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medpundit |
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Friday, December 13, 2002About albuterol -- please, please don't make it available over the counter. Why? It will worsen asthma care substantially. According to published data, only about 30% of patients with persistent asthma take a controller medication (inhaled corticosteroid or leukotriene modifier, from the Asthma in America study, and also from the NHLBI National Asthma Education Program, see also Milgrom, J Allergy Clin Immunol, 1996). Many of the patients not on controllers over-use albuterol, with the result of unabated, persistent airway inflammation. This leads to continued poor control of asthma over time. That in turn increases substantially the risk of death (Suissa, NEJM, 343:332, 2000), decreases future responsiveness to controller therapy (Haahtela, NEJM, 331:700, 1994), and increases the risk of being hospitalized for asthma (Donahue, JAMA, 227:887, 1997). One of my colleagues... has examined public-aid health data in Chicago to look at albuterol over-use. He's examined public aid pharmacy claims databases for albuterol and controller prescriptions by zip code in Chicago. If you're properly treated, you should have (on average) one controller prescription per month, and at most, one albuterol prescription. If the albuterol:controller ratio is higher than that, it suggests that asthmatics in that zip code aren't properly controlled and are over-relying on rescue inhalers. In about 3/4 of the zip code regions, the albuterol:controller ratio exceeds 4. In none of the zip codes is the ratio less than 2. Either 1) asthmatics are using their inhaled steroid but still taking about 16 puffs of albuterol a day, or 2) you have a large number of asthmatics who are taking albuterol but no controller. Since the proportion of patients with intermittent asthma (no need for controllers) is only about 20% of all asthmatics, this suggests that we're doing a poor job of treating the persistent asthmatics. [ed. note - Controller medications are medicine like steroid inhalers or Singulair that prevent asthma attacks, or at least reduce their frequency.] The reasons why asthmatics are over-relying on rescue inhalers are many, from family and social disintegration, lack of access to medical care, apathy and acquiescence of chronic illness on the part of patients, poorly educated primary care providers (sorry, I'm a pulmonologist and I see this every day), insurance policies that force changes in medication based on preferred pricing for them which leads to confusion on the part of patients, and so on. If you make albuterol over the counter, the temptation is for an asthmatic to just buy it and skip seeing the doctor. That's the point of over-the-counter claritin, after all -- just take it and don't bug the doctor with your hay fever. In this way asthma remains poorly controlled, and we docs never see them to address it. Asthma control in the community is poor enough as it is, and I'm afraid this would just make it worse. For the record, I don't think albuterol should be over the counter, either, for the same reasons the author lists. My point was that it makes no sense for high dose hormone pills to be made available over the counter when other drugs, with less side effects, aren't. Holding the high dose hormones in emergency contraception kits to different standards than other drugs makes no sense medically. It only makes sense politically. posted by Sydney on 12/13/2002 06:07:00 AM 0 comments 0 Comments: |
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