emDOCs Videocast: EBM Update – Inhaled Corticosteroids for Asthma in the ED

Background:

• Asthma is a common ED issue, with patient presentations ranging from needing a medication refill to severe exacerbation in respiratory failure.
• Unfortunately, Asthma disproportionately affects patients with lower socioeconomic status and poor follow-up.
• Guidelines recommend using inhaled corticosteroids (ICS) for chronic/long-term management of asthma.
• However, inhaled steroids can reduce reduce ED length of stay and need for admission. They reduce inflammation and improve the sensitivity of beta-receptors to improve beta-agonist efficacy.

Study:

• Kligler SK, Vargas-Torres C, Abbott EE, Lin MP. Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care. J Emerg Med. 2023 May;64(5):555-563.

Clinical question:  

• In adult patients with asthma discharged from the ED, what are prescription rates for ICS?

Design:

• Retrospective chart review of ED patients presenting over 2 years with a diagnosis of asthma who also received an ICS prescription.
• 5 urban academic EDs, attending charts.
• Excluded admitted, transferred, or expired patients during their ED visit.
• 4000 visits amount 3000 patients.
• Authors selected a sample of 150 (3%) for consistency.
• Primary outcome: Prescription of ICS on ED discharge from the index visit
• Secondary outcomes:
  • ICS prescription rates in high-risk subgroups
  • Rates of outpatient follow-up within 30 days of an ED visit for asthma
  • Variation in ICS prescription rates among attending ED physicians.

Results:

• ICS prescribed in 6.02% (n = 238) of all ED visits.
• Approximately half (49%) had an established primary care provider.
• Patients receiving an ICS during the ED course of treatment (OR 9.96; 95% CI 8.08–12.27) and those who received a prescription for a β-agonist at discharge (OR 2.66; 95% CI 2.09–3.38) were more likely to receive an ICS prescription at time of ED discharge.
• For follow up, 13.98% of visits were followed by an outpatient visit within 30 days, and 3.77% of index visits were followed by an ED revisit within 30 days. Among patients with a primary provider documented in the chart, 30-day outpatient follow-up rate was 21.3% (n = 313).

Conclusions:

• Emergency physicians are missing a major opportunity to improve the long-term health of patients and reduce the need for visits for asthma exacerbation.
• Prescribe ICS when discharging patients for asthma exacerbations.
• Consider using the combination ICS/LABA inhalers or separate inhalers.

• The 2019 Global Initiative for Asthma (GINA) guidelines recommend that all patients with asthma be prescribed ICS.
• GINA 2023 guidelines have two tracks:
  • Track 1 – ICS/formoterol combo PRN for intermittent asthma
  • Track 2 – ICS to be taken whenever SABA is used (separate or as combo drug)
  • Thus, every asthma track includes an ICS for outpatient therapy.

Considerations:

• One issue may be cost: Albuterol $17, Formoterol $300, Budesonide $40, Fluticasone $200. Budesonide/Formoterol combo – $100 (wide pricing range).
• Potential side effects of ICHS include hoarse voice, thrush, contact dermatitis, but there are almost no systemic effects.
• Once inhaled, the deposits into the lungs or the GI tract. If ingested in the GI tract, the steroid undergoes first pass metabolism through the liver and has minimal systemic effect.
• Recommendation: Consider prescribing an ICS with or without short term oral steroids in the patient with an asthma exacerbation who will be discharged from the ED. Options include budesonide 200-400 mcg or fluticasone 100-250 mcg daily.  A short acting beta-agonist should be used for worsening symptoms but should not be used alone. Have the patient swish with water and spit after using the steroid inhaler to prevent oral thrush.

• Kearns N, Maijers I, Harper J, Beasley R, Weatherall M. Inhaled Corticosteroids in Acute Asthma: A Systemic Review and Meta-Analysis. J Allergy Clin Immunol Pract. 2020 Feb;8(2):605-617.e6.

Objective: 

• To estimate the efficacy of ICS in the treatment of acute moderate/severe asthma in the ED.

Design:

• Included RCTs from PubMed, The Cochrane Library, and EMBASE.
• The primary outcome was hospital admission rates.
• The primary comparison was between administration of ICS in addition to systemic corticosteroids (SCS) and to SCS alone.
• Secondary comparisons were ICS alone compared with SCS alone and ICS compared with placebo.

Results:

• 25 studies involving 2733 participants.
• For the primary comparison, ICS + SCS reduced the risk of hospital admission compared with SCS; fixed-effects odds ratio (95% confidence interval) 0.73 (0.57-0.94).
• Lung function poorly reported.
• There was moderate evidence of an improvement in clinical scores and vital signs with ICS in addition to SCS.
• Relatively few studies reported adverse events.

Conclusion: 

• There is moderate evidence that high doses of ICS, with SCS, reduce the risk of admission when used in the ED for moderate-to-severe asthma exacerbations.