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Juntunen P, Salmela P, Pakkasela J, Karjalainen J, Lehtimäki L. Diagnoses and prescription patterns among users of medications for obstructive airway diseases in Finland. BMC Pulm Med 2024; 24:64. [PMID: 38297257 PMCID: PMC10829254 DOI: 10.1186/s12890-024-02870-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 01/19/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Asthma and chronic obstructive pulmonary disease (COPD) are common diseases mostly treated in primary care. However, the usage patterns of drugs for obstructive airway diseases (R03 drugs) at the national level are not known. OBJECTIVE The aims of this study were to describe (1) for which diagnoses each class of R03 drugs were used, (2) the usage pattern of different drug classes for asthma and COPD, and (3) how often these medications were used without a diagnosis of asthma or COPD in Finland. METHODS We sent questionnaires that included questions on physician-diagnosed asthma and COPD to a random sample of 2000 Finnish subjects who had been dispensed R03 medications in the previous year. Details of R03 medications dispensed were retrieved from national registries. RESULTS Altogether, 803 subjects (40.6%) responded. Of these, 61.6% had asthma, 5.7% had both asthma and COPD, 5.1% had COPD, and 27.5% had neither asthma nor COPD. Among subjects with asthma or asthma and COPD, inhaled corticosteroids (ICS) were the most frequently dispensed class of drugs (93.7% and 97.8%, respectively). Even among subjects with COPD, ICS were dispensed as frequently (68.3%) as long-acting bronchodilators (70.7%). Antileukotrienes were dispensed mainly to asthmatic individuals only (18.4%) but far less frequently than ICS. The use of theophylline and roflumilast was rare. CONCLUSIONS R03 medications are dispensed far more frequently for asthma than for COPD and often also for subjects without asthma or COPD. In line with guidelines, asthma is treated mainly with ICS, but there seems to be overuse of ICS for COPD.
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Affiliation(s)
- Pekka Juntunen
- Department of Respiratory Medicine, Tampere University Hospital, PO Box 2000, Tampere, N33521, Finland.
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Petri Salmela
- Department of Respiratory Medicine, Tampere University Hospital, PO Box 2000, Tampere, N33521, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Johanna Pakkasela
- Department of Respiratory Medicine, Tampere University Hospital, PO Box 2000, Tampere, N33521, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
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Shabaan AY, Daabis RG, Abdelhady AM, Ibrahim DH. Prevalence of asthma—chronic obstructive pulmonary disease overlap in patients with airflow limitation. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2021. [DOI: 10.1186/s43168-021-00055-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Asthma-COPD overlap (ACO) according to GINA and GOLD is not a single disease and is described by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. Some different protocols were proposed to diagnose ACO, besides those reported in GINA and GOLD guidelines. Despite the discrepancy between all the proposed diagnostic protocols, the diagnosis of ACO is still worthy as it may lead to a more appropriate treatment plan. In Egypt, prevalence of ACO is hardly estimated due to lack of database of patients. Our aim of work was to detect the prevalence of ACO in patients diagnosed as having a chronic airflow limiting disease.
Results
In asthma group (75 patients), 53.3% (40 patients) were diagnosed as ACO with 3 statistically significant favoring diagnostic criteria; post-BDR test FEV1/FVC < 70%, longer disease duration, and sputum neutrophilia ≥ 57%. While in COPD group (75 patients), 42.7% (32 patients) were diagnosed as ACO with four statistically significant favoring diagnostic criteria; higher BDR, presence of personal history of either asthma or atopy and sputum eosinophils > 1%.
Conclusions
ACO has an underestimated prevalence among those diagnosed with either asthma or COPD. More consensus guidelines are needed to focus on the more effective and the more practical criteria to diagnose such hidden disease.
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Qian J, Banks E, Macartney K, Heywood AE, Lassere MN, Liu B. Corticosteroid Use and Risk of Herpes Zoster in a Population-Based Cohort. Mayo Clin Proc 2021; 96:2843-2853. [PMID: 34736610 DOI: 10.1016/j.mayocp.2021.05.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/18/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To examine the relationship between corticosteroid use and herpes zoster risk. METHODS With data from a large cohort of adults (the 45 and Up Study) recruited between 2006 and 2009 and linked to health data sets, the effect of corticosteroid use on zoster risk was analyzed by Cox proportional hazards models, adjusting for age, sex, and other characteristics. RESULTS During 602,152 person-years (median, 7.36 years) of follow-up, there were 20,048 new systemic corticosteroid users and 6294 incident herpes zoster events among 94,677 participants (zoster incidence, 11.0 per 1000 person-years). Compared with nonusers, the risk of zoster was 59% higher in those using systemic corticosteroids (adjusted hazard ratio [aHR], 1.59; 95% CI, 1.48 to 1.71) and greater with higher cumulative doses: aHR of 1.32 (95% CI, 1.17 to 1.48), 1.74 (95% CI, 1.55 to 1.95), and 1.80 (95% CI, 1.61 to 2.02) for use of less than 500 mg, 500 mg to less than 1000 mg, and 1000 mg or more prednisolone equivalents, respectively (P value for trend, <.001). Compared with nonusers, zoster risk increased significantly (aHR, 6.00; 95% CI, 4.85 to 7.42) in the month after a single prescription of systemic corticosteroids and returned to levels similar to those in nonusers by the third month after dispensing (aHR, 0.91; 95% CI, 0.49 to 1.69). CONCLUSION Practitioners should be alert to the increased risk of zoster among patients taking systemic corticosteroids. Given the significant morbidity from zoster, particularly in older adults, these findings support judicious prescribing of corticosteroids, including using as low a dose and as short a course as possible.
