In the beginning of the COVID-19 pandemic there were major concerns regarding the huge demand for asthma inhalers. Using primary care medical records for 614,700 asthma patients between January and June 2020, we found that there was a substantial increase in inhalers solely in March 2020. Patients significantly associated with receiving higher inhaled corticosteroid prescriptions were younger, of higher socioeconomic status and had milder asthma

Bloom, C

Elkin, S

Hickman, K

Wong, E

npj Primary Care Respiratory Medicine

English

Spiral - Imperial College Digital Repository

BRIEF COMMUNICATION OPENInfluence of the first wave of COVID-19 on asthma inhalerprescriptionsC. I. Bloom 1✉, E. Wong2, K. Hickman3 and S. Elkin2In the beginning of the COVID-19 pandemic, there were major concerns regarding the huge demand for asthma inhalers. Using theprimary-care medical records for 614,700 asthma patients between January and June 2020, we found that there was a substantialincrease in inhalers solely in March 2020. Patients significantly associated with receiving higher inhaled corticosteroid prescriptionswere younger, of higher socioeconomic status, and had milder asthma.npj Primary Care Respiratory Medicine           (2021) 31:45 ; https://doi.org/10.1038/s41533-021-00260-wDuring the first wave of COVID-19 in the UK, there was reported asubstantial surge in prescriptions for asthma inhalers such thatmanufacturers stated certain inhalers were out of stock and theDepartment of Health and Social Care issued a statement askingpractitioners not to overprescribe inhalers1. In this same periodthere was a significant reduction in the number of asthmaexacerbations managed within primary care2; one reason pro-posed is an increased adherence to asthma medication. Otherreasons include reduced viral exposure and fear of presentation tohealthcare facilities.In this study we have used primary-care records to quantifychanges in asthma prescriptions during this period, relative tonon-asthma medications. We have also sought to understandwhich patients were more likely to receive increased prescriptions,as this could inform on whether these increased prescriptionswere likely to be related to increased adherence.A total of 614,700 asthma patients and 240,661,066 issuedprescriptions were identified. All prescriptions increased duringMarch 2020, with a peak on the 16th of March, corresponding tothe dotted line in Fig. 1.The proportion of the following medications increased sig-nificantly in March 2020 as compared to March 2019; the largestchange was seen in asthma medications: (a) ICS: 52.55% increase(2019: 3.92% (95% CI 3.85–4.00), 2020: 5.98% (95% CI 5.91–6.06), p< 0.0001); (b) SABA: 44.23% increase (2019: 10.31 (95% CI10.20–10.43), 2020: 14.87% (95% CI 14.76–14.99), p < 0.0001); (c)OCS: 17.37% increase (2019: 1.9% (95% CI 1.85–1.95), 2020: 2.23%(95% CI 2.19–2.28), p < 0.0001); and (d) LABA-ICS: 14.19% increase(2019: 3.92 (95% CI 3.85–4.00), 2020: 5.98% (95% CI 5.91–6.06), p <0.0001).The following medications decreased significantly in March2020 as compared to March 2019 (p < 0.0001): LTRA (0.53%decrease), antidepressants (10.15% decrease), statins (10.33%decrease), NCS (3.31% decrease), and PPIs (6.95% decrease).The most highly prescribed ICS inhaler in March 2019 and 2020was Clenil Modulite 100 mcg, and Fostair 100/6 was the mosthighly prescribed LABA-ICS in both years. There was a 212.96%increase in Clenil Modulite prescriptions in March 2020 and170.78% increase in Fostair 100/6 prescriptions (Fig. 2). Changes inthe months before and after March were considerably less; thelevel of change is in keeping with the mild changes that occurbetween calendar years.In all, 97,692 patients were included in the regression model.Several factors were significantly associated with an increasedodds of receiving more ICS prescriptions in March 2020 than inMarch 2019; these included age under 50 years, not having COPD,higher socioeconomic status, having had no exacerbations in theyear prior, and receiving a prescription for a low-dose ICS orreceiving less than three maintenance inhalers (see Supplemen-tary Table 1). Patient’s gender, having had a recent annual asthmareview, and their number of reliever inhalers in the year prior werenot significantly associated with receiving more ICS prescriptions(p > 0.05).The factors significantly associated with an increase in odds ofreceiving more