Children on Medicaid in Kentucky who experience asthma may have had a tougher time managing their symptoms following a payer-initiated formulary change that led to the use of a different inhaler device, according to a recent study.

A formulary change undertaken in August 2016 by a Medicaid payer in Kentucky eliminated coverage of beclomethasone dipropionate, a commonly used metered dose inhaler (MDI), in favor of mometasone furoate, available as both an MDI and a dry powder inhaler (DPI). The study found that children who switched from an MDI to a DPI experienced a significant decrease in lung function, whereas children who remained on an MDI had no drop in lung function.

This decline in lung function could be due to a lack of adequate, timely educational intervention as well as the inability of some children to use DPIs. After the Medicaid change, pediatricians’ prescribing patterns changed from using MDIs almost exclusively to a near-even mix between MDIs and DPIs.

The landmark study on the Impact of arbitrary switching of inhaled asthma drugs on overall lung function appeared in the Journal of Pediatrics. It was co-authored by Norton Children’s Pulmonology physicians Scott G. Bickel, M.D.; Ronald L. Morton, M.D.; Adrian R. O’Hagan, M.D.; and Nemr S. Eid, M.D.; along with Jonathan G. Sayat, M.D., pediatrician with Norton Children’s Medical Group – Novak Center, all affiliated with the UofL School of Medicine; as well as another local pediatrician, Caitlin A. Canal, M.D.

“Nonmedical switching has received significant attention lately because of its negative impact on health care in the U.S. and in Europe,” Dr. Bickel said.

Using ICS to treat children with asthma

Treating asthma in an adult differs greatly from a child. In pediatric asthma, the medication and delivery devices must be taken into careful consideration based on the age and maturity of the patient.

ICS therapy is the cornerstone of chronic management for persistent asthma. ICS therapy has demonstrated superiority over nonsteroidal therapies in lung function improvements, symptom-free days and inflammatory markers. Consistent, correct use of ICS has been linked to significant decreases in asthma morbidity and mortality, health care utilization and costs.

The delivery mechanism is especially important in pediatric patients. Younger children may struggle to use devices that require an inspiratory effort to actuate the device or require long breath holds to optimize deposition.

Improper device use possibly can result in oral candidiasis, dysphonia, pharyngitis and higher rates of systemic absorption via the gastrointestinal system if swallowed. ICS particle size may be an important attribute to consider in pediatric patients, as ultrafine formulations have superior peripheral airway distribution.

MPI vs. DPI: Which is easier to use?

ICS are delivered by one of three mechanisms: nebulization, MDI or DPI. Nebulized ICS therapy may be appropriate in very young children or those with special health care needs but overall is inefficient and time-consuming, and has limited therapy options.

While used in the treatment of asthma in children of all ages, MDIs and DPIs originally were developed for use in adults. They interact differently with children.

Adolescents (ages 13 to 18) generally are able to use the full range of MDIs and DPIs that are available for use in adults, though they should still use a valved holding chamber with MDIs. Children ages 5 to 12 can use an MDI with a valved holding chamber, if given appropriate instruction and coaching.

Children younger than age 4 to 5 often are unable to generate the inspiratory flow rate necessary to effectively deliver the medication from a DPI and, therefore, require either a nebulizer or an MDI with a holding chamber and mask of appropriate size with a good fit.

MDI vs. DPI: Switching inhaler devices

Despite the multitude of ICS options and considerations, selection of a specific ICS frequently is dictated by insurance formulary coverage. Formularies often are changed abruptly and tailored toward adults, with limited pediatric specialist input.

The sudden inability to control asthma can occur any time a device switch is made without face-to-face consultation or hands-on teaching, whether the switch is from DPI to an MDI or vice versa.

“Any added confusion to patients and their families about medications and devices, along with lack of timely communication between patients and their providers, ultimately can lead to a patient’s inability to use the medication correctly,” Dr. Morton said. “Patients who are stable should remain on their current device.”

If a switch is considered, it should be discussed first with the patient and family. The physician should consider the patient’s preference, their age and cognitive ability to correctly use the device, and the availability of the preferred drug in the preferred device.