Stepping down of asthma treatment 'worryingly infrequent' despite clinical and cost benefits

Asthma guidelines recommend stepping down of medication in stable patients, but new research shows this is not happening routinely in practice despite being safe and cost-effective.

Stepping down of asthma treatment can reduce the risk of side-effects from long-term use of medication, particularly inhaled corticosteroids. | GETTY IMAGES
Stepping down of asthma treatment can reduce the risk of side-effects from long-term use of medication, particularly inhaled corticosteroids. | GETTY IMAGES

Patients with asthma are increasingly being prescribed 'higher-level' treatment – often without clear clinical need – and a large proportion never have their medication stepped down despite the clinical and cost benefits of doing so, according to a study by UK researchers

'Worryingly, although stepping down of treatment is recommended by clinical guidelines, we found that it happened infrequently,' said the researchers. 'Stepping down inhaled corticosteroids or add-on therapy did not appear to worsen health outcomes but did appear to result in significant cost savings,' they report. 

Stepping down

The researchers, from Imperial College London and the University of Edinburgh, used UK primary care records from 2001 to 2017 to identify 508,459 adults with asthma who were prescribed preventer medication. 

They found that prescriptions of higher-level medication, such as medium- or high-dose inhaled corticosteroids, or inhaled corticosteroids with add-on medication such as long-acting ß2-agonists (LABAs), increased from 49.8% in 2001 to 68.3% in 2017.

Among patients prescribed their first preventer, one third were prescribed a higher-level medication. Half of these had no reliever prescription or asthma exacerbation in the preceding year, suggesting the prescribers were not following clinical guidelines. Of the patients first prescribed inhaled corticosteroids with one add-on treatment, the majority (70.4%) remained on the same medication during a mean follow-up of 6.6 years. 

One in 8 patients (13.0%) who were prescribed a medium- or high-dose inhaled corticosteroid as their first preventer already had conditions that could be worsened by corticosteroids, such as diabetes, glaucoma or osteoporosis.

The researchers analysed a subset of 125,341 patients to assess the impact of stepping down medication (ie, stopping the patient's LABA, stopping other add-on treatment, or halving their dose of inhaled corticosteroids). They found that there was no increase in exacerbation risk or reliever prescriptions for any type of medication stepdown. 

Cost savings

Stepping down treatment - particularly stopping add-on LABAs - could generate 'considerable savings' for the NHS, according to the researchers.

Assuming only half of all stable treated patients are stepped down, they estimate that stopping LABAs could potentially save around £17 million per year, equivalent to 2% of the UK’s asthma budget, and stepping down inhaled corticosteroids could save around £8.6 million per year.

The researchers point out that many patients prescribed higher doses of asthma medication have suboptimal inhaler technique, so only a small proportion of the medication reaches their airways. They suggest the money saved on stepping down could instead be spent on 'improving and adapting education tools for patients and professionals'.

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