OCS prescriptions included having had anexacerbation in the year prior (adjusted OR= 5.74, 95% CI5.39–6.12, p < 0.0001), having COPD (adjusted OR= 1.99, 95% CI1.87–2.12, p < 0.0001), using high-dose ICS (adjusted OR= 1.43,95% CI 1.27–1.60, p < 0.0001), and having at least six maintenanceinhalers (adjusted OR= 1.25, 95% CI 1.19–1.35, p < 0.0001).In summary, there was an increase in inhaler prescriptions, butnot other commonly prescribed medications, in asthma patientsduring the month of March 2020, but the levels fell back to typicalnumbers thereafter. The peak in March coincided with the daythat the government announced people with asthma shouldshield (16th March)3. The total number of prescriptions for themost frequently prescribed ICS inhaler, Clenil Modulite 100mcg,doubled in March 2020. Asthma patients who increased their ICSprescriptions were more likely to be younger, have minimalsocioeconomic deprivation, and have mild asthma (no recentexacerbation, on low-dose ICS, and have infrequent ICS prescrip-tions). A possible study limitation was selection bias; to capturethe change in individual patient’s prescriptions beyond thatoccurring year-on-year, only patients with at least 5 years ofinhaler data were included. It seems unlikely that the increase inprescriptions was related to increased prolonged adherenceleading to a reduction in exacerbations, but adherence data forthis study were not available. In contrast, the factors associatedwith increased OCS prescriptions were synonymous with patientswho had more severe respiratory disease.1National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK. 2Imperial College Healthcare NHS Trust andImperial College London, NHLI, London, UK. 3West Yorkshire & Harrogate Health and Care Partnership, Low Moor Medical Practice, Bradford, West Yorkshire, UK.✉email: Chloe.bloom06@imperial.ac.ukwww.nature.com/npjpcrmPublished in partnership with Primary Care Respiratory Society UK1234567890():,;METHODSData sources and variablesWe used the Clinical Practice Research Datalink (CPRD) Aurum, adatabase of primary-care medical records covering approximately19% of the UK4. A cohort of adult (≥18 years) asthma patients usinga validated algorithm5 were identified; patients were excluded iftheir last asthma code was over 3 years ago or they had less than 5years of prescription data. Medications between 1st January 2010and 31st May 2020 were included. Asthma medications includedinhaled corticosteroids (ICS), short-acting beta-agonists (SABA),combination long-acting beta-agonists and ICS (LABA-ICS), andleukotriene receptor antagonist (LTRA); non-asthma medicationsincluded the frequently prescribed medications, nasal corticoster-oids (NCS), proton pump inhibitors (PPI), statins, and the threemost prescribed antidepressants (fluoxetine, citalopram, andsertraline)6. Comparing the prescription of asthma medications tothe most commonly prescribed of all medications allows assess-ment of the specificity of changes in asthma medications.Statistical analysisPrescriptions were visualised using histograms, including all prescrip-tions. Thereafter, analysis was performed after removing repeatprescriptions on the same day for the same medication (attemptingto reduce the prescriptions intended for stock piling). The differencein prescriptions per patient between 1st and 31st March 2019, andthe same period in 2020, was reported using percentage change.Wilcoxon signed-rank test was used to confirm if there was astatistical difference, where significance was defined as p< 0.001. Thedifference in the two most frequently prescribed ICS and LABA-ICSinhalers was measured using the percentage change of the absoluteprescription numbers. Multivariable logistic regression was used toestimate the association between increased ICS prescriptions (March2019 to March 2020) and patient’s age, gender, age, socioeconomicstatus, COPD comorbidity, and in the year prior: exacerbationsmanaged within primary care (defined as a short course of OCS),annual asthma review, frequency of SABA use and maintenanceinhaler use (ICS or ICS-LABA), and dose of ICS (low< 800mcg,medium, or high ≥1000mcg).EthicsThe protocol for this research was approved by the IndependentScientific Advisory Committee (ISAC) for MHRA Database Research(protocol 20_096). CPRD data are already approved via a nationalresearch ethics committee for non-interventional research. Becausepatients cannot be identified from the data that GP practices sendto CPRD, GPs do not need to seek individual written patientconsent when they share the data with CPRD. However, patientscan opt out of their patient information being shared for research.Reporting SummaryFurther information on research design is available in the NatureResearch Reporting Summary linked to this article.DATA AVAILABILITYData were obtained from a third party (CPRD) and are not publicly available. CPRDdata cannot be directly shared by the researchers but are available directly fromCPRD subject to standard conditions. Access to anonymised patient data from CPRDFig. 