Disease control and treatment pathways of asthma patients after initiating ICS/LABA

Introduction GINA guidelines recommend medium dose (MED) and high dose (HD) ICS/LABA as the preferred controller for step 4 asthma patients and clinicians should consider step up/down based on their patientsʼ asthma control. Limited data is available on how step 4 patients respond to ICS/LABA and how they step up/down in clinical practice.

Methods We conducted a retrospective cohort study using UK Clinical Practice Research Datalink to assess control status of asthma patients in one year after initiating a MED or HD ICS/LABA between 2007 and 2015, and examined their treatment pathways within one year after the treatment initiation.

Results 29,229 and 16, 575 patients initiated MED and HD ICS/LABA during the study period. 10,983 on MED (37.6%) and 8067 on HD (48.7%) ICS/LABA were adherent with a Medication Possession Ratio of 0.8. Among adherent patients, 16.4% had moderate exacerbations leading to office visit requiring OCS bursts, and 7.7% had severe exacerbations leading to ER visit or hospitalization. 12.0% of patients had mean SABA daily dose > 2 puffs/day. 29.3% of MED and 37.9% HD ICS/LABA patients stepped up, vs. 29.0% and 32.7% stepped down. Common step-ups from MED ICS/LABA were addition of LTRA (44.5%), addition of LAMA (23.5%), and increased ICS dose (18.1%), while addition of LAMA (42.4%) and addition of LTRA (38.8%) were common from HD ICS/LABA. Among patients who stepped down from MED or HD ICS/LABA, 42.1% (MED) vs. 69.4% (HD) lowered ICS dose in ICS/LABA, and 57.9% (MED) vs. 30.6% (HD) stepped down to single ICS.

Conclusion A significant percentage of patients remain prone to exacerbation on MED or HD ICS/LABA, highlighting the need for timely assessment of asthma control.