Matthew Rank, M.D. (@MatthewRankMD) is a practicing allergy and asthma specialist and associate professor of medicine based in Arizona. He is also the director of the Kern Scholars Program in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.
For those who struggle with asthma, the goal is to find the lowest level of medication that will allow them to live well and breathe easier, without fear of emergency events.
This “sweet spot” for asthma medication management is not the same for everyone. Further, the long-term outcomes and risks after reducing or “stepping down” asthma medications have previously been poorly defined, hindering decision-making discussions between patients and providers.
In a recently published study in CHEST, my colleagues and I were able to shed some light on this issue. Using the OptumLabs™ Data Warehouse, we conducted a retrospective time-to-event analysis of individuals diagnosed with asthma who stepped down their asthma controller medications.
We found that 32 percent of more than 26,000 included individuals had an asthma exacerbation in the two years following a step down event. A much smaller group – 7 percent – had an emergency department visit or hospitalization. Step downs were defined as at least a 50 percent decrease in days-supplied of controller medications between one 4-month period and the next. Asthma stability within a period meant not having an asthma exacerbation (inpatient visit, emergency department visit, or dispensing of a systemic corticosteroid linked to an asthma visit) and having two or fewer rescue inhaler claim in the same 4-month period.
Unsurprisingly, we found that the longer individuals exhibited asthma stability before stepping down asthma medication, they experienced a corresponding decrease in the likelihood of an exacerbation event in the next two years. This chart summarizes the events we categorized, and the asthma stability period that preceded them.
Understanding longer-term outcomes is an essential part of the doctor-patient conversation as each individual determines the ideal asthma medication protocol for themselves. This study gives a clearer picture of extended medication management outcomes when seeking to reduce the amount of medication used to manage an individual’s asthma. Our findings were somewhat reassuring in that most individuals with asthma were able to successfully step down their asthma controller medications safely, but also concerning in that we do not currently have great ways to predict if a patient will fall into the 32% of individuals who end up having an exacerbation. Length of stability prior to the step down event appears to be a promising predictor. This research is important because needing less medication benefits patients financially and can improve their quality of life. We hope to build on this study in the near future, developing and validating a clinical prediction rule in a prospective study that will allow practitioners and patients more precise guidance when making decisions about stepping down chronic asthma medicines.
Study collaborators included Mayo Clinic’s Ryan Johnson; Megan Branda; Holly van Houten; Michael Gionfriddo, Pharm.D.; and Nilay Shah, Ph.D. (also of OptumLabs™); and Jeph Herrin, Ph.D., of Yale University and the American Hospital Association’s Health Research & Educational Trust.
This study was made possible in part by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. Learn more about health care delivery research at the upcoming Delivery Science Summit 2015 – Building the Evidence Base in Health Care Delivery, September 16-18, 2015, in Rochester, Minnesota.