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Affiliation(s)
- Jiahui Qian
- School of Population Health, University of New South Wales, Sydney, NSW, Australia.
| | - Emily Banks
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia; The Sax Institute, Sydney, NSW, Australia
| | - Kristine Macartney
- National Centre for Immunisation Research and Surveillance, Westmead, NSW, Australia; Discipline of Child and Adolescent Health, University of Sydney, Sydney, NSW, Australia
| | | | - Marissa Nichole Lassere
- School of Population Health, University of New South Wales, Sydney, NSW, Australia; St George Hospital, Kogarah, NSW, Australia
| | - Bette Liu
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
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Villamañán E, Sobrino C, Carpio C, Moreno M, Arancón A, Lara C, Pérez E, Jiménez C, Zamarrón E, Jiménez-Nácher I, Herrero A, Álvarez-Sala R. Inhaled bronchodilators use and clinical course of adult inpatients with Covid-19 pneumonia in Spain: A retrospective cohort study. Pulm Pharmacol Ther 2021; 69:102007. [PMID: 34129946 PMCID: PMC8196225 DOI: 10.1016/j.pupt.2021.102007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/20/2021] [Accepted: 03/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND In the current coronavirus health crisis, inhaled bronchodilators(IB) have been suggested as a possible treatment for patients hospitalized. Patients with evidence of Covid-19 pneumonia worldwide have been prescribed these medications as part of therapy for the disease, an indication for which this medications could be ineffective taken on account the pathophysiology and mechanisms of disease progression. OBJECTIVE The main objective was to evaluate whether there is an association between IB use and length of stay. Primary end points were the number of days that a patient stayed in the hospital and death as a final event in a time to event analysis. Pneumonia severity, oxygen requirement, involved drugs, comorbidity, historical or current respiratory diagnoses and other drugs prescribed to treat coronavirus pneumonia were also evaluated. METHODS A descriptive, observational, cross-sectional study was performed in this tertiary hospital in Madrid (Spain). Data were obtained regarding patients hospitalized with Covid-19, excluding those who were intubated. The primary and secondary outcomes such as duration of hospitalization and death were compared in patients who received IB with those in patients who did not. RESULTS 327 patients were evaluated, mean age was 64.4 ± 15.8 years. Median length of hospitalization stay was 10 days. Of them 292 (89.3%) overcame the disease, the remaining 35 died. Patients who had received IB did not have less mortality rate (odds ratio 0.839; 95% CI: 0.401 to 1.752) and less hospitalization period when compared with patients who did not received IB (odds ratio 1.280; 95% CI: 0.813 to 2.027). There was no significant association between IB use and recovery or death. Hypertension and diabetes were the most common comorbidities. The prevalence of chronic respiratory disease in our cohort was low (21.1%). Anticholinergics were the IB more frequently prescribed for Covid-19 pneumonia. Better response in patients treated with inhaled corticosteroids was not observed. CONCLUSION Off-label indication of inhaled-bronchodilators for Covid-19 patients are common in admitted patients. Taken on account our results, the use of IB for coronavirus pneumonia apparently is not associated with a significantly patient's improvement. Our study confirms the hypothesis that inhaled bronchodilators do not improve clinical outcomes or reduce the risk of Covid-19 mortality. This could be due to the fact that the virus mainly affects the lung parenchyma and the pulmonary vasculature and probably not the airway. More researches are necessary in order to fill the gap in evidence for this new indication.
