Stepping down asthma medication does not adversely affect patient outcomes and could save millions of pounds in medicines costs, a study in PLoS Medicine (21 July 2020) has found.
The researchers used data from UK primary care medical records between 2001 and 2017 to find 508,459 adult asthma patients managed with preventer medication.
They found that prescriptions of higher-level medication such as medium or high doses of inhaled corticosteroids (ICSs), or an ICS plus an add-on medication, such as a long acting beta-2 agonist (LABA); leukotriene receptor antagonist (LTRA); theophylline; or long-acting muscarinic antagonist (LAMA) had steadily increased over time. The proportion of patients on these higher-level medications was 49.8% in 2001 compared to 68.3% in 2017.
In 2017, only 31.7% of patients were treated with low-dose ICSs alone; most were managed with ICSs and one add-on.
The data showed that stepping down medication — defined as either dropping an add-on therapy, halving the ICS inhaler dose, or halving the mean-daily ICS dose — occurred infrequently. Of patients first prescribed ICSs plus one add-on, 70.4% remained on the same medication during a mean follow-up time of 6.6 years.
However, for those who were stepped down, there was no increased exacerbation risk for each possible medication step-down and no increase in reliever prescriptions.
In addition, the researchers calculated that stepping down medication, either LABAs or ICSs, could result in annual savings of around £17,000,000 and £8,600,000, respectively.
The authors said that there was an “increasing tendency” for prescribing higher-dose, expensive asthma medications despite there often being “no clear clinical requirement” for them.
“Stepping down ICSs or add-on therapy did not appear to worsen health outcomes, but did appear to result in significant cost savings,” they concluded.
Toby Capstick, lead respiratory pharmacist at Leeds Teaching Hospitals NHS Trust and chair of the UK Clinical Pharmacy Association Respiratory Group, said that the proportion of asthma patients on higher level medication was “too high”.
“The study clearly demonstrates that there appears to be a reluctance to step down patients on unnecessarily excessive medication, with approximately 77% of patients on ICS plus one additional preventer, and 54% on medium/high-dose who did not have their treatment stepped down despite being stable on existing therapy,” he added.
“Similarly, it’s concerning that patients with evidence of adverse effects of asthma medication (e.g. diabetes, cataracts, glaucoma, osteopenia and osteoporosis) did not prompt a reduction in asthma medication.”
However, Capstick said the study was “reassuring” because it showed that patients could be safely stepped down when stable on therapy with no increase in exacerbation rate or need for additional reliever use.