Inhaler formulary changes may worsen asthma control in children

Scott G. Bickel

NEW ORLEANS — Switching inhaler types due to insurance formulary changes may lead to reduced lung function in children with asthma, according to data presented at the CHEST Annual Meeting.

“Insurance formulary changes have been a major reason why many of our children with asthma who were otherwise stable have been switched from one long-term controller to another. Anecdotally, these changes cause considerable confusion for both families and health care professionals,” Scott G. Bickel, MD, from the University of Louisville School of Medicine, wrote in an email to Healio Pulmonology. “In doing this study, we sought to provide objective data on how these changes influence prescribing patterns and lung function.”

For the study, Bickel and colleagues conducted a retrospective chart review of 68 children aged 6 to 18 years with asthma from a population predominantly covered by Medicaid. The children were seen and had spirometry done at a large, university-based general pediatric clinic before and after a regional Medicaid provider discontinued coverage of beclomethasone dipropionate in metered-dose inhaler form in favor of mometasone furoate, which is available in a metered-dose inhaler and a dry powder inhaler.

The proportion of patients on inhaled controller therapy who were using a metered-dose inhaler decreased from 98.5% before the formulary change to 60% after the change, with 41% of those who were initially on a beclomethasone dipropionate metered-dose inhaler switching to a dry powder inhaler.

Among the children switched to a dry powder inhaler, the average FEV₁ declined from 99% predicted before the change to 89% predicted after the change (P = .01). Forced expiratory flow at 25% to 75% also declined from an average of 89% before the switch to a dry powder inhaler to 77% after the switch (P = .04).

“We have seen some regression in asthma control with frequent mandated switching. However, we were somewhat surprised by the magnitude of lung function decline in those who were switched to breath-actuated devices,” Bickel said.

Notably, among children who remained on a metered-dose inhaler, results revealed no statistically significant change in lung function from before to after the formulary change (FEV₁, 101% vs. 98.9%; P = .68).

“Insurance providers should be partners with health care professionals in ensuring that all children with asthma have easy access to inhalers that they are capable of using and best suited for the child’s individualized care,” Bickel said. “The short-term financial advantages of formulary switching should not outweigh the potential harm to children, increased administrative burden to health care professionals and possible increased long-term costs associated with loss of asthma control.”

Looking ahead, Bickel noted that he would like to see further studies examining patterns in adherence to asthma treatment and changes in health care utilization after similar formulary changes.

“I suspect these events lead to decreased adherence and increased rates of systemic corticosteroid use, ED visits and hospital admissions. Thus, increases in acute health care costs may offset any short-term financial gains realized through formulary changes,” he told Healio Pulmonology. – by Melissa Foster

Reference:

Bickel S, et al. Do inhaled corticosteroid formulary changes impact control in pediatric asthma? Presented at: CHEST Annual Meeting; Oct. 19-23, 2019; New Orleans.

For more information:

Scott G. Bickel, MD, can be reached at scott.bickel@louisville.edu; Twitter: @scottgbickel.

Disclosures : The authors report no relevant financial disclosures.