Changes in rates of prescriptions for inhaled corticosteroids during the COVID-19 pandemic.

During the COVID-19 pandemic, despite early concerns the impact oral corticosteroids might have on the effects of acute COVID-19 reported by the WHO and the potential severity of disease in patients with asthma and chronic obstructive pulmonary disease (COPD), patients were advised to continue inhaled corticosteroid (ICS) therapy to reduce the burden of disease, the risk of exacerbations, and admission to hospital where there would be an increase in risk of exposure to SARS-CoV-2. One way of examining patient and practitioner responses in this context is to investigate changes in primary care ICS prescribing during this period.

Open prescribing is a digital interface that enables primary care prescribing data, released monthly from National Health Service (NHS) England, to be accessed and analysed on an open platform. National activity of general practice (GP) appointments is reported monthly by NHS Digital to support winter preparedness and provide information about activity within primary care. The pandemic rapidly changed the provision of primary care services, with a reduction in face-to-face consultations and a move towards telephone or virtual consultations. The total number of reported telephone appointments (24·7 million) from March to May, 2020, accounted for, on average, 42% of the total number of all reported appointments in primary care (58·6 million), increasing 250% compared with the same period in the previous year (9·9 million), with a 17% absolute reduction in the total number of all reported appointments compared with the previous year. This time period encompassed the first legally imposed national lockdown in England.

Patients often do not take their medicines as directed; patients with asthma prescribed ICS often have suboptimal inhaler technique or do not take ICS regularly as prescribed. The provision of medicines information, support, and regular checks of inhaler technique by a multidisciplinary team can prevent this fixable cause of treatment failure and improve health outcomes. The COVID-19 pandemic and imposed lockdowns brought about dramatic changes to social behaviour, impacting health behaviour of patients. Changes in patient medication taking behaviour, a reduction in self-management behaviours, and stockpiling of acute respiratory medicines were reported.

An increase in presentation of patients with respiratory symptoms and consequent increase in number of prescribed ICS is usually seen during the winter months due to contributory factors, including seasonal variation in weather, increase in circulating pathogens, and changes to adherence to ICS during summer versus winter months. Before the exit of the UK from the EU, the Department of Health and Social Care issued guidance for local providers, whether in hospitals or primary care, not to stockpile medicines, or for clinicians to write longer prescriptions for patients. Despite reassurances surrounding the availability of medicines released to the public and health-care professionals at this time, patient demand and prescribing of ICS therapy increased. In March–May, 2020, the total number of all ICS inhaler items prescribed increased 20% compared with the corresponding period in 2019 (table ). Panic ordering was reported by pharmacists, with many patients requesting prescriptions, including those who had not ordered inhalers for prolonged periods of time and those who did not have an imminent clinical need. A peak in demand was seen in March, 2020, with a 43% average increase in ICS items compared with the previous year. Despite a reduction in absolute primary care appointments during this time, the number of ICS issued per appointment increased 26%.

Table

Number of inhaled corticosteroid items prescribed in primary care during the first lockdown of the COVID-19 pandemic in England, compared with the previous year

	Number prescribed, 2019	Number prescribed, 2020
March	1 748 675	2 499 890
April	1 689 206	1 999 216
May	1 794 833	1 802 634
Total	5 232 714	6 301 740

An increase in prescribing rates during virtual consultations compared with in-person appointments is a recognised challenge for clinicians. Patient pressure to leave the consultation with a prescription is a known cause of over prescribing. Additionally, the reduced immediate diagnostic information and inability to assess patients physically or to confirm inhaler technique, adds to the prescriber's dilemma to ensure medicines optimisation within a telephone consultation. Changes in ICS adherence are complex and multi-factorial, the perception of risk and value patients place on use of controller therapies and self-management plans are important contributing factors. Any increases in adherence to controller therapies during the pandemic might have been driven by fear of the potential severity of COVID-19 symptoms in patients with underlying health conditions, including respiratory conditions and effect of respiratory symptoms on self-isolation periods. Reports of increased disease severity and high risk of admission to hospital with COVID-19 for both adults and children with uncontrolled asthma, have compounded these fears, specifically those patients who were not regularly taking ICS during the preceding weeks to infection.

The peak in demand for ICS prescription items cannot be definitively linked to increased patient adherence once the prescription is collected. Electronic medication monitors, which measure the number of doses taken by patients over a period of time, can enable clinicians to track trends in adherence. During Jan–March, 2020, a 14·5% relative increase in adherence to controller inhaler medication was reported for patients with asthma and COPD, suggesting the increased prescribing rate could reflect a trend of increased adherence during this time. A key component of a respiratory assessment should include level of adherence to inhaled therapies, ensuring patients have a good understanding of inhaler technique, is crucial to optimise drug delivery. Choosing the right questions during consultation—ie, “Can you show me how you use your inhaler?”, rather than “Do you know how to use your inhaler?”—along with the ability to visualise the patient's technique can quickly ascertain any improvements required. Changes in self-management behaviours, including anticipatory uptake of medicines, increased desire to stop smoking, accessing online health-care services, and watching online inhaler technique videos were also reported during the pandemic, suggesting patients were motivated to ensure symptom control through self management.

As we approach another difficult winter in the NHS for respiratory services, and the potential of future lockdowns, it is important to ensure clinicians can take advantage of any improvements to levels of adherence and self-management motivation, prescribers should be supported to optimise both aspects during telemedicine and face-to-face consultations. Patients and clinicians should have the opportunity to provide and choose the most effective and convenient method of consultation delivery. Opportunities to check and improve the level of adherence and visualise inhaler technique should be prioritised as a key component of consultation. Innovations in telemedicine and home monitoring, including virtual spirometry, auscultation, oxygen saturation, and electronic inhaler adherence monitoring, are essential tools to support prescribers to make informed treatment decisions with patients. Prescribing appropriate quantities of medication to ensure the supply chain is not unduly affected during times of peak demand should continue. Pharmacists, and the wider team, are well placed to ensure requests for medications are appropriate and timely, as well as provide additional support, self-care advice, and check patient inhaler technique. The expansion of available diagnostic tools available to patients via smart phone at home, without the right multidisciplinary support to use them effectively, could have grave consequences. The importance of well informed and supported self-management plans, including when to seek medical help during an acute flare, will become increasingly vital. By enhancing and further evaluating telemedicine's diagnostic and monitoring capabilities, health-care professionals will effectively support patients to manage their symptoms virtually at home and optimise therapeutic choices.