Formulary Changes to Medicaid Inhalers Worsens Pediatric Lung Function

Scott Bickel, MD

Changing inhaler use due to insurance formulary changes can reduce the control of pediatric asthma, according to new prospective findings.

In new data presented at the CHEST 2019 Annual Meeting in New Orleans, LA, investigators reported significant declines in forced expiratory volume (FEV) and forced expiratory flow (FEF) among pediatric patients with asthma who switched inhaler forms due to discontinued Medicaid coverage.

The findings, which surround a 2016 discontinuation of beclomethasone dipropionate (BDP) in favor of mometasone furoate (MF), provide tangible understanding of the insurance coverage change’s effect on patient asthma control—which adds to the already-understood narrative of patient and caregiver confusion at the time of the discontinuation.

“We sought to characterize the objective impact of this change by examining prescription patterns and patient’s lung function pre- and post-change,” investigators, led by Scott Bickel, MD, wrote.

Bickel, of the University of Louisville, conducted the retrospective chart review of children aged 6-18 years old with asthma from a large, university-based general pediatric clinic that’s comprised of a predominately Medicaid-covered population.

Qualified patients had a spirometry both before and after the 2016 formulary change, which discontinued traditional metered dose inhaler (MDI)-available BDP in favor of an MF formula available in both MDI and dry powder inhaler (DPI) form.

Prior to the formulary change, 67 of 68 (98.5%) children on inhaled controller therapy were using MDI. After the change, just 39 of 65 (60%) were using MDI. Of patients initially on BDP via MDI, 24 of 59 (41%) had switched to a DPI after the change. Of those 24 patients, mean predicted FEV₁ dropped from 99% to 89% (P = .01).

Investigators also observed a statistically significant decline in FEF25-75, where the mean predicted patient score fell from 89% to 77% (P = .04). Of patients to remain on an MDI, however, investigators found no statistically significant change in lung function—FEV₁ mean predicted score was 101% pre-change, and 98.9% post-change (P = .68).

Bickel and colleagues concluded changes to inhaled corticosteroid formulary can negatively affect pediatric lung function, especially when the formulary change involves a different type of inhaler.

“This is likely secondary to patient and family confusion on proper device use owing to a lack of adequate timely education intervention as well as the inability for some younger children to use DPIs,” they wrote.

The team suggested insurance formulary changes be more clearly and promptly communicated to physicians, pharmacists, and families prior to their taking place—and that pediatric difficulty with such changes be better considered in the first place.

The study, “Do Inhaled Corticosteroid Formulary Changes Impact Control in Pediatric Asthma?” was presented at CHEST 2019.