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Affiliation(s)
- Elena Villamañán
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain.
| | - Carmen Sobrino
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Carlos Carpio
- Pneumology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Marta Moreno
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Ana Arancón
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Catalina Lara
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Ester Pérez
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Carlos Jiménez
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Ester Zamarrón
- Pneumology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | | | - Alicia Herrero
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
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Villamañán E, Sobrino C, Bilbao C, Fernández J, Herrero A, Calle M, Alvaro D, Segura M, Picazo G, Rodríguez JM, Baldominos G, Ramirez MT, Larrubia Y, Llorente J, Martinez A, Alvarez-Sala R. Off-label use of inhaled bronchodilators in hospitalised patients in Spain: a multicentre observational study. Eur J Hosp Pharm 2020; 28:e23-e28. [PMID: 32332071 DOI: 10.1136/ejhpharm-2019-002171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Off-label prescription of inhaled bronchodilators (IB) is frequent, despite the fact that they can be ineffective and increase avoidable healthcare costs. OBJECTIVE To analyse the frequency of off-label prescription of IB in hospitalised patients. Indications and level of evidence, involved drugs, medical specialties prescribing off-label IB and patients' adherence to IBs were also evaluated. METHOD A descriptive, observational, cross-sectional study was performed in four tertiary hospitals in Spain. The main outcome measure was the number of patients prescribed off-label IBs. Prescriptions were checked against the European Medicines Agency-approved indications. The level of evidence supporting off-label prescription of IBs (according to MICROMEDEX 2.0) was also analysed. Patients were interviewed to test differences (off-label vs on-label) in adherence and knowledge about their inhaled therapy. RESULTS 217 patients were prescribed IBs, 92 of whom were givend off-label IBs (54.7% men, mean age 73.9±12.9 years). The most common off-label prescriptions for IBs were: unspecified dyspnoea (not related to COPD or asthma) (27.2%), respiratory infections (23.9%) and heart failure (22.8%). 76.8% of patients did not have evidence supporting them. Beta2-agonist+corticosteroids and anticholinergics were most commonly prescribed off-label. Internal Medicine was the main medical specialty involved. There were no differences between off-label and on-label users in terms of patients' knowledge about treatment and adherence. CONCLUSION Off-label indications for IBs are common in hospitalised patients and are generally indicated without scientific support. Dyspnoea not related to COPD or asthma, respiratory infections and heart failure were the main off-label indications, most frequently treated with anticholinergics and beta2-agonists+corticosteroids, for which their efficacy and safety has not been proved. Our results show that prescribing needs to be improved to follow the evidence that exists. Moreover, further research focused on off-label indications is needed to clarify whether they are effective, safe and cost-effective.
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Affiliation(s)
| | | | - Cristina Bilbao
- Pharmacy, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | | | | | - Myriam Calle
- Pharmacy, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Dolores Alvaro
- Pneumology, Mostoles University Hospital, Mostoles, Spain
| | - Maria Segura
- Pharmacy, Mostoles University Hospital, Mostoles, Spain
| | - Gracia Picazo
- Pharmacy, Mostoles University Hospital, Mostoles, Spain
| | | | - Gema Baldominos
- Pharmacy, Hospital Universitario Principe de Asturias, Alcala de Henares, Spain
| | - Maria Teresa Ramirez
- Pneumology, Infanta Sofia University Hospital, San Sebastian de los Reyes, Spain
| | - Yolanda Larrubia
- Pharmacy, Infanta Sofia University Hospital, San Sebastian de los Reyes, Spain
| | - Jesús Llorente
- Pharmacy, Infanta Sofia University Hospital, San Sebastian de los Reyes, Spain
| | - Alicia Martinez
- Infanta Sofia University Hospital, San Sebastian de los Reyes, Spain
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Denholm R, van der Werf ET, Hay AD. Use of antibiotics and asthma medication for acute lower respiratory tract infections in people with and without asthma: retrospective cohort study. Respir Res 2020; 21:4. [PMID: 31906966 PMCID: PMC6945474 DOI: 10.1186/s12931-019-1233-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/07/2019] [Indexed: 02/13/2023] Open
Abstract
Background Antibiotics are overused in patients with acute lower respiratory tract infections (ALRTIs), but less is known about their use in patients with asthma, or the use of asthma medication for ALRTI in patients without asthma. Our aim was to describe the frequency, variation and drivers in antibiotic and asthma medication prescribing for ALRTI in adults with and without asthma in primary care. Methods A retrospective cohort analysis of patients aged ≥12 years, diagnosed with an ALRTI in primary care in 2014–15 was conducted using data from the Clinical Practice Research Datalink. Current asthma status, asthma medication and oral antibiotic use within 3 days of ALRTI infection was determined. Treatment frequency was calculated by asthma status. Mixed-effect regression models were used to explore between-practice variation and treatment determinants. Results There were 127,976 ALRTIs reported among 110,418 patients during the study period, of whom 17,952 (16%) had asthma. Respectively, 81 and 79% of patients with and without asthma received antibiotics, and 41 and 15% asthma medication. There were significant differences in between-practice prescribing for all treatments, with greatest differences seen for oral steroids (odds ratio (OR) 18; 95% CI 7–82 and OR = 94; 33–363, with and without asthma) and asthma medication only (OR 7; 4–18 and OR = 17; 10–33, with and without asthma). Independent predictors of antibiotic prescribing among patients with asthma included fewer previous ALRTI presentations (≥2 vs. 0 previous ALRTI: OR = 0.25; 0.16–0.39), higher practice (OR = 1.47; 1.35–1.60 per SD) and prior antibiotic prescribing (3+ vs. 1 prescriptions OR = 1.28; 1.04–1.57) and concurrent asthma medication (OR = 1.44; 1.32–1.57). Independent predictors of asthma medication in patients without asthma included higher prior asthma medication prescribing (≥7 vs. 0 prescriptions OR = 2.31; 1.83–2.91) and concurrent antibiotic prescribing (OR = 3.59; 3.22–4.01). Conclusion Findings from the study indicate that antibiotics are over-used for ALRTI, irrespective of asthma status, and asthma medication is over-used in patients without asthma, with between-practice variation suggesting considerable clinical uncertainty. Further research is urgently needed to clarify the role of these medications for ALRTI.
