Asthma: Overuse of Oral Steroids Suggests Underuse of Inhalers

Bridget M. Kuehn

April 12, 2017

Overprescribing of oral corticosteroids appears common among children with asthma, especially the youngest children, a new study shows. Underuse of inhaled corticosteroids may partly explain the overprescribing of the oral drugs, suggests an accompanying editorial.

"Given the large scale of [oral corticosteroid] use in our population, one must assume that a substantial portion of the use is for children who present with mild wheezing and/or coughing," write Harold Farber, MD, MSPH, from the Department of Pediatrics at Texas Children's Hospital, Houston, and colleagues. These children are unlikely to benefit from the medications, they note.

The researchers report their findings online April 10 in Pediatrics.

A brief course of oral corticosteroids is currently recommended to treat moderate to severe asthma exacerbations. But the drugs may trigger anxiety, mania, irritability, or aggressive behavior, and may weaken the bones. This has led to concerns about overuse of these medications among children with asthma.

To assess oral corticosteroid use in children with asthma, the researchers analyzed Medicaid and Children's Health Insurance claims for more than 69,000 children with asthma in Texas between 2011 and 2016. They found that 42.1% to 44.2% of these children were prescribed an oral corticosteroid more than once each of these years.

Children younger than 5 years were even more likely to receive multiple prescriptions for oral corticosteroids compared with older children in the cohort (49.0% vs 38.8%). Dispensing rates were lower for African-American children (35% - 36%) than for white (40% - 44%) or Hispanic (43% - 49%) children. More than 80% of those who received an oral corticosteroid prescription did not have other indications of poor asthma control such as excessive β-agonist refills, emergency department visits, or hospitalizations for asthma.

In addition, there was wide variation in prescribing patterns among physicians. Prescribing rates were lowest among board certified pediatricians at 41% to 42%. Prescribing rates were higher among internal medicine, family practices, or general practitioners (46% - 47%).

The authors suggest more clinician education is warranted to promote appropriate use.

"Asthma guidelines need to provide clear guidance for providers on when the use /of oral corticosteroids for asthma is not supported by evidence and when its use is not indicated in clinical practice," the researchers write.

They caution, as well, that the study was conducted among publicly insured children and may not be applicable to more affluent children, the researchers write.

In an accompanying editorial, Michael Cabana, MD, from the Department of Pediatrics at the University of California, San Francisco, calls the prescribing rates "stunning" but cautions that the findings were based on claims data. The study did not assess patient's' medical records.

"It can be hazardous to make clinical judgments based on administrative claims data," Dr Cabana writes. "Nevertheless, this frequency of [oral corticosteroid] use is notable and worth further consideration."

Regional variations in airborne irritants, allergens, climate, or local prescribing culture could have contributed to the high rates of prescribing seen in the study, Dr Cabana explains.

However, only 28% of the children who received multiple prescriptions for oral corticosteroids received an inhaled corticosteroid, suggesting underuse of the devices to reduce asthma exacerbations and reduce the need for oral steroids, writes Dr Cabana.

"[Oral corticosteroid] overuse may be merely a symptom of another important prescribing issue; that is the underuse of [inhaled corticosteroids] for children with persistent asthma," he notes.

The researchers suggest the pendulum of oral corticosteroid use may have swung too far.

"Over the past 30 years, [oral corticosteroid] prescribing for children with asthma has gone from underuse to what now appears to be substantial overprescribing," they write. "Like Goldilocks and the Three Bears, our challenge now is to get it just right."

Dr Farber is the associate medical director for the Texas Children's Health Plan. The remaining coauthors have reported no relevant financial relationships. Dr Cabana reports serving on Merck's speakers bureau and as a paid consultant for Genentech and Boehringer Ingelheim.

Pediatrics. 2017;139:e20164146, e20170598. Article full text, Editorial extract

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