The Association Between Short-Acting β <sub>2</sub>-Agonist Over-Prescription, and Patient-Reported Acquisition and Use on Asthma Control and Exacerbations: Data from Australia

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Abstract

Introduction

In Australia, short-acting β ₂-agonists (SABA) are available both over the counter (OTC) and on prescription. This ease of access may impact SABA use in the Australian population. Our aim was to assess patterns and outcome associations of prescribed, acquired OTC and reported use of SABA by Australians with asthma.

Methods

This was a cross-sectional study, using data derived from primary care electronic medical records (EMRs) and patient completed questionnaires within Optimum Patient Care Research Database Australia (OPCRDA). A total of 720 individuals aged ≥ 12 years with an asthma diagnosis in their EMRs and receiving asthma therapy were included. The annual number of SABA inhalers authorised on prescription, acquired OTC and reported, and the association with self-reported exacerbations and asthma control were investigated.

Results

92.9% ( n = 380/409) of individuals issued with SABA prescription were authorised ≥ 3 inhalers annually, although this differed from self-reported usage. Of individuals reporting SABA use ( n = 546) in the last 12 months, 37.0% reported using ≥ 3 inhalers. These patients who reported SABA overuse experienced 2.52 (95% confidence interval [CI] 1.73–3.70) times more severe exacerbations and were 4.51 times (95% CI 3.13–6.55) more likely to have poor asthma control than those who reported using 1–2 SABA inhalers. Patients who did not receive SABA on prescription (43.2%; n = 311/720) also experienced 2.71 (95% CI 1.07–7.26) times more severe exacerbations than those prescribed 1–2 inhalers. Of these patients, 38.9% reported using OTC SABA and other prescription medications, 26.4% reported using SABA OTC as their only asthma medication, 13.2% were prescribed other therapies but not SABA OTC and 14.5% were not using any medication.

Conclusion

Both self-reported SABA overuse and zero SABA prescriptions were associated with poor asthma outcomes. The disconnect between prescribing authorisation, OTC availability and actual use, make it difficult for clinicians to quantify SABA use.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-023-02746-0.

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Most cited references 26

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Overuse of short-acting β 2 -agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme

Bright I. Nwaru, Magnus P Ekström, Pål Hasvold … (2020)

Background Overuse of short-acting β2-agonists (SABA) may indicate poor asthma control and adverse health outcomes. Contemporary population-based data on use, risk factors and impact of SABA (over)use on asthma exacerbations and mortality are scarce, prompting initiation of the global SABINA (SABA use IN Asthma) programme. Methods By linking data from Swedish national registries, asthma patients aged 12–45 years with two or more collections of drugs for obstructive lung disease during 2006–2014 were included. SABA overuse was defined as collection of more than two SABA canisters in a 1-year baseline period following inclusion. SABA use was grouped into 3–5, 6–10 and ≥11 canisters per baseline-year. Cox regression was used to examine associations between SABA use and exacerbation (hospitalisations and/or oral corticosteroid claims) and mortality. Results The analysis included 365 324 asthma patients (mean age 27.6 years; 55% female); average follow-up was 85.4 months. 30% overused SABA, with 21% collecting 3–5 canisters per year, 7% collecting 6–10 canisters per year and 2% collecting ≥11 canisters per year. Increasing number of collected SABA canisters was associated with increased risk of exacerbation, as follows. 3–5 canisters: hazard ratio (HR) 1.26 (95% CI 1.24–1.28); 6–10 canisters: 1.44 (1.41–1.46); and ≥11 canisters: 1.77 (1.72–1.83), compared to two or fewer canisters per year. Higher SABA use was associated with incrementally increased mortality risk (2564 deaths observed), as follows. 3–5 canisters: HR 1.26 (95% CI 1.14–1.39); 6–10 canisters 1.67 (1.49–1.87); and ≥11 canisters: 2.35 (2.02–2.72) compared to two or fewer canisters per year. Conclusion One-third of asthma patients in Sweden collected three or more SABA canisters annually. SABA overuse was associated with increased risks of exacerbation and mortality. These findings emphasise that monitoring of SABA usage should be key in improving asthma management.