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Affiliation(s)
- Rachel Denholm
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Esther T van der Werf
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK.,School of Medicine, Taylor's University, Subang Jaya, Selangor, Malaysia
| | - Alastair D Hay
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
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7
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Trajectory Analyses of Adherence Patterns in a Real-Life Moderate to Severe Asthma Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:1961-1969.e6. [PMID: 31857262 DOI: 10.1016/j.jaip.2019.12.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/04/2019] [Accepted: 12/04/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Global Initiative for Asthma step 5 therapies (GINA-5), other than inhaled corticosteroids and long-acting β-agonists in fixed dose combinations (ICS/LABA FDC), often entail more expensive (eg, monoclonal biologics) or less safe (eg, maintenance oral corticosteroids [OCS]) treatments. It is therefore important to assess poor inhaler adherence as a possible cause of suboptimal response to ICS/LABA FDC before additional GINA-5. OBJECTIVE To determine rates of, and time to, additional GINA-5 after first-year ICS/LABA FDC use, and their association with inhaler adherence. METHODS Patients initiating ICS/LABA FDC between 2013 and 2017 were identified from Australian national dispensing data. Group-based trajectory modeling was used to estimate medication adherence patterns. Multivariable Cox proportional hazards models were used to examine the association between adherence trajectories and GINA-5 addition during 2-year follow-up. RESULTS In total, 3062 new ICS/LABA FDC users were identified, of whom 120 (3.9%) received additional GINA-5 (OCS: 89; long-acting muscarinic antagonists: 39; biologics: <3). Mean time to commencing additional GINA-5 was 705.2 (standard deviation, 1.7) days. Adherence trajectories were nonpersistent use (20%), seasonal use (8%), poor adherence (58%), and good adherence (13%). Although poor adherence was associated with longer time to additional GINA-5 (adjusted hazard ratio: 0.58; 95% confidence interval: 0.35-0.95), over 80% of additional GINA-5 was commenced in poorly adherent patients. Use of ≥2 OCS/antibiotic courses also predicted additional GINA-5. CONCLUSIONS Almost 1 in 20 people with asthma commenced additional GINA-5 after ICS/LABA initiation, most of whom (>80%) were poorly adherent to inhaled preventers. There is a substantial unmet need for inhaler adherence to be addressed before prescribing additional GINA-5.
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8
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Askin CC, Coviello MJ, Reis MJ. An unusual mimicker of asthma in an active duty army physician: Common variable immunodeficiency presenting as granulomatous lymphocytic interstitial lung disease. Respir Med Case Rep 2019; 29:100965. [PMID: 31828008 PMCID: PMC6889248 DOI: 10.1016/j.rmcr.2019.100965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 01/02/2023] Open
Abstract
Active duty service members are frequently diagnosed with asthma after referral to pulmonary for undifferentiated cough and dyspnea. Occasionally, patients have symptoms despite optimal therapy necessitating evaluation for asthma mimickers. We present a 48 year-old active duty physician who initially presented in 2007 with dyspnea and cough. Despite the absence of variable obstruction on spirometry, a clinical diagnosis of asthma was made. The patient's symptoms were temporized with inhaled corticosteroids and bronchodilators, titrated to his symptoms, until eventual therapeutic failure resulted in re-referral to pulmonary. Chest computed tomography (CT) showed ground-glass nodules and patchy airspace opacities with evidence of thoracic lymphadenopathy. A positron emission tomography CT (PET CT) showed diffuse adenopathy throughout his thorax and abdomen with high avidity for fluorodeoxyglucose (FGD)-18. This prompted a comprehensive pathologic and serologic evaluation that unveiled a diagnosis of granulomatous-lymphocytic interstitial lung disease (GLILD) secondary to common variable immunodeficiency (CVID). Once the diagnosis was made, the patient was treated with intravenous immunoglobulin resulting in clinical improvement. Given the patient's time-to-diagnosis and response to IVIG monotherapy, this case serves as a unique presentation of a rare pathophysiologic entity which should be considered in refractory cough and dyspnea with radiographic abnormalities.
