Prescribing Emergency Oral Steroids in Asthma Clinics [published online ahead of print June 11, 2019]

To assess how often acutely wheezing pediatric patients requiring oral corticosteroids (OCS) had filled their controller inhaled steroids in the preceding six months.

Wheezing children in a tertiary pediatric respiratory care clinic in London, England, during a two-year period (2016–2017) who were prescribed oral steroids at that visit were included in analysis.

This retrospective study reviewed charts to identify asthmatic patients who were symptomatic and prescribed an oral steroid at their office visit. Children were excluded if there was no evidence of asthma, longstanding corticosteroid use, OCS used for a trial of responsiveness, or given oral steroids to have at home for emergency circumstances. Charts were reviewed to identify age, sex, comorbidities, atopy, perception of asthma if commented upon, lung function, and bronchodilator response. Prescriptions of inhaled steroids or combination inhalers were documented in the 6 months preceding the date of OCS prescription.

There were 32 courses of prednisolone that were prescribed in 25 children, with 20 having 1 prescription, 4 had two, and 1 had four prescriptions. Sixty percent were boys, and 68% had atopic comorbidities, including allergic rhinitis (n = 14), eczema (n = 9), and food allergies (n = 5). The median dose of OCS was 40 mg (range 20–40 mg) for a median of 3 days (range 3–10 days). 41% of patients had an associated upper or lower respiratory tract infection at the time of the OCS prescription. The median FEV₁% = 62% (range 50% to 73%), FEV₁/FVC% = 73% (range 67% to 83%) and FEV₁% change = 18% (range 7% to 42%) following bronchodilator prior to OCS were recorded. In the 6 months before their exacerbation, patients were prescribed maintenance medications including budesonide/formoterol (12 patients), fluticasone/salmeterol (19 patients), beclomethasone (1 patient), and additionally montelukast in 22 patients. Prescription controller refill information was unavailable for three patients. For the remaining 28 episodes, the median controller refill rate was 33% (range 16% to 79%), and only 29% of children obtained the controller medicine >75% of the time. In those patients with multiple courses of OCS, 10% of them refilled their controller medicine >75% of the time.

Prescribing OCS to a wheezing patient being seen for their routine asthma care and not a sick visit should be a red flag for poor adherence to maintenance therapy.

The need to treat asthma with oral corticosteroids, regardless of the provider, indicates the failure of chronic asthma treatment. This failure increases the risk of a subsequent attack. Nonadherence to therapy is a modifiable risk factor for asthma exacerbations and poor outcomes. When a patient requires oral steroids at a routine asthma visit, two-thirds of the time, they have not been taking their controller medicine as prescribed. With poorly controlled asthma. . .always think compliance with controller therapy first.