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Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study

David B. Price, Frank Trudo, Jaco Voorham … (2018)

Purpose Prior work suggests a threshold of four courses/year of systemic corticosteroid (SCS) therapy is associated with adverse consequences. The objective of this study was to investigate the onset of adverse outcomes beginning at SCS initiation in a broad asthma population. Patients and methods This historical matched cohort study utilized anonymized, longitudinal medical record data (1984–2017) of patients (≥18 years) with active asthma. Matched patients with first SCS prescription (SCS arm) and no SCS exposure (non-SCS arm) were followed until first outcome event. Associations between time-varying exposure measures and onset of 17 SCS-associated adverse outcomes were estimated using Cox proportional hazard regression, adjusting for confounders, in separate models. Results We matched 24,117 pairs of patients with median record availability before SCS initiation of 9.9 and 8.7 years and median follow-up 7.4 and 6.4 years in SCS and non-SCS arms, respectively. Compared with patients in the non-SCS arm, patients prescribed SCS had significantly increased risk of osteoporosis/osteoporotic fracture (adjusted hazard ratio 3.11; 95% CI 1.87–5.19), pneumonia (2.68; 2.30–3.11), cardio-/cerebrovascular diseases (1.53; 1.36–1.72), cataract (1.50; 1.31–1.73), sleep apnea (1.40; 1.04–1.86), renal impairment (1.36; 1.26–1.47), depression/anxiety (1.31; 1.21–1.41), type 2 diabetes (1.26; 1.15–1.37), and weight gain (1.14; 1.10–1.18). A dose-response relationship for cumulative SCS exposure with most adverse outcomes began at cumulative exposures of 1.0– 0–<0.5 g reference), equivalent to four lifetime SCS courses. Conclusion Our findings suggest urgent need for reappraisal of when patients need specialist care and consideration of nonsteroid therapy.

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Asthma progression and mortality: the role of inhaled corticosteroids

Paul O'Byrne, Leonardo M Fabbri, Ian Pavord … (2019)

Overall, asthma mortality rates have declined dramatically in the last 30 years, due to improved diagnosis and to better treatment, particularly in the 1990s following the more widespread use of inhaled corticosteroids (ICSs). The impact of ICS on other long-term outcomes, such as lung function decline, is less certain, in part because the factors associated with these outcomes are incompletely understood. The purpose of this review is to evaluate the effect of pharmacological interventions, particularly ICS, on asthma progression and mortality. Furthermore, we review the potential mechanisms of action of pharmacotherapy on asthma progression and mortality, the effects of ICS on long-term changes in lung function, and the role of ICS in various asthma phenotypes. Overall, there is compelling evidence of the value of ICS in improving asthma control, as measured by improved symptoms, pulmonary function and reduced exacerbations. There is, however, less convincing evidence that ICS prevents the decline in pulmonary function that occurs in some, although not all, patients with asthma. Severe exacerbations are associated with a more rapid decline in pulmonary function, and by reducing the risk of severe exacerbations, it is likely that ICS will, at least partially, prevent this decline. Studies using administrative databases also support an important role for ICS in reducing asthma mortality, but the fact that asthma mortality is, fortunately, an uncommon event makes it highly improbable that this will be demonstrated in prospective trials.