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Affiliation(s)
- Cpt Cyrus Askin
- Department of Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Maj Jean Coviello
- Department of Pathology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Maj Justin Reis
- Department of Pulmonary & Critical Care Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
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9
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Fens T, van der Pol S, Kocks JWH, Postma MJ, van Boven JFM. Economic Impact of Reducing Inappropriate Inhaled Corticosteroids Use in Patients With Chronic Obstructive Pulmonary Disease: ISPOR's Guidance on Budget Impact in Practice. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1092-1101. [PMID: 31563251 DOI: 10.1016/j.jval.2019.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/01/2019] [Accepted: 05/25/2019] [Indexed: 05/21/2023]
Abstract
OBJECTIVES To assess the budget impact of restricting inappropriate inhaled corticosteroids (ICS) use according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD)-guidelines indication for ICS use in the chronic obstructive pulmonary disease (COPD)-population, taking The Netherlands as a reference case. METHODS A budget impact model was developed and closely aligned with the International Society for Pharmacoeconomics and Outcomes Research best-practice guidelines. The model estimates the impact of pharmacologic COPD maintenance treatments on clinical events (exacerbations and pneumonias) and associated healthcare utilization and costs. The current treatment mix included all maintenance treatments including long-acting muscarinic antagonists (LAMA), long-acting β2-agonists (LABA), LABA/ICS, LABA/LAMA, and triple therapy (LABA/LAMA/ICS). We modeled a situation where 25% of patients would use ICS-containing treatments and compared this to the current Dutch situation with 60% ICS use. A 5-year time horizon with a Dutch healthcare payer's perspective was used. In sensitivity analyses, a range of values for absolute ICS reduction (20%-40%), relative risks of exacerbations and pneumonia events, and other input parameters were explored. RESULTS Over a period of 5 years, the new treatment mix with Global Initiative for Chronic Obstructive Lung Disease guideline recommended ICS, and LABA/LAMA use resulted in potential avoidance of 17 405 exacerbations and 11 984 pneumonias and accompanied savings of €84 million in the base-case scenario. Savings were consistent in various sensitivity analyses, indicating cost savings between €30 and €200 million. CONCLUSION Reducing inappropriate ICS use and increasing use of LABA/LAMA in COPD patients could result in a reduction of exacerbations and pneumonias, corresponding with a reduction in total costs for COPD in The Netherlands.
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Affiliation(s)
- Tanja Fens
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Simon van der Pol
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | | | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands; Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Groningen, the Netherlands
| | - Job F M van Boven
- Department of General Practice & Elderly Care Medicine, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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10
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Mikalsen IB, Dalen I, Karlstad Ø, Eide GE, Magnus M, Nystad W, Øymar K. Airway symptoms and atopy in young children prescribed asthma medications: A large-scale cohort study. Pediatr Pulmonol 2019; 54:1557-1566. [PMID: 31273956 DOI: 10.1002/ppul.24437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/15/2019] [Indexed: 11/09/2022]
Abstract
Diagnosing asthma and deciding treatment are difficult in young children. An inappropriate and too high prescription rate of inhaled corticosteroids (ICS) is suggested, but how airway symptoms are associated with prescriptions of asthma medication is less known. We studied how strongly wheeze, lower respiratory tract infections (LRTI), and atopic diseases are associated with dispensing of asthma medications during early childhood. We used data from the Norwegian Mother and Child Cohort Study and the Norwegian Prescription Database at four age-intervals (0-6, 6-18, 18-36 months, and 3-7 years). Primary outcomes were dispensed asthma medications (no medication, short-acting β-2 agonist, or ICS). Relative risks (RRs) and average attributable fractions (AAFs) were estimated. Both wheeze and LRTI were positively associated with both medication groups (0-6 months: no data on wheeze). The RRs and AAFs were higher for wheeze than LRTI. For ICS, the AAFs (95% CI) for wheeze vs LRTI were: 6 to 18 months: 69.2 (67.2, 71.2)% vs 10.4 (9.0, 11.8)%, 18 to 36 months: 33.0 (30.5, 35.5)% vs 10.0 (8.0, 12.0)%, and 3 to 7 years: 33.7 (31.0, 36.5)% vs 1.2 (0.5, 1.9)%. Except at 3 to 7 years of age, the AAFs were lower for atopic diseases than for LRTI and wheeze. Atopic diseases modified the associations between wheeze and ICS at 18 to 36 months and between LRTI or wheeze and ICS at 3 to 7 years. In conclusion, both wheeze and LRTI were associated with prescriptions of asthma medications in young children, with the strongest associations seen for wheeze. Atopic diseases contributed to these associations only in the oldest age groups.
