A significant dissatisfier for both clinician and patient is that inhaled corticosteroids, commonly underutilized and potentially lifesaving medications, are almost never (if ever) covered at the lowest tier by insurance companies. We would select a first-tier medication if there were one that we could substitute for an ICS; but frequently there isn’t, so we can’t.
Because of this, patients may be financially motivated to simply stop the medication – especially if they perceive that they are on the lowest doses and believe the medication perhaps is not needed at all. Clinicians, meanwhile, are doing the balancing act of moving patients to the lowest doses in order to avoid side effects while maintaining optimal disease control.
So, what are the risks when patients stop using inhaled corticosteroids?
Dr. Matthew A. Rank of the Mayo Clinic, Rochester, Minn., and his colleagues recently published a systematic review of the literature to answer this question (J. Allergy Clin. Immunol. 2013;131:724-9). In this review, randomized, controlled clinical trials in which the study intervention was continuing or stopping low-dose ICSs were included. Studies had to have 4 or more weeks of a run-in with stable doses of ICSs to ensure a minimum period of asthma stability. Seven studies met inclusion criteria. Two studies were exclusively in children, and one was exclusively in adults.
Asthma exacerbations were more likely among patients who stopped ICSs, compared with those who did not (relative risk, 2.35; 95% CI: 1.88-2.92). The risk for an asthma exacerbation in the next 6 months on low-dose ICSs was 16% if patients continued taking the medications, and 38% if they stopped. For every five patients who stopped ICSs, one patient would be expected to have an asthma exacerbation in the next 6 months – which could have been prevented if steroids had been continued. The mean decrease in forced expiratory volume in 1 second associated with discontinued ICSs use was 130 mL.
Most patients can step down with ICSs if they are on long-acting beta-agonists. Expert panels have suggested that patients should be controlled for 3 months before stepping down therapy. Findings from this study further suggest that patients who discontinue low-dose ICSs are at an increased risk of asthma exacerbation.
We need to help our patients understand the risk of stopping low-dose ICSs and encourage them, as much as they are able, to stay on them.
Dr. Ebbert is professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He reported having no relevant financial conflicts. The opinions expressed are those of the author.
This column, "What Matters," appears regularly in Internal Medicine News.