Evidence Is Clear

Despite these recommendations, significant gaps exist in our treatment of patients with asthma—notably ICS prescribing rates. Filling quality gaps in medicine is tricky.

Inhaled corticosteroids are infrequently prescribed from the ED. This may be because ICS fall into the “it’s not my job” part of emergency medicine. We presume that a primary care physician will prescribe an ICS if clinically indicated; however, this isn’t always the case.

One study found that in patients treated in an ED for an asthma exacerbation, only a minority who were not prescribed an ICS at ED or hospital discharge and had a six-month follow-up visit received a prescription for an ICS at that follow-up visit.⁷ Inhaled corticosteroids and ICS–LABA therapy can also be expensive, and it can be technically difficult to navigate depending on a patient’s insurance coverage.

The data are clear, however: Regardless of the barriers, most of our ED patients with asthma would benefit and have fewer exacerbations if they were on an ICS. If we have difficulty initiating therapy, we should, at a minimum, urge patients to discuss starting an ICS (with or without a LABA) with their primary care physician.

Dr. Westafer (@Lwestafer) is assistant professor in the department of emergency medicine at the UMass Chan Medical School–Baystate and co-host of FOAMcast.

References

1. Fauvel AD, Southerland LT, Panchal AR, et al. Emergency department course of patients with asthma receiving initial emergency medical services care–perspectives from the National Hospital Ambulatory Medical Care Survey. J Am Coll Emerg Physicians Open. 2023;4(4):e13026.
2. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. J Allergy Clin Immunol. 2007;120(5 Suppl):S94-138.
3. Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al. 2020 Focused Updates to the Asthma Management Guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6):1217-1270.
4. Global Initiative for Asthma. 2023 GINA Main Report. Published May 2, 2023. Accessed November 15, 2024.
5. Rayner DG, Ferri DM, Guyatt GH, et al. Inhaled reliever therapies for asthma: a systematic review and metaanalysis. JAMA. 2024:e2422700.
6. Kligler SK, Vargas-Torres C, Abbott EE, Lin MP. Inhaled corticosteroids rarely prescribed at emergency department discharge despite low rates of follow-up care. J Emerg Med. 2023;64(5):555-563.
7. Cydulka RK, Tamayo-Sarver JH, Wolf C, et al. Inadequate follow-up controller medications among patients with asthma who visit the emergency department. Ann Emerg Med. 2005;46(4):316-322.