Time to improve practice around OCS use in asthma: TSANZ

Prof Philip Bardin

Clinicians have a new blueprint for oral corticosteroid (OCS) stewardship for asthma in adults and adolescents, in the form of a position statement from the TSANZ.

The statement, published in Respirology, revisits the many known short term and long term harms associated with oral corticosteroids and the evidence that OCS are overused.

It references an Australian study from last year which found cumulative exposure to OCS in Australia reaches levels associated with toxicity in one-quarter of patients with asthma using ICS.

Importantly, it also found patients who had been dispensed >1000 mg prednisolone-equivalent were significantly more likely to require medication for diabetes mellitus and osteoporosis.

The study noted GPs were the main providers of scripts for OCS (76%).

The TSANZ position statement, authored by a 16-member expert panel, said OCS use in asthma was an indicator for specialist review.

It said OCS use was excessive in relation to asthma severity, and OCS were being dispensed to people with asthma who currently have suboptimal adherence with ICS treatment.

“It is firmly established that improvements in asthma control, prevention of exacerbations and reductions in the need for OCS therapy can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, specialist and/or multidisciplinary review and optimised medications,” the position statement said.

“Recently, add-on therapies including novel biological agents have also demonstrated reductions in OCS requirements.”

It said monoclonal antibodies currently available in Australia for severe eosinophilic asthma had been shown to reduce exposure to OCS.

“In this context, referral of people with asthma controlled only by frequent OCS courses or maintenance OCS prescription is a priority for primary care,” one of the core principles of OCS stewardship in asthma said.

The position statement said other resources were available to support OCS stewardship including expert consensus on tapering OCS and the Severe Asthma Toolkit.

Respiratory physicians are big prescribers

Co-chair of the TSANZ position statement writing group Professor Philip Bardin told the limbic there was unfortunately limited appreciation of the risks and problems of repeated burst OCS therapy and exceeding the cumulative 1000 mg life-time threshold.

He said closer links and better communication between GPs and respiratory physicians could enable strategies to reduce OCS use in particular patients.

For example, adherence and inhaler technique were not checked often enough in ‘severe’ asthma – often on the presumption the GP had already done this.

Professor Bardin, director of the Monash Lung and Sleep Unit, said more and better education around severe asthma, the problems of OCS use, and the new biological alternatives that require specialist review was required.

“The shocking thing is that between 50-70% of all steroid prescriptions are done for lung disease in Australia. We are the big prescribers not rheumatology or other specialties. It’s respiratory disease that is right at the pointy end of this.”

He said regulatory changes such as making OCS a streamlined authority prescription might encourage both GPs and specialists to “think again” before prescribing OCS for asthma.

“A key problem is that patients are automatically provided with a bottle of 30 x 25mg tablets despite the prescription being for only a few days (usually 5-10 days at 25-50mg per day, maximum this would use is 20 tablets).”

“Consequently many patients use OCS repeatedly on their own initiative, often for transient symptoms and without consulting their GP,” he said.

The position statement also recommended OCS rescue packs could be reduced to 10 ×25 mg tablets instead of 30 tablets.

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