1 Number of daily prescriptions by drug type from 1st January 2010 until 1st June 2020. Each bar represents a day. The dotted line isplaced on the date 16th March 2020.Fig. 2 The number of prescriptions by inhaler, month and year.Comparison of the number of prescriptions in March 2019 andMarch 2020 for the most highly prescribed ICS (Clenil Modulite100mcg) and LABA-ICS (Fostair 100/6).CI Bloom et al.2npj Primary Care Respiratory Medicine (2021)    45 Published in partnership with Primary Care Respiratory Society UK1234567890():,;is subject to a data sharing agreement (DSA) containing the detailed terms andconditions of use following protocol approval from CPRD’s ISAC. The generatedsynthetic data set discussed in this paper can also be requested from CPRD subject toa DSA (https://www.cprd.com/content/synthetic-data).Received: 21 May 2021; Accepted: 3 November 2021;REFERENCES1. Wickware, C. & Robinson, J. Asthma inhaler stocks low after COVID-19 linkeddemand spike, government says. Pharm. J. https://www.pharmaceutical-journal.com/news-andanalysis/news/asthma-inhaler-stocks-low-after-covid-19-linkeddemand-spike-government-says/20207873.article?firstPass=false (2020).2. Shah, SA., Quint, JK., Nwaru, BI. & Sheikh, A. Impact of COVID-19 national lockdownon asthma exacerbations: interrupted time-series analysis of English primary caredata. Thorax 76, 860–866 (2021).3. Prime Minister’s statement on coronavirus (COVID-19): 16 March 2020. https://www.gov.uk/government/speeches/pm-statement-on-coronavirus-16-march-2020 (2020).4. Herrett, E. et al. Data Resource Profile: Clinical Practice Research Datalink (CPRD).Int. J. Epidemiol. 44, 827–836 (2015).5. Nissen, F. et al. Validation of asthma recording in the Clinical Practice ResearchDatalink (CPRD). BMJ Open 7, e017474 (2017).6. Audi, S. et al. The ‘top 100’ drugs and classes in England: an updated ‘starterformulary’ for trainee prescribers. Br. J. Clin. Pharm. 84, 2562–2571 (2018).AUTHOR CONTRIBUTIONSCIB was responsible for the initial concept, analysis, and first draft of the manuscript.EW, KH, and SE provided intellectual discussion of the concept and were responsiblefor reviewing and editing the manuscript.COMPETING INTERESTSThe authors declare no competing interests.ADDITIONAL INFORMATIONSupplementary information The online version contains supplementary materialavailable at https://doi.org/10.1038/s41533-021-00260-w.Correspondence and requests for materials should be addressed to C. I. Bloom.Reprints and permission information is available at http://www.nature.com/reprintsPublisher’s note Springer Nature remains neutral with regard to jurisdictional claimsin published maps and institutional affiliations.Open Access This article is licensed under a Creative CommonsAttribution 4.0 International License, which permits use, sharing,adaptation, distribution and reproduction in anymedium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the CreativeCommons license, and indicate if changes were made. The images or other third partymaterial in this article are included in the article’s Creative Commons license, unlessindicated otherwise in a credit line to the material. If material is not included in thearticle’s Creative Commons license and your intended use is not permitted by statutoryregulation or exceeds the permitted use, you will need to obtain permission directlyfrom the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.© The Author(s) 2021CI Bloom et al.3Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2021)    45 

Influence of the first wave of COVID-19 on asthma inhaler prescriptions

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Influence of the first wave of COVID-19 on asthma inhaler prescriptions

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