Short courses of oral corticosteroid (OCS) medication are recommended for treatment of moderate to severe asthma exacerbations. Concern has been raised about OCS overuse. Our objective is to describe rates of OCS dispensing among children with asthma and factors associated with variation in OCS dispensing.
Claims data for children 1 to <18 years of age with an asthma diagnosis between January 2011 and January 2016 were extracted from the computerized databases of Texas Children’s Health Plan.
In the years 2011 to 2015, 17.1% to 21.8% of children had an asthma diagnosis. In each of these years 42.1% to 44.2% of these children had ≥1 OCS dispensing. OCS dispensing rates were higher for the children 1 to 4 years of age compared with older children. Repeated OCS dispensing was common, and was most common for children 1 to 4 years of age. Most children with an OCS dispensing (81%–83%) did not have other utilization suggesting poor asthma control (excessive β-agonist refills, emergency department visit, or hospitalization for asthma). OCSs were less commonly prescribed to patients whose primary care provider was a board-certified pediatrician compared with other types of primary care providers. There was large variation in OCS prescribing rates among pediatricians (15%–86%). There were minimal differences in asthma emergency department visits and no differences in hospitalization rates by the pediatrician’s OCS dispensing rate quartile.
The patterns of dispensing observed suggest substantial overprescribing of OCS for children with an asthma diagnosis.
That appropriate use of oral corticosteroid medication (OCS) for moderate to severe asthma exacerbations does not excuse its inappropriate use. The patterns of oral corticosteroid dispensing observed in our study that suggest that a very large number of children are getting oral corticosteroids inappropriately. Although not assessed by the study data, I would speculate that much of the inappropriate oral corticosteroid prescribing is for either mild asthma or for respiratory symptoms that are not asthma. That substantial overuse is occurring is support by the observation that board certified pediatricians had lower rates of oral corticosteroid dispensing than other physicians as well as the observation of minimal and inconsistent differences in asthma hospitalization and emergency department visits by a pediatrician’s oral corticosteroid dispensing rate. (1) Antibiotics used in the right situations can be life saving; however overuse of antibiotics has become a substantial public health problem. The data presented in “Oral Corticosteroid Prescribing for Children With Asthma in a Medicaid Managed Care Program” strongly suggests that there is a similar problem with oral corticosteroids. Their benefit when used in appropriately does not excuse the harm when used inappropriately.
Drs. Grasso, et al. misinterpret the article when they assert that it concludes, “that ICS (inhaled corticosteroid medication) should be prescribed instead of OCS for the treatment of an acute asthma attack”. The conclusion of the article was, “The patterns of dispensing observed suggest substantial overprescribing of OCS for children with an asthma diagnosis”. The role of inhaled corticosteroids in the treatment of acute asthma was not tested by the methods nor assessed by the results nor was it mentioned in the discussion or conclusions. If Dr. Grasso and co-authors would like a detailed evidence based analysis of the intermittent escalation of inhaled corticosteroids for asthma, I would suggest that they refer to the Joint Task Force on Practice Parameters evidence based statement, “Management of Acute Loss of Asthma Control in the Yellow Zone: A Practice Parameter” (2) and to the Point/Counterpoint Debate, “Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? (3,4)
References:
1)Farber HJ, Silveira EA, Vicere DR, Kothari VD, Giardino AP. Oral Corticosteroid Prescribing for Children With Asthma in a Medicaid Managed Care Program. Pediatrics. 2017 May;139(5). pii: e20164146.
2)Dinakar C, Oppenheimer J, Portnoy J, Bacharier LB, Li J, Kercsmar CM, Bernstein D, Blessing-Moore J, Khan D, Lang D, Nicklas R, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; Practice Parameter Workgroup; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology. Management of acute loss of asthma control in the yellow zone: a practice parameter. Ann Allergy Asthma Immunol. 2014 Aug;113(2):143-59.
3)Farber HJ. POINT: Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? Yes.
Chest. 2016 Sep;150(3):488-90.
4)Weinberger M. COUNTERPOINT: Is Escalation of the Inhaled Corticosteroid Dose Appropriate for Acute Loss of Asthma Control in an Attempt to Reduce Need for Oral Corticosteroids in Children? No. Chest. 2016 Sep;150(3):490-2.
