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​’Clinical uncertainty’ has led to asthma meds being overused by GPs



GPs are ‘overusing’ inhalers and oral steroids in people without asthma who have an acute chest infection due to ‘uncertainty’ over the best course of management, researchers have concluded. 

Data from more than 115,000 patients also showed overprescribing of antibiotics in all patients with lower respiratory tract infections, whether they had asthma or not.

The team found wide variation between practices and concluded there was ‘clinical uncertainty’ in what the best course of action should be.

The RCGP said GPs were highly trained to assess all factors affecting patients before prescribing, which ‘may not be coded in the medical record and thus not picked up in research studies.’

Presenting the study at the Society for Academic Primary Care conference, the researchers from the University of Bristol said changes in guidance had led to uncertainty over the management of acute lower respiratory tract infections.

There was a significant difference between practices in prescribing across the board, but most notably in the use of oral steroids and step-up asthma medication.

Non-asthmatic patients were most likely to receive step-up asthma medication if they were young, had higher prior asthma medication prescribing and were also prescribed antibiotics.

The study, which looked at data on adult patients from 2014-15, found that eight in ten were prescribed antibiotics regardless of asthma status.

And 38% of patients with asthma and 14% of those without asthma who had been diagnosed with an acute lower respiratory tract infection were given ‘step-up’ asthma medication.

The researchers concluded: ‘Findings from the study indicate that antibiotics are over-used for acute lower respiratory tract infection irrespective of asthma status, and step-up asthma medication is over-used in non-asthmatic patients, with between practice variation suggesting considerable clinical uncertainty.

‘Further research is urgently needed to clarify the role of these medications.’

Research has shown that oral steroids are unnecessary in chest infections in those who do not have asthma or COPD.

Antibiotic prescribing has been falling in recent years but Dr Dermot Ryan, a retired GP and an honorary clinical fellow at the University of Edinburgh, said the results showed it remained a tricky issue to tackle.

He said: ‘There remains a reluctance not to prescribe antibiotics when patients present, especially if that patient has high expectations of receiving them which would be reinforced in practices which prescribed lots of them and also in patients who are used to receiving them.’

NICE guidance published in 2018 recommended more cautious use of antibiotics in COPD exacerbations.

He added that while prescribing behaviour may need to be addressed, as long as the issue is ‘exacerbated by misplaced Government initiatives, such as rescue packs for COPD, it is going to be a tough hill to climb’.

Professor Helen Stokes-Lampard, chair of the RCGP, stressed it was important to remember that ‘prescribing guidelines are not tramlines’.

She said: ‘Prescribing safely and appropriately is a core skill in general practice, and GPs are highly-trained to consider the physical, psychological, and social factors potentially affecting the health of a patient before deciding whether or not to prescribe medication.

‘Regardless of the issue a patient presents with, we will always aim to take into account their full medical history, including any medications they are currently taking, or have taken in the past, and how different drugs can potentially interact with each other.’

She added: ‘For acute illnesses, such as chest infections, GPs will also consider using medications such as antibiotics or steroids if they think they are the most appropriate course of action and most likely to help the person sitting in front of them, bearing in mind a huge range of factors that may not be coded in the medical record and thus not picked up in research studies’

It follows research that found asthma-related GP appointments triple during the back-to-school period, due to fluctuations in weather and the stress of starting a new school year.