This study describes GP asthma prescribing in children within a large UK clinical database in June 2003. At this time an extensive body of well-publicised research had questioned the safety and efficacy of high-dose inhaled corticosteroid use in paediatric asthma and emphasised the use of add-on therapy at an early stage in children uncontrolled on standard doses.
We observed that 4.5% of all children were prescribed inhaled corticosteroids for the treatment of asthma. Ten per cent of children aged 5–11 years who were treated with inhaled corticosteroids were receiving high doses; a slightly lower proportion of those aged under 5 years (5.6%) also appeared to be receiving high-dose corticosteroid treatments. Very high and unlicensed doses of inhaled corticosteroids were recommended to 1 in 20 of the 5–11 year old patients and 1 in 26 of the under-5s; fluticasone was the main drug associated with high-dose prescribing. Add-on therapy was lacking in half of the patients prescribed >400 mcg/day, and unlicensed use of long acting β-agonists was the commonest form of add-on therapy in the under 5s. Evidence-based treatment as summarised in the BTS guidelines specifies that no child should receive over 400 mcg/day of inhaled corticosteroid without having had sequential trials of add-on therapy (initially long acting β-agonists, followed by leukotriene-receptor antagonist chromone or slow-release theophylline), and that the only recommended add-on therapy in children aged under 5 years is a leukotriene-receptor antagonist.
Our results indicate that prescribing for childhood asthma in the UK in 2003 was not always consistent with current best practice or with license; some children were prescribed doses of corticosteroid that risked life-threatening adrenal suppression, and some children failed to receive add-on therapy associated with fewer symptoms, less exacerbations and lower exogenous corticosteroid exposure.
The limitations of this study include its cross-sectional nature, thereby providing information on only one point in time. In addition, we cannot be certain that add-on therapies had previously been trialled in all patients studied as, due to patients moving between general practices, full information from birth was not present for all individuals. Prescribing instructions were not clear for some 14% of children and we could not determine whether the original prescription for those on whom we did have data was ordered by a GP or a paediatrician. To combat this we took the approach that as the repeat prescription was issued by the GP, final responsibility for the prescribing advice should lie with him or her. The strength of this study is that it accessed data from large numbers of representative subjects in a large well-validated clinical database. The prescribing information held in the database is accurate and likely to reflect what was actually occurring in real-world UK practice at the time of the survey.