Evolution of inhaled corticosteroid prescription rates during the COVID-19 pandemic

During the COVID-19 pandemic, despite early concerns about the impact oral corticosteroids could have on the effects of acute COVID-19 reported by the WHO and the potential severity of the disease in patients with asthma and of chronic obstructive pulmonary disease (COPD), patients were advised to continue with inhaled corticosteroid therapy (ICS) to reduce disease burden, risk of exacerbations and admission to hospital where there would be an increased risk exposure to SARS-CoV-2. One way to examine patient and practitioner responses in this context is to study changes in prescribing ICS in primary care during this time period.
Open Prescribing is a digital interface for accessing and analyzing primary care prescribing data, published monthly by the National Health Service (NHS) in England, on an open platform. National general practice (GP) appointment activity is reported monthly by NHS Digital to support winter preparation and provide information on activity within primary care. The pandemic quickly changed the supply of primary care services, with a reduction in face-to-face consultations and a move towards telephone or virtual consultations. The total number of reported telephone appointments (24.7 million) from March to May 2020, represented, on average, 42% of the total number of reported appointments in primary care (58.6 million), up from 250 % compared to with the same period of the previous year (9.9 million), with an absolute reduction of 17% in the total number of all appointments reported compared to the previous year. This period encompassed the first legally enforced national lockdown in England.
Often, patients do not take their medications as directed; asthma patients prescribed ICS often have suboptimal inhalation technique or do not take ICS regularly as prescribed. Providing drug information, support, and regular inhalation technique checks by a multidisciplinary team can prevent this repairable cause of treatment failure and improve health outcomes. The COVID-19 pandemic and imposed lockdowns have resulted in dramatic changes in social behavior, impacting patient health behavior. Changes in patient medication behavior, reduced self-management behaviors, and acute respiratory medication storage have been reported.
An increase in the presentation of patients with respiratory symptoms and a consequent increase in the number of ICS prescribed is usually observed during the winter months due to contributing factors including seasonal variations in weather conditions, increase in circulating pathogens and changes in ICS membership during the summer versus winter months. Ahead of the UK’s exit from the EU, the Department of Health and Social Affairs issued guidelines for local providers, whether in hospitals or primary care, not to store medicines, or to clinicians to write longer prescriptions for patients. Despite assurances about the availability of drugs made available to the public and healthcare professionals at that time, patient demand and prescription of ICS therapies increased. In March-May 2020, the total number of all prescribed ICS inhaler items increased by 20% compared to the corresponding period in 2019 (table). Panic orders were reported by pharmacists, with many patients requesting prescriptions, including those who had not ordered inhalers for extended periods of time and those who had no imminent clinical need. A peak in demand was observed in March 2020, with an average increase of 43% of ICS articles compared to the previous year. Despite a reduction in absolute primary care appointments during this period, the number of ICS delivered per appointment increased by 26%.

ChartNumber of inhaled corticosteroids prescribed in primary care during the first containment of the COVID-19 pandemic in England, compared to the previous year

An increase in prescription rates during virtual consultations compared to in-person appointments is a recognized challenge for clinicians. Pressure from patients to leave the clinic with a prescription is a known cause of overprescribing. Additionally, the reduction in immediate diagnostic information and the inability to physically assess patients or confirm inhaler technique adds to the prescriber’s dilemma of ensuring medication optimization during a telephone consultation. Changes in ICS adherence are complex and multifactorial, and the perception of risk and value that patients place on the use of control therapies and self-management plans are important contributing factors. Any increase in adherence to control therapies during the pandemic may have been driven by fear of the potential severity of COVID-19 symptoms in patients with underlying health conditions, including respiratory problems and the disease. effect of respiratory symptoms on periods of self-isolation. Reports of increased disease severity and a high risk of hospital admission with COVID-19 for adults and children with uncontrolled asthma have compounded those fears, especially patients who were not taking ICS regularly in the weeks before infection.
The spike in demand for CSI prescription items cannot be definitively linked to increased patient adherence once the prescription is collected. Electronic medication monitors, which measure the number of doses taken by patients over a period of time, can allow clinicians to monitor adherence trends. Between January and March 2020, a 14.5% relative increase in compliance with control inhaler therapy was reported in patients with asthma and COPD, suggesting that the increase in the prescription rate could reflect a trend towards increased adherence during this period. A key component of a respiratory assessment should include the level of adherence to inhalation therapy, ensuring patients have a good understanding of inhalation technique, is crucial to optimizing drug delivery. Choose the right questions during the consultation, ie “Can you show me how you use your inhaler?” Rather than “Do you know how to use your inhaler? “, As well as the ability to visualize the patient’s technique can quickly determine any improvement. obligatory. Changes in self-management behaviors, including taking medications early, increased desire to quit smoking, accessing health services online, and watching videos of inhalation techniques online have also been observed. been reported during the pandemic, suggesting that patients were motivated to achieve symptom control through self-management.

As we approach another tough winter in the NHS for respiratory services and the potential for future blockages, it is important to ensure that clinicians can take advantage of any improvements in levels of adherence and motivation to the hospital. Self-management, prescribers must be supported to optimize both aspects during telemedicine and face-to-face consultations. Patients and clinicians should be given the opportunity to suggest and choose the most efficient and convenient method of consultation. Opportunities to check and improve the level of adherence and visualize the inhalation technique should be prioritized as a key part of the consultation. Innovations in telemedicine and home monitoring, including virtual spirometry, auscultation, oxygen saturation, and electronic inhaler compliance monitoring, are essential tools to help prescribers make treatment decisions. informed with patients. Prescribing appropriate quantities of drugs to ensure the supply chain is not unduly affected during peak demand periods must continue. Pharmacists, and the entire team, are in a good position to ensure that drug requests are appropriate and timely, as well as to provide additional support, self-care advice, and verify technique. patient inhalation. The expansion of diagnostic tools available to patients via the smartphone at home, without the appropriate multidisciplinary support to use them effectively, could have serious consequences. The importance of well-informed and supported self-management plans, including when to seek medical help during an acute attack, will become increasingly vital. By improving and further evaluating the diagnostic and monitoring capabilities of telemedicine, healthcare professionals will effectively help patients manage their symptoms virtually at home and optimize treatment choices.

We do not declare any competing interests.

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