Corticosteroids Overprescribed in Young Asthmatics

May 1, 2017

Prescribing has gone from underuse to substantial overprescribing. The challenge is to get it just right.

Oral corticosteroids appear to be substantially overprescribed for children who have asthma, according to a new study. The highest prescription rates are in the youngest children.[[{"type":"media","view_mode":"media_crop","fid":"58891","attributes":{"alt":"","class":"media-image media-image-right","height":"150","id":"media_crop_9047792239709","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7449","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 5px; float: right;","title":" ","typeof":"foaf:Image","width":"181"}}]]

Short courses of oral corticosteroids are used to treat patients with moderate to severe asthma exacerbations, but concerns have been raised about high prescribing rates of these drugs among children with asthma. Researchers led by Harold J. Farber, MD, Baylor College of Medicine and Texas Children’s Hospital in Houston, conducted a study to describe rates of oral corticosteroid dispensing among children with asthma.

The researchers extracted data from the computerized databases of Texas Children’s Health Plan, a large, not-for-profit Medicaid and Children’s Health Insurance Program managed care organization. They analyzed claims data for children from age 1 year to under 18 years who had an asthma diagnosis.

In the years 2011 to 2015, 17.1% to 21.8% of children had an asthma diagnosis. In each of these years, more than 40% of these children were dispensed 1 or more oral corticosteroids. Dispensing rates were higher for the children age 1 to 4 years than for older children. Repeated oral corticosteroid dispensing was common, most common for children age 1 to 4 years.

More than 80% of the children who were dispensed an oral corticosteroid did not have other utilization suggesting poor asthma control, such as excessive β-agonist refills, emergency department visits, or hospitalization for asthma.

Oral corticosteroids were prescribed less frequently to children whose primary care provider was a board-certified pediatrician compared with other types of primary care providers. Also, there was large variation in oral corticosteroid prescribing rates among pediatricians, ranging from 15% to 86%.

Minimal differences were found in asthma emergency department visits and no differences in hospitalization rates by the pediatrician’s oral corticosteroid dispensing.

The substantial variation in practice without variation in outcomes supports the researchers’ hypothesis that a large portion of oral corticosteroid dispensing is inappropriate.

“If we assume that a large part of this oral steroid dispensing was for mild asthma, or perhaps respiratory symptoms that were not asthma, then one must conclude that a large number of children are being put at risk for adverse effects of systemic corticosteroids with little to no likelihood of benefit,” the researchers stated.

They noted that the oral corticosteroid dispensing rates and prevalence of asthma diagnoses were higher in their study than in other reports. They suggested that the high asthma prevalence rates may be the result of health disparities in a low-income population; adverse effects of air pollution; adverse selection, with asthma patients selecting the health plan at greater rates than patients without asthma; and overdiagnosis of asthma among providers in their health plan.

They concluded, “Over the past 30 years, (oral corticosteroid) prescribing for children with asthma has gone from underuse to what now appears to be substantial overprescribing. Like Goldilocks and the Three Bears, our challenge now is to get it just right.”

The researchers published their results in the April 2017 Pediatrics.