Re: Guidance is needed on inhaled glucocorticoids and acute adrenal crises
Mackenzie(1) has highlighted the lack of guidance regarding the use of inhaled corticosteroids (ICS) and the risk of adrenal suppression. There have been increasing calls for prescribers to be aware of the potential risks, especially when high doses of ICS are used(2,3). The MHRA has recommended the use of a corticosteroid treatment card when high doses of ICS are used(4), but as Mackenzie points out, the current UK asthma guidelines do not support the use of these cards for fear of alarming patients and the risk of poor adherence to medication. This may result in worsening asthma control and increase exacerbations. There is also no real consensus as to what constitutes a high dose of ICS. High doses of ICS, especially when combined with a long acting beta agonist (LABA) are very frequently prescribed. Currently, high potency combination inhalers (where daily licensed dose is ≥ 1000 micrograms beclomethasone (BDP) equivalent per day) are the costliest drugs to the NHS(5), and are also the most frequently prescribed combination inhalers. This would suggest that a disproportionate number of asthmatics in England are at step 4 or above of the BTS/SIGN guidelines(6) which clearly cannot be the case. Considering that the evidence base for using doses above 1000 micrograms of BDP equivalent is grade D, this also suggests that many patients are at risk of adverse effects for potentially little benefit.
High potency ICS combined with LABAs are also commonly used in the treatment of chronic obstructive pulmonary disease (COPD), yet their role in management is still not clear(7). There has been increasing concern about the potential overtreatment of patients with mild and moderately severe COPD with ICS(8). Not only are these patients at risk of adrenal suppression, but they are also at increased risk of non-fatal pneumonia and other well known side effects of ICS(8).
The NHS London Respiratory Team(9) has developed a specific ICS patient safety card that is currently being evaluated for use and acceptability amongst prescribers and patients. Attached to the card are prescribing notes for the clinician that detail the additional risks of high potency ICS, the lack of evidence for use of high doses in asthma, and alternative lower doses that can be used in COPD. As up to 90% of patients have difficulty using aerosol inhalers(10), the notes also explain that ensuring a patient is using the inhaler optimally is often a more cost effective and safer option than stepping up the dose. However, for many patients, it is hoped that the prescriber will be able to appreciate that lower doses of ICS can be equally effective when used correctly, or other more cost effective evidenced based interventions can be offered. This would avoid having to issue a card at all, and avoid having the discussion with the patient about why they are being asked to use a treatment that may do them more harm than good.
Dr Vincent Mak
On behalf of the NHS London Respiratory Team Programme Board
01. Mackenzie SD. Guidance is needed on inhaled glucocorticoids and acute adrenal crises. BMJ 2012;345:e7436
02. Grossman A and Tomlinson JW. Position statement of the Society for Endocrinology on the endocrine effects of inhaled corticosteroids in respiratory disease. 2011. www.endocrinology.org/policy/docs/
03. Lapi F et al. The use of inhaled corticosteroids and the risk of adrenal insufficiency
Eur Respir J erj00809-2012; published ahead of print 2012, doi:10.1183/09031936.00080912
04. MHRA 2006. www.mhra.gov.uk/home/groups/plp/documents/websiteresources/con2023860.pdf
05. www.drugtariff.co.uk
06. BTS/SIGN. 2008 rev 2012. British Guideline on the management of asthma.
07. Park HY, et al. Inhaled corticosteroids for chronic obstructive pulmonary disease. BMJ 2012;345:e6843.
08. Price D et al. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. Prim Care Respir J 2012; Available from: URL: http://dx.doi.org/10.4104/pcrj.2012.00092
09. http://www.london.nhs.uk/what-we-do/our-current-projects/london-respirat...
10. Bosnic-Anticcevich SZ et al. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma. 2010: 47: 251-6
Rapid Response:
Re: Guidance is needed on inhaled glucocorticoids and acute adrenal crises
Mackenzie(1) has highlighted the lack of guidance regarding the use of inhaled corticosteroids (ICS) and the risk of adrenal suppression. There have been increasing calls for prescribers to be aware of the potential risks, especially when high doses of ICS are used(2,3). The MHRA has recommended the use of a corticosteroid treatment card when high doses of ICS are used(4), but as Mackenzie points out, the current UK asthma guidelines do not support the use of these cards for fear of alarming patients and the risk of poor adherence to medication. This may result in worsening asthma control and increase exacerbations. There is also no real consensus as to what constitutes a high dose of ICS. High doses of ICS, especially when combined with a long acting beta agonist (LABA) are very frequently prescribed. Currently, high potency combination inhalers (where daily licensed dose is ≥ 1000 micrograms beclomethasone (BDP) equivalent per day) are the costliest drugs to the NHS(5), and are also the most frequently prescribed combination inhalers. This would suggest that a disproportionate number of asthmatics in England are at step 4 or above of the BTS/SIGN guidelines(6) which clearly cannot be the case. Considering that the evidence base for using doses above 1000 micrograms of BDP equivalent is grade D, this also suggests that many patients are at risk of adverse effects for potentially little benefit.
High potency ICS combined with LABAs are also commonly used in the treatment of chronic obstructive pulmonary disease (COPD), yet their role in management is still not clear(7). There has been increasing concern about the potential overtreatment of patients with mild and moderately severe COPD with ICS(8). Not only are these patients at risk of adrenal suppression, but they are also at increased risk of non-fatal pneumonia and other well known side effects of ICS(8).
The NHS London Respiratory Team(9) has developed a specific ICS patient safety card that is currently being evaluated for use and acceptability amongst prescribers and patients. Attached to the card are prescribing notes for the clinician that detail the additional risks of high potency ICS, the lack of evidence for use of high doses in asthma, and alternative lower doses that can be used in COPD. As up to 90% of patients have difficulty using aerosol inhalers(10), the notes also explain that ensuring a patient is using the inhaler optimally is often a more cost effective and safer option than stepping up the dose. However, for many patients, it is hoped that the prescriber will be able to appreciate that lower doses of ICS can be equally effective when used correctly, or other more cost effective evidenced based interventions can be offered. This would avoid having to issue a card at all, and avoid having the discussion with the patient about why they are being asked to use a treatment that may do them more harm than good.
Dr Vincent Mak
On behalf of the NHS London Respiratory Team Programme Board
01. Mackenzie SD. Guidance is needed on inhaled glucocorticoids and acute adrenal crises. BMJ 2012;345:e7436
02. Grossman A and Tomlinson JW. Position statement of the Society for Endocrinology on the endocrine effects of inhaled corticosteroids in respiratory disease. 2011. www.endocrinology.org/policy/docs/
03. Lapi F et al. The use of inhaled corticosteroids and the risk of adrenal insufficiency
Eur Respir J erj00809-2012; published ahead of print 2012, doi:10.1183/09031936.00080912
04. MHRA 2006. www.mhra.gov.uk/home/groups/plp/documents/websiteresources/con2023860.pdf
05. www.drugtariff.co.uk
06. BTS/SIGN. 2008 rev 2012. British Guideline on the management of asthma.
07. Park HY, et al. Inhaled corticosteroids for chronic obstructive pulmonary disease. BMJ 2012;345:e6843.
08. Price D et al. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. Prim Care Respir J 2012; Available from: URL: http://dx.doi.org/10.4104/pcrj.2012.00092
09. http://www.london.nhs.uk/what-we-do/our-current-projects/london-respirat...
10. Bosnic-Anticcevich SZ et al. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma. 2010: 47: 251-6
Competing interests: No competing interests