FROM CHEST

Nearly a third of patients have asthma exacerbation in the 2 years after medication step-down, according to a new study published in the September issue of Chest.

With the goal of using the least amount of medication to control asthma, guidelines recommend considering medication step-down after 3 months of stabilized asthma. However, there is limited evidence backing these recommendations, especially when it comes to understanding the long-term outcomes after asthma medication step-down.

Dr. Matthew A. Rank of the division of allergy, asthma, and clinical immunology at the Mayo Clinic in Scottsdale, Ariz., and colleagues analyzed the long-term outcomes of patients after asthma medication step-down.

The investigators conducted a retrospective claims-based analysis using data obtained from the Optum Labs Data Warehouse which contains information from more than 100 million deidentified patients with Medicare Advantage or commercial insurance plans ( Chest. 2015;148[3]:630-39 ). .

Data was extracted on patients who had an asthma diagnosis code between 2000 and 2012 with continuous medical and pharmacy coverage for 3 or more years during the study period and with a history of medication step-down.

Investigators defined a medication step-down as greater or equal to 50% decrease in asthma controller medication between evaluations. Stability was defined as not having an asthma exacerbation requiring care in the hospital or ED, or systemic corticosteroids and claiming fewer than two rescue inhalers prescriptions in the 4 month study period.

The study cohort was divided into four asthma stability groups: 0-3 months, 4-7 months, 8-11 months, and greater to or equal to 12 months of stability.

Of the 26,292 individuals included in the study, 32% developed an asthma exacerbation during the 2 years after medication step-down. There was a strong association between the risk of developing an asthma exacerbation during the 2-year study period and the length of asthma stability prior to medication step-down. For instance, 44% in participants with less than 4 months of stability, 34% with 4-7 months of stability, 30% with 8-11 months of stability, and 21% with more than 12 months of stability (P less than .001).

In addition, study participants who were women, were black, were younger than 19 years old, had a Charlson comorbidity index great than or equal to 1, and at least two outpatient visits for asthma were significantly associated with a shorter interval to asthma exacerbation (P less than.001 for all variables).

Finally, most study participants had a hospital or ED visit, systemic corticosteroids, two rescue inhalers in a 4-month period, or needed to return to baseline asthma controller treatment. The authors suggest that this is evidence that most of the cohort continued to have underlying asthma during the 2-year study period. Furthermore, 33% of participants with less than 4 months of stability required return to baseline treatment versus 8%, 13%, and 15% for more than 12 months of stability, 8-11 months, and 4-7 months, respectively.

Among the limitations noted by the authors: Data were from insured patients, data did not indicate if step-down involved consultation with a health care provider, and the cohort did not include patients who did not step-down as a comparison.

“Individuals and their providers can cautiously apply the data from this study to decisions about stepping down asthma medications. The novel insights from this analysis that contribute to this decision making process are consideration to the length of stability prior to step-down and the rate of asthma exacerbations in the 24 months following step-down,” the authors wrote.

The study was funded by the Mayo Foundation for Medical Education and Research. The authors report no disclosures.

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