Characteristics of patients with asthma overprescribed short-acting beta-agonist (SABA) reliever inhalers stratified by blood eosinophil count in North East London: a cross-sectional observational study

Pfeffer, Paul; Hajmohammadi, Hajar; Cole, Jim; Griffiths, Chris; Hull, Sally; Simoni, Anna De

doi:10.3399/bjgpo.2023.0020

Cited by 3 publications

(5 citation statements)

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“…Failure to diagnose asthma-like comorbidities is likely a major contributor to a large number of patients overusing SABA inhalers for frequent breathlessness symptoms. In particular, based on our recent observational study, the majority of patients with asthma over-prescribed SABA inhalers were non-eosinophilic ( 8 , 42 ). Whilst over-reliance on SABA is clearly dangerous in exacerbation-prone patients, even in patients who are not exacerbation prone, overuse of SABA is potentially harmful.…”

Section: Harms Associated With Non-implementation Of the Treatable Tr...mentioning

confidence: 99%

“…Blood eosinophil counts are not only feasible in primary care in most regions but are also often checked with results available. For example, based on our recent evaluation of patients over-prescribed SABA inhalers, over 75% had a blood count with eosinophil count measured in the last 2 years ( 8 ). Guidance whether to consider stepping up from a medium-strength ICS–LABA to a high-strength ICS–LABA based on blood eosinophil count could be implemented in primary care.…”

Section: Implementation Of the Treatable Traits Approach In Primary Carementioning

confidence: 99%

“…Importantly, these comorbidities can worsen the impact of asthma symptoms, and interventions for anxiety and depression have the potential to improve asthma symptom control ( 69 ). Our recent research shows the increased prevalence of anxiety and depression in non-eosinophilic asthmatic patients over-prescribed SABA inhalers ( 8 ).…”

Section: Implementation Of the Treatable Traits Approach In Primary Carementioning

confidence: 99%

“…Based on a recent study of over 30,000 patients with asthma from North-East London, over 6,000 patients with mild asthma (low exacerbation frequency, low asthma medication step, low probability of being eosinophilic) were prescribed six or more short-acting beta-agonist (SABA) reliever inhalers in the preceding year, suggesting high levels of symptoms in the absence of severe disease ( 8 ). Management approaches other than the pharmacotherapeutic ladders would likely be more appropriate to treat such patients that are commonly encountered in primary care.…”

Section: Introductionmentioning

confidence: 99%

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Bringing the treatable traits approach to primary care asthma management

Pfeffer,

Rupani,

De Simoni

2023

Front. Allergy

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Asthma continues to be a major cause of illness with a significant mortality, despite its increasing range of treatments. Adoption of a treatable traits approach in specialist centres has led to improvements in control of asthma and reduced exacerbations in patients with severe asthma. However, most patients with this illness, particularly those with mild-to-moderate asthma, are cared for in primary care according to guidelines that emphasise the use of pharmacotherapeutic ladders uniformly implemented across all patients. These pharmacotherapeutic ladders are more consistent with a “one-size-fits-all” approach than the treatable traits approach. This can be harmful, especially in patients whose symptoms and airway inflammation are discordant, and extra-pulmonary treatable traits are often overlooked. Primary care has extensive experience in patient-centred holistic care, and many aspects of the treatable traits approach could be rapidly implemented in primary care. Blood eosinophil counts, as a biomarker of the treatable trait of eosinophilia, are already included in routine haematology tests and could be used in primary care to guide titration of inhaled corticosteroids. Similarly, poor inhaler adherence could be further assessed and managed in primary care. However, further research is needed to guide how some treatable traits could feasibly be assessed and/or managed in primary care, for example, how to best manage patients in primary care, who are likely suffering from breathing pattern disorders and extra-pulmonary treatable traits, with frequent use of their reliever inhaler in the absence of raised T2 biomarkers. Implementation of the treatable traits approach across the disease severity spectrum will improve the quality of life of patients with asthma but will take time and research to embed across care settings.

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Section: Harms Associated With Non-implementation Of the Treatable Tr...mentioning

confidence: 99%

Section: Implementation Of the Treatable Traits Approach In Primary Carementioning

confidence: 99%

Section: Implementation Of the Treatable Traits Approach In Primary Carementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Bringing the treatable traits approach to primary care asthma management

Pfeffer,

Rupani,

De Simoni

2023

Front. Allergy

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“…Previous research has shown that in adults with moderate-severe asthma, exacerbation risk is significantly higher in women, obese subjects, smokers and those who have poor lung function, as assessed by spirometric measures; these factors have also been associated with variable or decreased symptom control [ 4 , 5 ]. However, despite evidence showing that patients achieving control require less reliever medication and have a lower risk of exacerbation [ 6 ], the correlation among symptom control, reliever use and reduction in future risk has not been fully characterised.…”

Section: Introductionmentioning

confidence: 99%

Effect of Individual Patient Characteristics and Treatment Choices on Reliever Medication Use in Moderate-Severe Asthma: A Poisson Analysis of Randomised Clinical Trials

van Dijkman,

Yorgancıoğlu,

Pavord

et al. 2024

Adv Ther

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Introduction Even though increased use of reliever medication, including short-acting beta agonists (SABA), provides an indirect measure of symptom worsening, there have been limited efforts to assess how different patterns of reliever use correlate with symptom control and future risk of exacerbations. Here, we evaluate the effect of individual baseline characteristics on reliever use in patients with moderate-severe asthma on regular maintenance therapy with fluticasone propionate (FP) or combination therapy with fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR). Methods A drug-disease model describing the number of 24-h puffs and overnight occasions was developed with data from five clinical studies ( N = 6212). The model was implemented using a nonlinear mixed effects approach and a Poisson function, considering clinical and demographic baseline characteristics. Goodness of fit and model predictive performance were assessed. Heatmaps were created to summarise the effect of concurrent baseline factors on reliever utilisation. Results The final model accurately described individual patterns of reliever use, which is significantly increased with time since diagnosis, smoking, higher Asthma Control Questionnaire (ACQ-5) score and higher body mass index (BMI) at baseline. Whilst the number of puffs decreases slowly after an initial drop relative to the start of treatment, exacerbating patients utilise significantly more reliever than those who do not exacerbate. The mean effect of FP/SAL (median dose: 250/50 μg BID) on reliever use was slightly higher than that of BUD/FOR (median dose: 160/4.5 μg BID), i.e. a 75.3% vs 69.3% reduction in reliever use, respectively. Conclusions The availability of individual-level patient data in conjunction with a parametric approach enabled the characterisation of interindividual differences in the patterns of reliever use in patients with moderate-severe asthma. Taken together, individual demographic and clinical characteristics, as well as exacerbation history, can be considered an indicator of the degree of asthma control. High SABA reliever use suggests suboptimal clinical management of patients on maintenance therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-023-02774-w.

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