A snapshot of SABA co‐prescribing with ICS ‐formoterol maintenance and reliever therapy

In adolescents and adults with moderate to severe asthma, the recommendation for inhaled corticosteroid (ICS)-formoterol maintenance and reliever therapy (MART) is based on its reduction of severe exacerbation risk compared to ICS or ICS/long-acting beta-agonist (LABA) maintenance with short-acting beta-agonist (SABA) reliever therapy.1, 2 Despite this high quality evidence, the uptake of ICS-formoterol MART has been poor internationally, and in clinical practice its use may be contaminated by SABA co-prescribing.3, 4 This contamination potentially undermines the reduction in severe exacerbation risk, as well as other advantages such as the simplicity of a single inhaler.5 In New Zealand, national dispensing data has shown widespread uptake of ICS-formoterol in adolescents and adults with asthma.6 It was not possible from this data to determine the degree of SABA co-prescribing in patients prescribed ICS-formoterol MART; to investigate the extent of this practice we undertook a survey of individual ICS-formoterol prescriptions from selected pharmacies across New Zealand in 2020. Five pharmacies geographically spread across New Zealand (2 urban, 3 rural) were included in this review of Symbicort (budesonide/formoterol turbuhaler 100/6 mcg and 200/6 mcg) scripts dispensed to those aged 12 and over from 1st to 15th of each month, from April to December 2020. Symbicort was the only ICS-formoterol product registered for reliever inhaler use (either alone or according to the MART regimen) in New Zealand during this period. Data collected included a unique prescriber identifier (asthma prescribing is predominantly done in general practice in New Zealand), Symbicort strength, dosing instructions as per annotation and co-prescribed SABA. The Table 1 summarizes the intent of the 370 Symbicort prescriptions reviewed. Co-prescription of SABA with Symbicort MART occurred in 29/177 (16%) scripts, and with Symbicort reliever alone in 1/22 (5%) scripts. In 18/199 (9%) Symbicort MART or reliever alone scripts, the reliever dose instructed that more than one inhalation could be taken (1–2 inhalations n = 9, 2 inhalations n = 9). There are many limitations to this review, including the small number of pharmacies and prescriptions for review, and the narrow time period. Despite these limitations, several important clinical observations can be made regarding the findings. Firstly, the frequency of SABA co-prescribing with Symbicort MART was low, and at 16% was less than that previously reported, ranging from 23% to 85%, in countries with low rates of MART prescribing.3, 4 It has been suggested that SABA co-prescribing with MART most commonly occurs due to patients' request based on a perception of safety or convenience4; our findings indicate most patients can be appropriately reassured by the prescribing practitioner. Secondly, it was evident that there was early adoption of the ICS-formoterol reliever alone regimen following its regulatory approval in June 2019, with minimal SABA co-prescribing. Thirdly, the reliever dose instructed that more than one inhalation could be taken in 9% of prescriptions, contrary to its approved use of one actuation at a time for relief. In conclusion, the widespread transition to ICS-formoterol MART or reliever therapy alone can be achieved in clinical practice with lesser degrees of SABA co-prescribing than that occurring in communities with infrequent ICS-formoterol reliever use. Rebekah Lamb: Data curation (equal); formal analysis (lead); writing – original draft (equal); writing – review and editing (equal). Kyley Kerse: Conceptualization (equal); data curation (equal); investigation (lead); methodology (equal); writing – review and editing (supporting). Heidi Kristono: Conceptualization (equal); investigation (supporting); methodology (equal); writing – review and editing (supporting). Karen Oldfield: Formal analysis (supporting); writing – original draft (equal); writing – review and editing (supporting). Richard Beasley: Conceptualization (supporting); supervision (lead); writing – original draft (equal); writing – review and editing (equal). Richard Beasley is an Advisory Board member for Respirology and was excluded from all editorial decision-making related to the acceptance of this article for publication. He has received institutional research funding from AstraZeneca, Genentech, Health Research Council of New Zealand and CureKids (NZ); personal fees from AstraZeneca, Avillion, Cipla and Teva, and is Chair of the Asthma and Respiratory Foundation of New Zealand Adolescent and Adult Asthma Guidelines. The other authors have no conflicts to declare. Ethics approval was not required as the survey was an audit related activity with no identifiable information collected. The data that support the findings of this study are available from the corresponding author upon reasonable request.