Cumulative dispensing of high oral corticosteroid doses for treating asthma in Australia.

OBJECTIVE: To estimate the level of dispensing of oral corticosteroids (OCS) for managing asthma in Australia, with a particular focus on the cumulative dispensing of doses associated with long term toxicity (≥ 1000 mg prednisolone-equivalent). DESIGN: Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data. PARTICIPANTS, SETTING: People aged 12 years or more treated for asthma during 2014-2018, according to dispensing of controller inhaled corticosteroids (ICS). MAIN OUTCOME MEASURES: Number of people dispensed OCS for managing asthma during 2014-2018; proportion who were cumulatively dispensed at least 1000 mg prednisolone-equivalent. The secondary outcome was the number of people dispensed at least 1000 mg prednisolone-equivalent during 2018, stratified by inhaler controller dose and use. RESULTS: 124 011 people had been dispensed at least two prescriptions of ICS during 2014-2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone-equivalent or more. Of 138 073 people dispensed OCS at this level, 68 077 (49%) were patients with airway diseases. Dispensing of diabetes and osteoporosis medications was more common for people cumulatively dispensed 1000 mg prednisolone-equivalent or more. During 2018, 4633 people with asthma using high dose ICS controllers were dispensed 1000 mg prednisolone-equivalent or more, for 2316 of whom (50%) controller use was inadequate. CONCLUSIONS: Cumulative exposure to OCS in Australia reaches levels associated with toxicity in one-quarter of patients with asthma using ICS. Cumulative dispensing of potentially toxic OCS amounts often accompanies inadequate inhaler controller dispensing. Better approaches are needed to improve adherence to controller therapy, improve outcomes for people with asthma, and to minimise the use and toxicity of OCS.

Coexisting chronic obstructive pulmonary disease and cardiovascular disease in clinical practice: a diagnostic and therapeutic challenge.

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently coexist but combined disease is often not recognised. Since symptoms overlap significantly, it is common for patients' presentations to be attributed to one disease alone, and for the other to be overlooked. The effect of COPD and CVD goes beyond the shared risk factors of smoking and advancing age. The presence of COPD adversely affects cardiac disease and vice versa. In comparison to individuals with one disease alone, those with both conditions have a higher mortality rate, experience more frequent exacerbations with more hospitalisations and have worse quality of life. More patients with mild and moderate COPD die from CVD than from COPD, and there is a higher rate of arrhythmias, particularly atrial fibrillation. Accurate and timely diagnosis is therefore crucial. Retrospective evidence indicates that individuals with COPD and CVD may have better outcomes with appropriate CVD pharmacotherapy, yet robust prospective evidence is lacking. Inhaled medications for patients with stable COPD improve quality of life and reduce exacerbations, but there is limited evidence that they reduce mortality. A low threshold for investigation and treatment of CVD in COPD and COPD in CVD is essential.