ONE-quarter of people with asthma who use inhaler controllers are dispensed potentially toxic cumulative oral corticosteroid doses, according to new research published by the MJA.

Associate Professor Mark Hew, Head of Allergy, Asthma and Clinical Immunology at the Alfred Hospital in Melbourne, and colleagues, analysed a 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data, specifically of people aged 12 years or more who were treated for asthma during 2014–2018, according to dispensing of controller inhaled corticosteroids (ICS).

“Oral corticosteroids (OCS) are used for treating acute asthma attacks, and sometimes for longer term control, but the risk of long-term toxicity increases with cumulative doses exceeding 1000 mg prednisolone,” wrote Hew and colleagues.

“[We found that] 124 011 people had been dispensed at least two prescriptions of ICS during 2014–2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone-equivalent or more,” they found.

“We estimate that [in Australia] almost 350 000 people with asthma were cumulatively dispensed 1000 mg oral prednisolone-equivalents or more during 2014–2018, a level associated with long term systemic toxicity.

“While we did not specifically examine harms, we found that larger proportions of patients cumulatively dispensed 1000 mg prednisolone-equivalents or more were also dispensed medications for treating diabetes or osteoporosis than of people receiving lower amounts.

The need for frequent short courses or long-term OCS therapy is neither benign nor acceptable.” Of equal concern, “many patients dispensed OCS are not adhering to appropriate ICS controller therapy”.

Over 12 months among patients with asthma on high-dosage controllers dispensed 1000 mg prednisolone-equivalent or more, more than half had inadequate (< 50%) controller usage.

Hew and colleagues suggested that as three-quarters of OCS prescriptions were provided by GPs, patients for whom OCS therapy was needed should undergo a comprehensive asthma review by their GP, focusing on education and medication adherence.

“[Until] methods for objectively checking adherence and more reliable monitoring of disease activity are [available] … patient review should include checking their inhaler and peak flowmeter technique, updating their treatment plans, and assessing them for treatment escalation according to national guidelines or for specialist review,” they wrote.

“Measures for assuring adequate asthma control should include thorough primary care review and, when appropriate, referral to specialist care or specialised asthma centres for difficult-to-treat patients,” they concluded.

Also online at the MJA

Perspective: Call for infant formula reconstitution uniformity and improvements in manufacturer feeding guides
Farrent et al; doi: 10.5694/mja2.50760 … FREE ACCESS for 1 week

Systematic review: Motherhood and medicine: systematic review of the experiences of mothers who are doctors
Hoffman et al; doi: 10.5694/mja2.50747 … OPEN ACCESS permanently


5 thoughts on “Asthma: potential toxicity of cumulative doses of oral corticosteroids

  1. Anonymous says:

    Perhaps Prof Hew is too young to remember the epidemic of asthma deaths we had in the 1980’s. What exactly is the toxicity of 1000 mg cumulative dose OCS? cataracts? There are people who are alive today because their doctors chose to treat their asthma patients with systemic corticosteroids – we are now made to feel guilty if we initiate a pulse of corticosteroids.

  2. Anonymous says:

    so asthma as a cause of death has been virtually eradicated from ICUs across the country.
    And we’re still having a go at steroids then. Do we want to return to 03:25 deaths from asthma in the back of an ambulance or not?

  3. Anonymous says:

    Agree, asthma more than most other conditions would have a significant mismatch between dispensed and used medication. To support compliance patients will often have more than one ICS device on the go ie handbag, bathroom cabinet, car or workplace drawer. I am sure that every asthmatic has had to dispose of expired OCS and ICS

  4. David Maconochie says:

    Typical dramatic overstatement for effect. Do you take us for idiots? Make pack sizes of 10x 25mg and that is what I will prescribe for most patients requiring 5d of pred.

  5. Anonymous says:

    Sorry, but this research is seriously flawed. That flaw is briefly mentioned right at the end of the paper: “Finally, we could not ascertain the proportion of OCS dispensed that was actually taken by patients.” Exactly. The prescribing/dispensing data essentially reflect the PBS quantities, not the specified dosage and duration of therapy. Everyone in primary care knows that patients with asthma exacerbations will have heaps of tablets left over after treating the episode. Using dispensed quantities and assuming they are all consumed markedly overstates the issue and falsely implies poor primary care.

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