Dear Editors
We would argue about the article “Oral Corticosteroid Prescribing for Children With Asthma in a Medicaid Managed Care Program”.
We strongly disagree with the conclusion that ICS should be prescribed instead of OCS for the treatment of acute asthma attack (particularly in preschool children). Though the last meta-analysis on the therapy of pre-schooler with wheezing was favourable to the use of intermittent high dose of ICS in acute asthma attacks, we want to point out that of five RCTs considered only one was statistically significant (1). This RCT was designed by Ducharme just as a proof-of-concept trial and the author himself explains that treatment with ICS analysed in the study currently outweighs the benefit. We want to highlight that ICS dose used in the trial was extremely high (750 µg of fluticasone twice daily for 10 days), and a systemic effect at this dosage should be considered very likely to be similar to OCS or even more significant; in effect author finds that patients treated with ICS had a smaller gain in height than in the control group treated with OCS. Moreover, we would like to emphasize that OCS are effective even in single dose instead of 10 days as reported by Ducharme et coll. for ICS
In accordance to guidelines we think that a short course of OCS should be given to every child with an ongoing moderate to severe attack, or to children with a previous history of severe attack, even more easily under the age of 5, because such patients are more prone to undergo severe asthma attack with hospitalization (3). We would like to remind also that no reliable characteristics could serve as effective predictors of the need of OCS therapy in patients incompletely responsive to bronchodilators(4).
Lastly, OCS are much less expensive than ICS and most of the studies published about the efficacy of ICS in the acute asthma attack is sponsored by ICS manufacturers (5).
1. Kaiser S V, Huynh T, Bacharier LB, Rosenthal JL, Bakel LA, Parkin PC, et al. Preventing Exacerbations in Preschoolers With Recurrent Wheeze: A Meta-analysis. Pediatrics. 2016;137(6).
2. Ducharme FM, Lemire C, Noya FJD, Davis GM, Alos N, Leblond H, et al. Preemptive use of high-dose fluticasone for virus-induced wheezing in young children. N Engl J Med. 2009 Jan 22;360(4):339–53.
3. Ducharme FM, Tse SM, Chauhan B. Diagnosis, management, and prognosis of preschool wheeze. Lancet (London, England). 2014 May 3;383(9928):1593–604.
4. Harris JB, Weinberger MM, Nassif E, Smith G, Milavetz G, Stillerman A. Early intervention with short courses of prednisone to prevent progression of asthma in ambulatory patients incompletely responsive to bronchodilators. J Pediatr. 1987 Apr;110(4):627–33.
5. Lipworth B. Treatment of acute asthma. Lancet 1997 vol 350 october
Asthma is a chronic inflammatory disorder of the airways characterized by recurrent wheezing, breathlessness, and coughing. Mainstay of treatment for acute exacerbations are inhaled beta 2 agonist and anticholinergic agents,oxygen along with corticosteroids.
Acute exacerbations of asthma are an important cause of morbidity, school absenteeism and frequent hospital visits. Global data shows that there is increase in prevalence and severity of asthma.
The broad anti-inflammatory profile of corticosteroids accounts for their clinical effectiveness in asthma. As there is airway inflammation which cause airway compromise in acute exacerbations, there are proven benefits of steroids in acute asthma in resolving the obstruction of the airways.
Corticosteroids have been used in the treatment of asthma for approximately five decades and their proven benefits in the emergency room in treatment of asthma exacerbations. Corticosteroids are the first line drug therapies in the management of acute asthma exacerbations. Oral or parenteral corticosteroids have been been effective equally but parenteral steroids are preferred for critically ill children.
Short-term use of high-dose steroids usually don’t have significant side effects, but may be associated with hyperglycemia, hypertension and other psychiatric problems.
A Cochrane review demonstrated improved outcomes for children who have received corticosteroids at the earliest in the emergency department.
As there is difficulty to decide when steroids should be administered. It has been proved in both adults and children that steroids given for a short duration of 3-7 days, improve the resolution and reduce the chances of an early relapse.
Indications for starting steroids : (i) A child with a severe or very severe attack of asthma; (ii) Previous history of life threatening attack or severe attacks not responding to bronchodilators; and (iii) If the child is on oral steroids or high doses of inhaled steroids for prophylaxis.
