Quarter of asthma patients given ‘potentially toxic’ level of steroids

More than one quarter of Australian patients with asthma have been prescribed ‘potentially toxic’ amounts of steroid tablets.
 
Such are the findings of new research published in the Medical Journal of Australia on 14 September.
 
The retrospective cohort study analysed a 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data in people aged 12 or older who were prescribed an inhaled corticosteroid (ICS) or ICS/long-acting beta-agonist (LABA) inhaler on two or more occasions by their doctor during 2014–18.
 
That equated to more than 120,000 cases.
 
The research not only found that cumulative exposure to oral corticosteroids reached levels associated with toxicity in one-quarter of patients, it also found this was often accompanied by inadequate inhaler controller dispensing.
 
Lead researcher John Upham is a Professor of Respiratory Medicine at the Princess Alexandra Hospital in Brisbane and the University of Queensland.
 
He told newsGP the research intended to examine whether patients given short courses of steroids could develop chronic health problems as a result.
 
‘We used to think that all the toxicity that was associated with oral steroid tablets occurred in people who took them continuously over long periods of time, months and months, over years and years,’ he said.
 
‘But it became much more apparent in recent years that you can start to have toxicity from intermittent short courses of steroid tablets; particularly as you get over a certain dose you start to see increases in the risk of osteoporosis, diabetes, cataracts, etcetera.
 
‘So what we wanted to do was find out how often that sort of thing happened in Australia.’

Professor Upham says there were 124,000 people with probable asthma identified in the PBS database on the basis of using ICS or ICS/LABA inhalers.
 
‘Of those, 64,000 [51%] had at least one OCS [oral corticosteroid] script, including 34,500 [just over 25%] who were dispensed more than 1000 mg of prednisone or equivalent,’ he said.
 
Professor Upham says this is concerning considering such doses of oral steroids have been shown to increase risk of chronic conditions.
 
‘The data coming out now shows that if you have more than 500 mg of prednisone – even more so if you have more than 1000 mg of prednisone – within the space of a few years, your risk of cataracts, diabetes, hypertension, osteoporosis, etcetera, goes up quite remarkably,’ he said.

If a patient is given a five-day course of 50 mg of prednisone, Professor Upham says, they only need to have taken four courses to reach these ‘toxic’ levels. 
 
‘The threshold of concern for OCS use may therefore need to be re‐examined and asthma care pathways re‐evaluated,’ the researchers wrote.
 
‘The need for frequent short courses or long-term OCS therapy is neither benign nor acceptable.’


Professor John Upham says oral corticosteroids are life-saving treatments for patients with asthma but that repeated courses should be given with caution.

While the researchers wanted to see how many times patients with asthma were given repeat scripts for oral corticosteroids, they also wanted to see whether such patients were regularly using their preventer inhalers.
 
‘And the sad news was it was probably only half the people who were having these repeated courses of steroid tablets that were using adequate amounts of preventer inhalers,’ Professor Upham said.
 
‘They either weren’t using them, or if they were using them they were maybe only picking up one or two scripts a year, which suggests that they were massively under-dosed.’
 
According to Professor Upham, the best way to avoid or minimise the need for oral corticosteroids and their side effects is to better educate and support patients to encourage them to use preventer inhalers regularly.
 
There also needs to be more consideration given to prescription of short courses of oral corticosteroids.
 
‘There’s been a bit of a tendency – and I have to say, I’ve been guilty of it myself – of giving people with asthma a script for a reserve supply of steroid tablets to have over the winter just in case they have an exacerbation, and that’s fine,’ he said.
 
‘But if you do that, you’ve just got to keep in touch with the person and say to them, “Look, if you have to do this more than a couple of times, you better let me know because we need to have a bit of a look and find out what’s going on”, rather than just letting them free-range so to speak.’
 
Professor Upham maintains that oral corticosteroids have a vital place in treating acute exacerbations of asthma.
 
‘These treatments are certainly life-saving,’ he said. ‘They keep people out of hospital, they stop people dying of asthma.’
 
He says prescribing intermittent short courses of oral corticosteroids ‘once, twice or maybe even three times is fine’.
 
‘But the message for clinicians and GPs needs to be, if it keeps on happening, if someone’s on their fourth or fifth [course of oral steroids] you really want to be looking into what’s going on,’ he said.
 
‘Are they not using their preventer? Is their inhaler technique not right? Are they smoking? Is the diagnosis wrong?
 
‘It really says you should be asking big questions about what’s happening, otherwise you’re setting them up for more health problems down the track.’
 
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