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Affiliation(s)
- Ingvild Bruun Mikalsen
- Department of Pediatrics, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Norway
| | - Ingvild Dalen
- Department of Research, Section of Biostatistics, Stavanger University Hospital, Stavanger, Norway
| | - Øystein Karlstad
- Department of Chronic Diseases and Aging, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Maria Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway.,MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Wenche Nystad
- Department of Chronic Diseases and Aging, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Knut Øymar
- Department of Pediatrics, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Norway
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11
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Belhassen M, Nolin M, Nibber A, Ginoux M, Devouassoux G, Van Ganse E. Changes in Persistent Asthma Care and Outcomes From 2006 to 2016 in France. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1858-1867. [PMID: 30836232 DOI: 10.1016/j.jaip.2019.02.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Changes in asthma care need to be documented at arrival of biotherapies. OBJECTIVES To characterize changes in asthma care and outcomes in patients with persistent asthma. METHODS Repeated transversal analyses were conducted on a historical cohort using the French national claims data over 10 years. Patients aged 18 to 40 years with either 1 or more (any-use population) or 4 or more (high-use population) yearly dispensings of controller therapy were selected. Clinical and demographic features were characterized, and comparisons were made between 2006 and 2016 to assess temporal changes in asthma therapy, health care resource utilization, and outcomes. RESULTS In 2016, prevalent use of controller therapy was 5.2% (any-use population) and 0.8% (high-use population) of the population aged 18 to 40 years. In the any-use population, the use of long-acting β2-agonists in monotherapy, and inhaled corticosteroids decreased (1.7% and 40.3% in 2016, respectively), whereas the use of fixed-dose combinations increased (56.4%). In both populations, visits to respiratory or hospital physicians and pulmonary function testing increased with time, in parallel to a decreasing number of general practitioner visits; in addition, oral corticosteroid use and incidence of emergency room visits increased. However, asthma hospitalizations and mortality remained low in both populations. CONCLUSIONS Changes in persistent asthma care included replacement of inhaled corticosteroids by fixed-dose combinations, decreased use of long-acting β2-agonists as a monotherapy, and increased involvement of secondary care physicians. In parallel, despite low figures for hospital admissions and mortality, overall use of oral corticosteroids and incidence of emergency room visits have increased over the last decade.
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Affiliation(s)
| | - Maëva Nolin
- PELyon, PharmacoEpidemiology Lyon, Lyon, France
| | - Anjan Nibber
- University of Oxford Medical School, Oxford, United Kingdom
| | | | - Gilles Devouassoux
- Respiratory Medicine, Croix Rousse University Hospital, and EA7426 University Claude Bernard Lyon-1, Lyon, France
| | - Eric Van Ganse
- PELyon, PharmacoEpidemiology Lyon, Lyon, France; Respiratory Medicine, Croix Rousse University Hospital, and EA7426 University Claude Bernard Lyon-1, Lyon, France; HESPER 7425, Health Services and Performance Research, University Claude Bernard Lyon 1, Lyon, France
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12
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Vrijens B, Dima AL, Van Ganse E, van Boven JFM, Eakin MN, Foster JM, de Bruin M, Chisholm A, Price D. What We Mean When We Talk About Adherence in Respiratory Medicine. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 4:802-12. [PMID: 27587314 DOI: 10.1016/j.jaip.2016.05.019] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/19/2016] [Accepted: 05/27/2016] [Indexed: 11/26/2022]
Abstract
Adequate medication adherence is key for optimal benefit of pharmacological treatments. A wealth of research has been conducted to understand and identify opportunities to intervene to improve medication adherence, but variations in adherence definitions within prior research have led to ambiguity in study findings. The lack of a standard taxonomy hinders the development of cumulative science in adherence research. This article reviews the newly established Ascertaining Barriers to Compliance (ABC) taxonomy for medication adherence with a particular focus on its relevance and applicability within the context of asthma and chronic obstructive pulmonary disease management. Building on traditional definitions and concepts within medication adherence, the ABC taxonomy considers the temporal sequence of steps a patient must undertake to be defined as "adherent to treatment": (A) initiation, (B) implementation, and (C) persistence. We explain the clinical and research relevance of differentiating between these phases, point to differences in its applicability in observational and experimental research, review strengths and limitations of available measures, and highlight recent findings on specific determinants of these behaviors. Finally, we provide recommendations for research and practice with a view to supporting and sign posting opportunities to improve future respiratory medication adherence and associated research.