Guidelines mention use of prednisolone 1-2 mg/kg/dose every 6 h for 24 h then 1-2 mg/kg/day in divided doses every 8-12 hours. The total duration of therapy can be 3-7 days depending upon the response. However 5-day courses of oral corticosteroids have not been shown to be superior to 3-day courses for outpatient management of acute exacerbations in children.
Studies have shown that the efficacy of steroid therapy is maximum when they are given as early as possible in the emergency room, where as benefits were minimal when steroids were initiated after 24hours of diagnosis. Newer guidelines however, advise use of initial dose of steroids in every attack that is of moderate or more severity.
Aerosolized steroids were earlier found to be ineffective in an acute attack of asthma but reports showing that nebulized dexamethasone may be faster acting than oral prednisolone.
Inhaled corticosteroids are very effective drugs in suppressing airway inflammation.
A Cochrane review did not find a significant reduction in the need for oral corticosteroids in school-aged children. Intermittent ICS did show symptomatic improvement and lower likelihood of requiring oral corticosteroids in preschoolers,
Eventhough ICS treatment is generally considered safe in children. ICS are reported to cause some local and systemic adverse effects. ICS therapy should be started at its lowest effective dose because usually adverse effects are dose-dependent.
There is proven role for ICS in asthma exacerbations. Edmonds et al. showed that ICS reduced hospitalizations in acute asthma where patients did not receive systemic steroids.There is insufficient evidence to recommend that ICS can replace systemic corticosteroids in emergency room for acute asthma exacerbations.
In our view as there are evidence supporting minimal side effects of inhaled corticosteroids which are better than oral corticosteroids in treatment of acute moderate to severe asthma wherever possible. However, Inhaled medications are only effective if they are used properly.
Therefore adherence to daily ICS therapy is most important in asthma control. As asthma is not a curable disease but using good hygienic practices and creating awareness with appropriate controlling measures, child with asthma can lead a healthy life as other children.
References :
1) Chong J, Haran C, Chauhan BF, Asher I. Intermittent inhaled corticosteroid therapy versus placebo for persistent asthma in children and adults. Cochrane Database Syst Rev. 2015;7, CD011032.
2)Edmonds ML, Milan SJ, Camargo Jr CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev. 2012;12, CD002308.
3) Sunil Saharan & Rakesh Lodha & Sushil K. Kabra.Management of Status Asthmaticus in Children.Indian J Pediatr (2010) 77:1417–1423 DOI 10.1007/s12098-010-0189-8
4) Chang AB, Clark R, Sloots TP, et al. . A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial. Med J Aust. 2008;189(6):306–310 [PubMed]
5) Dahl R. Systemic side effects of inhaled corticosteroids in patients with asthma. Respir Med. 2006;100:1307–17.
6) Barnes PJ, Adcock IM. How do corticosteroids work in asthma? Ann Intern Med. 2003;139(5):359–70.
7) Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001; (1): CD002178
8) G.R. Sethi, Monika Bajaj, Vineet Sehgal. Management of Acute Asthma. Indian Pediatrics 1998; 35:745-762
9) Klein-Gitelman MS, Pachman LM. Intravenous corticosteroids: adverse reactions are more variable than expected in children. J Rheumatol. 1998;25:1995–2002
10) Fanta CH, Rossing TH, McFadden ER. Glucocorticoids in acute asthma: A critical controlled trial. Am J Med 1983; 74: 845-851
I appreciate the comment from Dr. Kontor raising the question as to whether out of pocket costs could have the impacted medication adherence and medication choices observed in our study. Texas Children's Health Plan serves a Medicaid insured population, these members had no out of pocket costs for the inhaled corticosteroid medications. A small part of our membership had Children's Health Insurance Plan (CHIP) insurance, which is designed for individuals whose income is too high for Medicaid but too low to purchase commercial insurance. CHIP insured members may have a small co-pay for medications. Although medication costs can be a barrier to adherence, as most of our membership had no medication co-pays and a small proportion had low co-pays out of pocket costs are unlikely to explain observed medication usage rates or medication choices in our study population.
Part of the problem may be due to insurance formularies. Some plans do not cover inhaled steroids and the patient/family may not afford it; will request and use low-cost oral steroid courses instead of preventing exacerbations with regular ICS therapy.