agonist (LABA) in pediatric and adolescent asthma patients in relation to multiple Food and Drug Administration (FDA) regulatory activities from 2003 to 2011.

METHODS

We estimated LABA dispensing to pediatric asthma patients across three periods: 2003-2004 (after the first labeling change), 2005-2009 (after regulatory activities in 2005 and before 2010 LABA labeling change) and 2010-2011 (after 2010 LABA labeling change), using the IMS Health Plan Claims database. We estimated dispensing patterns over time for single-ingredient (SI) LABA and fixed-dose combination (FDC) of inhaled corticosteroid (ICS) and LABA (FDC-ICS/LABA). We also evaluated prior use of non-LABA asthma-control medication (ACM) before LABA initiation.

RESULTS

Of the 147 862 pediatric and adolescent asthma patients who initiated a LABA during the entire study period, the majority (96%) were FDC-ICS/LABA initiators. The proportion of SI-LABA among any LABA initiators was small and declined (9%, 4% and 2%, trend test p < 0.001) for the three periods. Among the patients who initiated, the proportions with prior use of an ACM (1-90 days prior) were 35%, 36% and 39% for the three periods.

CONCLUSIONS

The significant decline in the proportion of SI-LABA initiation over these years is consistent with FDA's recommendations. However, the favorable trend cannot be solely attributed to FDA activities as changes to clinical practice guidelines, and media publicity may have played a role. Investigating the reasons for the low ACM use before LABA initiation may inform approaches to further improve appropriate use of LABA in young asthma patients.

Antidepressant medication dispensing among montelukast initiators

OBJECTIVE

This study investigates the potential association between montelukast use and psychiatric adverse events by monitoring changes in antidepressant medication dispensing rates before and after initiating montelukast.

METHODS

The primary study group of montelukast initiators was identified using the Wolters Kluwer's SOURCE Lx® pharmacy claims database (WK). This group included 232,159 patients ≤45 years old who had at least two montelukast prescriptions from 2003 to 2007. Comparison groups comprised of 264,704 fluticasone initiators and 89,635 long-acting β-agonist corticosteroid (LABA/ICS) initiators were also identified. Antidepressant medication dispensing rates in these three groups were determined using WK, and changes in rates before and after the first asthma controller medication prescription date were evaluated using interrupted time-series analysis (ITS). ITS was performed separately for four age categories, with a focus on youth (12-17 years) and young adult (18-24 years).

RESULTS

For patients 18-24 years old, antidepressant medication dispensing rates increased significantly after initiating montelukast [1.93% (1.55-2.32%, p < 0.001)] but also after initiating fluticasone and LABA/ICS [1.72% (1.30-2.15%, p < 0.001) and 2.76% (2.35-3.17%, p < 0.001)]. Similar patterns were observed across the three medication groups for other age categories but these differences were not all significant.

CONCLUSIONS

Small increases in antidepressant medication dispensing rates occurred after initiating montelukast. However, similar increases were observed in the fluticasone and LABA/ICS comparison groups. The results of this study cannot support a specific association between initiation of montelukast treatment and an increase in psychiatric adverse effects.

An evaluation of asthma medication utilization for risk evaluation and mitigation strategies (REMS) in the United States: 2005-2011

PURPOSE

The purpose of this study was to assess drug utilization patterns of fluticasone propionate (FP)/salmeterol (SAL) combination (FSC) and SAL over the 7-year period of 2005-2011 in patients with asthma as part of the Risk Evaluation and Mitigation Strategies (REMS).

METHODS

A descriptive, retrospective observational study utilizing national pharmacy data and employer-based claims data to characterize drug utilization patterns.

RESULTS

For patients with asthma, the total number of FSC and SAL dispensings and users of FSC and SAL has declined between 2005 and 2011. During this period, FSC and SAL dispensing for asthma decreased 24% and 76%, respectively, with a more pronounced decline between 2010 and 2011 relative to other years. The total number of patients with asthma who were dispensed FSC has decreased by 10% among adults and by 40% in children and adolescents. While SAL-containing medications decreased, dispensing of FP monotherapy increased 39% during the same 7-year period. The number of patients dispensed FP for asthma has increased 47% in children 4-11 years of age, 72% in adolescents 12-17 years of age, and 6% in adults. SAL use without a controller was infrequent and decreasing, reported by 1.7% and 0.5% of patients with asthma in 2005 and 2011, respectively.

CONCLUSIONS

In patients with asthma, use of FSC and SAL decreased between 2005 and 2011, while the use of FP increased. Use of SAL monotherapy was infrequent and declined during the study period. The data suggest that the substantial communication activities have encouraged appropriate prescribing of long-acting β2-adrenergic agonist (LABA).