How can asthma medication overprescribing be reduced?

There are currently around 2.7 million Australians living with asthma – making it among the top four most prevalent chronic conditions in 2020–21 at 10.7% of the population.
 
Of those people impacted by the condition, one in three (34.9%) uses asthma-related medication daily.
 
But when it comes to prescribing medication for asthma, more is ‘not always better’, according to a new paper published in Australian Prescriber.
 
The paper outlines current Australian guidelines for managing asthma, but points to research that finds seven in 10 Australians with asthma aged over 12 years may be overprescribed preventer medicine.
 
Low-dose inhaled corticosteroids (ICS) are the recommended treatment for most adult and adolescent people with asthma. However, prescribed doses are ‘higher than necessary’, the authors of the paper state, highlighting the importance of customised treatments to lower doses where asthma is well controlled.
 
‘With asthma, it is not a case of “one size fits all”,’ the paper’s lead author Professor Helen Reddel said.
 
‘The medicines and doses needed are personalised for each patient.’
 
A central part of personalised treatment involves finding the lowest dose to maintain control of asthma symptoms and reduce the risk of severe attacks, flare-ups, and other adverse effects.
 
This is in conjunction with an asthma action plan, for which GPs have a role, designed to optimise patients’ asthma management through shared decision-making.
 
According to the Australian Prescriber paper, possible reasons why patients may be overprescribed asthma medication include those with frequent symptoms at diagnosis being prescribed a high-dose preventer without the dose being reviewed after the symptoms improve.
 
Many patients may also have their preventer dose increased during a flare-up, but may not have a follow-up review after recovery so remain on unnecessarily high doses, the authors say.
 
With a recent increase of asthma medications available in Australia, experts say it is vital that GPs and other healthcare professionals keep up to date with national management guidelines.
 
‘Guidelines get updated and [GPs] can become a little bit complacent about checking those updates,’ Dr Kerry Hancock, Chair of RACGP Specific Interests Respiratory Medicine previously told newsGP.
 
‘So I would really like to emphasise that GPs look at these … guidelines and take them on board, review them and think about what implications they have for the way that they manage asthma.’
 
Australian Prescriber recommends that prescribers advise patients when starting treatment that one of the goals of asthma management is to first achieve good control, then find the lowest dose to ensure their asthma is well controlled.
 
Finding the lowest effective dose to control asthma will not only reduce the risk of side effects, but the cost of medication for patients, which the authors note may also ‘improve adherence to therapy’.
 
The authors say that while treatment for asthma should be personalised, medication can be stepped down safely following consultation with a GP if the condition has been stable for 2–3 months and a written asthma action plan is in place.
 
‘[T]he dose of ICS that will keep asthma well controlled varies between patients, so consider each step-down as a treatment trial and monitor the patient closely afterwards,’ the authors wrote.
 
‘Consider stepping down therapy when asthma has been well controlled by a stable dose of ICS or ICS–LABA [long-acting beta₂ agonist] for at least 2–3 months in adults and adolescents and after six months in children, particularly if the ICS dose is medium or high by age group.’
 
For children there is ‘much less evidence available’ on stepping down treatment, they note.
 
Australian Prescriber has a step-by-step guide to the asthma treatment step-down process.
 
While the benefits of reducing the dose of asthma treatment are identified, the authors say that preventive therapy should not be stopped completely.
 
‘If [patients] have very mild asthma, [they] may not need to take a preventer medicine regularly,’ Professor Reddel said.
 
‘[But they shouldn’t] stop taking preventer medicine without medical advice … and an updated asthma action plan.’
 
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