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Affiliation(s)
- Bernard Vrijens
- WestRock Healthcare, Visé, Belgium; Department of Public Health, University of Liège, Liège, Belgium.
| | - Alexandra L Dima
- Amsterdam School of Communication Research ASCoR, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric Van Ganse
- Pharmaco-Epidemiology Lyon (PEL), HESPER, Claude Bernard University, Lyon, France; Respiratory Medicine, Croix-Rousse University Hospital, Lyon, France
| | - Job F M van Boven
- Department of Primary Care, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Md
| | - Juliet M Foster
- Woolcock Institute of Medical Research, Clinical Management Group, University of Sydney, Sydney, Australia
| | - Marijn de Bruin
- Amsterdam School of Communication Research ASCoR, University of Amsterdam, Amsterdam, The Netherlands; Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - David Price
- Respiratory Effectiveness Group, Cambridge, UK; Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
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13
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Burnley B, P Jones H. Corticotropin-releasing hormone improves survival in pneumococcal pneumonia by reducing pulmonary inflammation. Physiol Rep 2017; 5:5/1/e13000. [PMID: 28057851 PMCID: PMC5256152 DOI: 10.14814/phy2.13000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/13/2016] [Accepted: 09/18/2016] [Indexed: 11/24/2022] Open
Abstract
The use of glucocorticoids to reduce inflammatory responses is largely based on the knowledge of the physiological action of the endogenous glucocorticoid, cortisol. Corticotropin‐releasing hormone (CRH) is a neuropeptide released from the hypothalamic–pituitary–adrenal axis of the central nervous system. This hormone serves as an important mediator of adaptive physiological responses to stress. In addition to its role in inducing downstream cortisol release that in turn regulates immune suppression, CRH has also been found to mediate inflammatory responses in peripheral tissues. Streptococcus pneumoniae is a microorganism commonly present among the commensal microflora along the upper respiratory tract. Transmission of disease stems from the resident asymptomatic pneumococcus along the nasal passages. Glucocorticoids are central mediators of immune suppression and are the primary adjuvant pharmacological treatment used to reduce inflammatory responses in patients with severe bacterial pneumonia. However, controversy exists in the effectiveness of glucocorticoid treatment in reducing mortality rates during S. pneumoniae infection. In this study, we compared the effect of the currently utilized pharmacologic glucocorticoid dexamethasone with CRH. Our results demonstrated that intranasal administration of CRH increases survival associated with a decrease in inflammatory cellular immune responses compared to dexamethasone independent of neutrophils. Thus, providing evidence of its use in the management of immune and inflammatory responses brought on by severe pneumococcal infection that could reduce mortality risks.
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Affiliation(s)
- Brittney Burnley
- Institute of Molecular Medicine, UNT Health Science Center, Fort Worth, Texas
| | - Harlan P Jones
- Institute of Molecular Medicine, UNT Health Science Center, Fort Worth, Texas
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14
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Reddel HK. Treatment of overlapping asthma-chronic obstructive pulmonary disease: Can guidelines contribute in an evidence-free zone? J Allergy Clin Immunol 2015; 136:546-52. [PMID: 26343938 DOI: 10.1016/j.jaci.2015.06.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 06/25/2015] [Accepted: 06/30/2015] [Indexed: 01/18/2023]
Abstract
In their most typical forms, asthma and chronic obstructive pulmonary disease (COPD) are clearly distinguishable, but many patients with chronic airflow limitation demonstrate features of both conditions and have worse health outcomes than those with either disease alone. This has been called the asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS), but as yet, it lacks a precise definition. However, given the different pathways by which a patient can come to demonstrate features of both asthma and COPD, ACOS is not thought to represent a single disease but to include several heterogeneous phenotypes with different underlying mechanisms. These issues have important implications for guidelines because some existing treatment recommendations for asthma and COPD are in conflict, and patients with both asthma and COPD have specifically been excluded from major pharmacologic trials. As a result, there is little evidence at present to support specific treatment recommendations for ACOS on the basis of efficacy or effectiveness, yet these patients continue to present for diagnosis and management, mainly in primary care. This article highlights the need for clinical guidance about ACOS, summarizes recommendations about its diagnosis and treatment from a sample of national asthma and COPD guidelines, and proposes a way forward, as suggested in a collaborative Global Initiative for Asthma/Global Initiative for Chronic Obstructive Lung Disease report, to provide health professionals with interim recommendations about syndromic recognition and initial treatment based on both potential effectiveness and potential risk. Additional research in broad populations is urgently needed to develop a precise definition for ACOS, characterize its phenotypes, and identify opportunities for targeted treatment.
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Affiliation(s)
- Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.
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15
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Øymar K, Mikalsen IB, Furu K, Nystad W, Karlstad Ø. Prescription patterns of inhaled corticosteroids for preschool children--A Norwegian register study. Pediatr Allergy Immunol 2015; 26:655-61. [PMID: 26110251 DOI: 10.1111/pai.12429] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although guidelines for treatment of wheeze and asthma in preschool children are available, symptoms are overlapping and it may be difficult to decide which children should be given inhaled corticosteroids (ICS). Previous studies suggest an inappropriate prescription pattern of ICS in this age group. We studied time trends of ICS use in preschool children in Norway during 2004-2013 by age, gender and physician specialty, and the persistence of ICS use during preschool years. METHODS Data were drawn from the Norwegian Prescription Database. The study population consisted of children ≤5 years who were prescribed ICS (alone or in combination) during 2004-2013. RESULTS The one-year prevalence of ICS use was generally high, and increased from 2004 to 2010, but decreased thereafter. The prevalence was highest in 2-year-olds (boys 12.9% and girls 9.3% in 2010) and declined by age, and higher among boys in all ages. 40-50% of ICS users received only one prescription per year. The share of children with persistent use of ICS over several preschool years was low, irrespective of the age at the first prescription. The majority of prescriptions were given by general practitioners, increasing during the study period. CONCLUSIONS The prevalence of ICS prescription for preschool children was high, but with low persistence, suggesting that ICS are frequently given for intermittent asthma-like symptoms. Asthma guidelines suggest a restrictive use of ICS during the first years of life, and the results may call for actions to better implement these guidelines.
