Australian children are being inappropriately prescribed fixed-dose combination (FDC) asthma medication, a University of New South Wales (UNSW) study has revealed.
According to national asthma guidelines, children under five shouldn’t be prescribed combination asthma controllers at all.
But the study shows the reality looks much different, with Australian children, particularly pre-schoolers, routinely prescribed this type of asthma inhaler, which contains a combination of two medicines.
The combination is only meant to be prescribed when inhalers with a single preventative medicine, called inhaled corticosteroid, or ICS, are infective in controlling asthma symptoms.
The study found 88% of FDC inhalers dispensed to children and adolescents aged between one and 18 were prescribed as the first line of controller therapy.
Looking at 10% of the Australian population, the study also found that about 3,500 children aged five or under are dispensed FDC inhalers annually.
“According to national asthma guidelines, children aged five or under shouldn’t be prescribed FDC inhalers at all,” said lead author, respiratory epidemiologist and senior lecturer in paediatrics at UNSW Medicine, Dr Nusrat Homaira.
Published in the International Journal of Environmental Research and Public Health, the findings emerge two years after the Pharmaceutical Benefits Advisory Committee (PBAC) made recommendations that FDC dispensing patterns in children were “unacceptably high” and needed to change.
There are two main types of asthma medications – reliever medication, which helps manage the symptoms of asthma (commonly known as blue puffers), and controller medication, which helps prevent and control asthma attacks.
Both FDC and ICS fall under controller medicines, which generally come in the form of puffers, and include corticosteroid, an anti-inflammatory medication, but FDC also includes a long-acting muscle relaxant.
According to the Australian Asthma Handbook, developed by the National Asthma Council, children and adolescents aged between six and 18 should only be prescribed FDCs after trying initial therapy with ICS.
The ‘step-up’ approach to asthma management aims to minimise the potential risks of prescribing the medication to young children.
Dr Homaira said there was a lack of evidence that FDC benefits children, especially pre-schoolers.
“Some data suggests it may even increase risk of asthma exacerbation and result in the development of tolerance to asthma relievers in young children,” she said.
Researchers used a set of routinely collected dispensing data from the Pharmaceutical Benefits Scheme (PBS).
The randomised data set included almost 36,000 children and adolescents aged 1-18 who were dispensed at least one FDC between January 2013 and December 2018.
Of this sample, more than 31,000 didn’t have a preceding ICS prescription.
The study is the first data analysis on national asthma dispensing patterns conducted since 2014.
Dr Homaira stressed that despite the high dispensing rates, asthma dispensing patters were improving.
“Overall, FDC dispensing in children – and more importantly, FDC dispensing without a preceding ICS – is declining in Australia,” she said.
“In 2013, around 15 in every 1,000 children were prescribed an FDC inhaler. By 2018, this dropped to around seven in every 1,000 children. More work needs to be done but we are moving in the right direction.
Dr Homaira said she was hopeful that the study’s findings would help monitor changes to asthma dispensing policies over time.
“While administrative data can’t always answer the granular questions, like why so many practitioners are prescribing FDCs to children, it can highlight a problem.
“Data gives the aerial view – a snapshot of what’s happening in Australian healthcare. Once you have this snapshot, you can dig into the details and potentially advocate for policy changes.”