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Author and article information

Contributors

David Price:

ORCID: http://orcid.org/0000-0002-9728-9992

dprice@opri.sg

Journal

Journal ID (nlm-ta): Adv Ther

Journal ID (iso-abbrev): Adv Ther

Title: Advances in Therapy

Publisher: Springer Healthcare (Cheshire )

ISSN (Print): 0741-238X

ISSN (Electronic): 1865-8652

Publication date (Electronic): 4 February 2024

Publication date PMC-release: 4 February 2024

Publication date (Print): 2024

Volume: 41

Issue: 3

Pages: 1262-1283

Affiliations

[1 ]Optimum Patient Care, 5 Coles Lane, Oakington, CB24 3BA Cambridgeshire UK

[2 ]Observational and Pragmatic Research Institute, ( https://ror.org/02gq3ch54) 22 Sin Ming Lane, #06-76, Midview City, 573969 Singapore

[3 ]Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, ( https://ror.org/016476m91) Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD UK

[4 ]Optimum Patient Care Australia, 27 Creek St, Brisbane, QLD 4000 Australia

[5 ]GRID grid.1013.3, ISNI 0000 0004 1936 834X, Thoracic Physician Concord Hospital, Head Respiratory Trials, George Institute, , University of Sydney, ; Sydney, Australia

[6 ]Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, ( https://ror.org/01ej9dk98) Level 3, 207 Bouverie Street, VIC, 3010 Australia

[7 ]BioPharmaceuticals Medical and Regional Medical Director for International, The Hague, The Netherlands

[8 ]Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, ( https://ror.org/01sf06y89) Sydney, Australia

[9 ]Woolcock Institute of Medical Research, ( https://ror.org/04hy0x592) 431 Glebe Point Road, Glebe, MSW 2037 Australia

[10 ]AstraZeneca Biopharmaceuticals Medical, Medical Affairs, 66 Talavera Road, Macquarie Park, NSW Australia

[11 ]HealthPlus Medical Centre, 28/26 Belgrave St, Kogarah, NSW 2217 Australia

[12 ]Blue Shield Family General Practice, Kogarah, NSW 2217 Australia

[13 ]Medical Education, and Events Management Pte Ltd, Singapore, Singapore

[14 ]Toukley Family Practice, 37-41 Canton Beach Road, Toukley, NSW 2263 Australia

[15 ]Redlands Medical Centre, 189 Vienna Rd, Alexandra Hills, 4161 Australia

[16 ]Woodcroft Medical Centre, Woodcroft, SA 5162 Australia

[17 ]School of Medicine, Griffith University, ( https://ror.org/02sc3r913) Gold Coast, Australia

[18 ]Cannon Hill Family Doctors, 17/1177 Wynnum Rd, Cannon Hill, QLD 4170 Australia

[19 ]Ripponlea Medical Centre, Ripponlea, VIC 3185 Australia

[20 ]Platinum Medical Centre, 18 Banfield St, Chermside, QLD 4032 Australia

[21 ]Victoria Point Surgery, Brisbane, QLD 4165 Australia

[22 ]Department of Medicine, University of Cape Town, and University Cape Town Lung Institute, ( https://ror.org/03p74gp79) Cape Town, South Africa

[23 ]Queensland Health, ( https://ror.org/00c1dt378) Brisbane, QLD Australia

[24 ]GRID grid.454047.6, ISNI 0000 0004 0584 7841, RACGP Resp Medicine SIG, ; 100 Wellington Parade, East Melbourne, Melbourne, VIC 3002 Australia

[25 ]School of Medicine, University of Tasmania, ( https://ror.org/01nfmeh72) Churchill Ave, Hobart, TAS 7005 Australia

Author information

David Price http://orcid.org/0000-0002-9728-9992

Article

Publisher ID: 2746

DOI: 10.1007/s12325-023-02746-0

PMC ID: 10879376

PubMed ID: 38310584

SO-VID: 651f1c22-de0c-4a65-ad19-684468838885

License:

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 3 August 2023

Date accepted : 20 November 2023

Funding

Funded by: Optimum Patient Care Australia

Funded by: FundRef http://dx.doi.org/10.13039/100004325, AstraZeneca;

Custom metadata

Keywords: short-acting β2-agonists,asthma management,over-the-counter medication,prescription patterns,asthma outcomes

Data availability:

Keywords: short-acting β2-agonists, asthma management, over-the-counter medication, prescription patterns, asthma outcomes