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Affiliation(s)
- Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Kari Furu
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Wenche Nystad
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Øystein Karlstad
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
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Reddel HK, Sawyer SM, Everett PW, Flood PV, Peters MJ. Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population. Med J Aust 2015; 202:492-7. [PMID: 25971575 DOI: 10.5694/mja14.01564] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 03/17/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify patterns of asthma control and treatment in Australian adults with asthma. DESIGN Cross-sectional web-based survey, conducted 1-27 November 2012. PARTICIPANTS Adults with current asthma, at least 16 years of age, drawn randomly from a web-based panel and weighted to reflect national population proportions for people with asthma. MAIN OUTCOME MEASURES Asthma Control Test (ACT) scores; health care utilisation; medication use. RESULTS 2686 participants completed the survey (57.1% female; median age group, 40-49 years). Mean ACT score was 19.2 (95% CI, 18.9-19.3), with asthma classified as "well controlled" for 54.4% of participants, "not well controlled" for 22.7% and "very poorly controlled" for 23.0%. 60.8% reported using preventer medication (mostly combined inhaled corticosteroid/long-acting β2-agonist) during the previous year. 23.4% had made at least one urgent visit to a general practitioner concerning their asthma, 10.0% at least one emergency department visit. Urgent consultations were more common for "very poorly controlled" than "well controlled" asthma (adjusted odds ratio, urgent GP visits 5.98 [95% CI, 4.75-7.54] and emergency department visits 2.59 [95% CI, 1.91-3.53] respectively). Participants were classified according to asthma symptom control and frequency of preventer medication usage: Those with "well controlled" asthma included Group A (40.0% of participants) who used preventer medication infrequently (less than 5 days a week) or not at all, consistent with mild asthma, and Group B (14.7%), who used it at least 5 days a week. Uncontrolled asthma symptoms were reported by Group C (19.7%) despite regular preventer use, and by Group D (25.7%), who used none or little. CONCLUSIONS This study provides the first data about asthma control and its relationship with treatment in a large representative Australian population. The findings highlight significant preventable asthma morbidity in Australia.
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Affiliation(s)
- Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, NSW, Australia.
| | - Susan M Sawyer
- Centre for Adolescent Health, Royal Children's Hospital, Melbourne, VIC, Australia
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Prevalence of inappropriate prescribing of inhaled corticosteroids for respiratory tract infections in the Netherlands: a retrospective cohort study. NPJ Prim Care Respir Med 2014; 24:14086. [PMID: 25320938 PMCID: PMC4373501 DOI: 10.1038/npjpcrm.2014.86] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 07/30/2014] [Accepted: 08/30/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are recommended in prevailing guidelines for use in patients with persistent asthma or moderate-to-severe chronic obstructive pulmonary disease (COPD) and recurrent exacerbations. Recent data from Australia showed that 44% of patients with a single ICS dispensing and without other respiratory inhalation medications ('one-off ICS') were co-dispensed oral antibiotics. Evidence of the merit of ICS for treating respiratory infections in subjects without asthma or COPD is lacking. AIMS The aims of the study were to describe the rate of one-off ICS dispensing in combination with oral antibiotics in subjects without chronic respiratory conditions in the Netherlands, and to compare this with the rate of one-off ICS dispensing in combination with oral antibiotics as reported earlier from Australia. METHODS Dispensing data were obtained from the Dutch Foundation of Pharmaceutical Statistics. Additional information was available on patients' age, sex and prescriber. Patients with any ICS dispensing in 2011 were selected. RESULTS Data were available from 1,725 Dutch community pharmacies (88%). Of 845,068 ICS users in 2011, 10% were dispensed one-off ICS, among which 13% had oral antibiotics co-dispensed. These ICS were mainly prescribed by general practitioners, mostly during winter months, for elderly persons, after high dosages of oral corticosteroids, and in single-inhaler combinations with a long-acting β2-agonist. The extrapolated total annual expense for this ICS use was € 555,000. CONCLUSION In the Netherlands one-off ICS dispensing in combination with oral antibiotics in subjects without chronic respiratory conditions was considerably lower than in Australia.
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