Table 2.

Barriers to OCS prescription changes and steps to implement change

Barriers	Solutions	Steps to implement change	Recommended stakeholders to implement change
It is accepted that exacerbations are an unavoidable part of living with asthma	Implementing effective, balanced communication and information campaigns	Governments or other appropriate authorities should launch a multipronged campaign to raise awareness of the appropriate use of OCS to ensure people with asthma receive the right care at the right time	Government and PAGs
There is inconsistency in OCS usage dose and thresholds in asthma	Identifying the appropriate threshold for OCS usage	Articulating a threshold for OCS use that prompts action is essential to provide a goal that the healthcare community can work toward to improve patient outcomes and reduce inappropriate OCS use in severe asthma	Government and PAGs
Inappropriate reliance on rescue (reliever) medication can increase the OCS burden	Addressing the inappropriate use of rescue reliever medication	Patients should have an annual asthma review with their clinician	HCPs
		Patients should receive an asthma review when an alert flags them as having an ICS autorefill of < 80% per year [53, 56, 75]	HCPs and EMRs
		Patients should receive a structured treatment review when an alert flags SABA usage more than twice per week, as this indicates uncontrolled asthma and a medication adjustment is needed [51]. This should be embedded across healthcare systems as a trigger	HCPs and EMRs
		SABA monotherapy use should be discouraged and guidelines implemented to remove most SABA monotherapy from routine asthma management	HCPs, government, and PAGs
OCS are perceived as cheap and effective and are often preferred over inhalation devices	Challenging the perception that OCS are cost-effective	Prescription of > 500 mg prednisolone or equivalent in 1 year for adults, or two courses of acute treatment, should prompt review by a primary HCP or specialist. This process should be established within guidelines	Government and PAGs
		OCS-sparing asthma care strategies should be adopted whenever possible, using targeted treatments to minimize OCS use	HCPs, government, and PAGs
		Specific goals or targets for OCS reduction should be introduced across the healthcare system with incentives or monitoring to minimize the inappropriate systemic prescribing of OCS	HCPs and EMRs
		When there is no alternative and OCS are used, measures should be put in place to monitor patients for acute and chronic adverse outcomes	HCPs and EMRs
	Improving understanding and recognition of the OCS side effect profile	Patients should not be able to obtain repeat prescriptions of OCS without consultation with an asthma specialist	Government and HCPs
		Clinicians should receive consistent education on OCS use to ensure that all who prescribe OCS do so appropriately, beginning at medical school and reinforced during the professional life of all HCPs (e.g., ensuring correct diagnosis and need, as well as correct dosage for the relevant length of time)	Government and HCPs
		Education on the role of specialist assessment and new treatment options for all clinicians who treat respiratory diseases is essential (e.g., primary care, specialist care, emergency care, pharmacy) to help ensure that people with asthma are given the most appropriate treatment for their condition	HCPs and PAGs
		Updated guidance and resources on safe OCS prescribing should be widely available to all clinicians who treat respiratory diseases (e.g., primary care, specialist care, emergency care, pharmacy)	HCPs, government, and PAGs
		Adherence to long-term OCS should be measured using an objective test, e.g., the serum prednisolone/cortisol assay [54]	HCPs and EMRs
Fragmented systems broaden access to OCS and limit oversight	Ensuring systems have oversight and surveillance of OCS use	An infrastructure that enables real-time sharing of clinical data must be implemented, including alerts for OCS, SABA prescribing, and serious exacerbation events experienced by patients	HCPs and EMRs
		Alerts should be introduced to identify when a referral to specialist care or other appropriate action is needed (e.g., nonadherence, comorbidities, uncertainty of diagnosis, lack of asthma prescription autorefill, lack of asthma review after exacerbation)	HCPs and EMRs
		OCS use across different parts of the system should be monitored and action initiated either through an EMR or patient self-tracking (e.g., patient passport or app), depending on system capabilities, as a means of collecting clinical data points	HCPs and EMRs
		Two or more courses of OCS or > 500 mg prednisolone or equivalent (Table 3) should warrant an in-depth clinical review and referral (as per criteria outlined in the Global Quality Standard for Identification and Management of Severe Asthma [51])
		Among HCPs, pharmacists are in a unique position to oversee patients’ medication regimens that may come from numerous prescribers. As such, pharmacists should play a role, along with all HCPs, in identifying patients who have excessive OCS use and should discourage OCS dispensation without an HCP prescription	Pharmacists

EMR electronic medical record, HCP healthcare provider, ICS inhaled corticosteroids, OCS oral corticosteroids, PAG patient advocacy group, SABA short-acting beta agonists