• 05 Apr 2018
  • 11 min
  • 05 Apr 2018
  • 11 min

David Liew interviews Professor Helen Reddel about the cost of asthma inhalers and implications for adherence. Read the full article in Australian Prescriber.

Transcript

Welcome to the Australian Prescriber podcast.Australian Prescriber, independent, peer reviewed and free.

I'm David Liew, your host for this episode and it's a pleasure to be speaking to Professor Helen Reddel today. And she's written in the April 2018 edition of Australian Prescriber on the cost of asthma medications. Professor Reddel, welcome to the program.

Thank you, David.

What is the problem with the cost of asthma medications?

We know that adherence with prescribed medications is poor and in Australia that's despite our having an excellent subsidies system. Pharmacists see cost-related issues affecting whether a patient will pick up a prescription. I've been interested for a long time in adherence with medication, so once it's been prescribed and picked up, does the patient actually take it? And there we have good evidence that in asthma as in many other conditions cost is a factor even in Australia. So, one of the aims with asthma treatment is to ensure that as many people as possible are getting a preventer inhaler and so we looked at the effect cost might have on this.

Okay so perhaps let's look at this in a little bit more depth. Firstly, how should asthma be ideally treated and then what happens in reality in Australia?

With asthma treatment the main recommendation is that most people with asthma should be on a preventer inhaler, so that's an anti-inflammatory inhaler and, with that, you get a very substantial reduction in both the symptoms of asthma and also in the risk of asthma. For many people in the community, asthma is quite mild and so it doesn't interfere much with patients’ daily lives, but it still carries the risk of severe flare-ups and even asthma-related death. We had a graphic example of that in the Melbourne thunderstorm asthma epidemic in 2016 for example. So, one of the key reasons that we would like people to be taking a regular preventer is to reduce that long-term risk. What most people associate with the treatment of asthma though is a blue or a grey inhaler which is a short-term reliever so that makes them feel better almost immediately but only lasts for around four or six hours and doesn't protect from those symptoms coming back again. It doesn't protect you from the risk of having a flare-up and in fact can make that risk worse if you over-rely on a blue inhaler. We're keen to see as many people as possible to be at least on a low dose of an asthma preventer.

So, it might be a little bit naive of me but while I'm sure that some people do think about the entirety of the asthma treatment being a salbutamol inhaler I would have thought that most patients they would have had it drilled into them that a preventer is an important part of the overall therapy. In Australia is that really a problem? Do we have any numbers on that?

Around about half of people with asthma in Australia have taken a preventer inhaler in the last 12 months so that's very much less than the target of treatment. So that's people who've taken at least some in the last 12 months but the studies we've done show that, out of all of the people who've had a preventer inhaler in the last 12 months, most of them have only actually had one dispensed or two or three at most, and the very small proportion of people are getting enough of it to have been taking it regularly.

I mean that's an outstanding statistic in all the wrong ways. Why do you think that this problem comes about, and what are the implications as far as this is concerned?

So there are the general issues that patients in the community don't take nearly as much medication as health professionals would like to think that they do. That's partly just lack of knowledge about what it's like as a person in the community struggling with day-to-day costs, remembering to take a medication regularly if you just have symptoms occasionally. In asthma there's the added complication that, particularly for people with mild asthma, that they may not only feel that they don't need the medication, but they may even have concerns about the safety of the medication. Steroid in Australia for example is most commonly associated with anabolic steroids that cause disastrous effects in athletes and there is confusion about that. So, there's a whole lot of factors. There are both barriers in terms of perceived necessity for the treatment and barriers in terms of concerns about the treatment and then you add on to that that cost is in fact a factor despite our having a good medicine subsidy scheme.

So if we keep in mind that cost is a factor, if you asked most subscribers what the instant thoughts were about a preventive medication, they'd probably think about combination puffers. What's the problem with prescribing a combination puffer. They work well, don't they?

Yes, they do. They're very effective, but in fact guidelines recommend that the majority of patients should be on an inhaled corticosteroid preventer alone and that only a proportion of patients will need to be stepped up to a combination inhaler. What we see though is that the majority of adults and very many children too are prescribed a combination inhaler as their initial treatment and as their ongoing treatment so that doesn't apply in other countries. So, for example we did a study with identical surveys done in Australia and in New Zealand and we found in Australia, of all of the adults who had any preventer treatment in the last 12 months, 82% of them were getting it as a combination iinhaler whereas in New Zealand it was 44%. So, in New Zealand there's very much more use of the inhaled corticosteroid only and in Australia very much more use of the combination inhalers, and when we compared outcomes in the patients in those two surveys they were almost identical, so similar levels of asthma symptom control and similar levels of need for urgent health care in terms of exacerbations or flare-ups. So, it seems to us that we have probably some over prescribing of combination inhalers relative both to guidelines and also relative to what the majority of patients would need. What are the other potential implications? One of these is in the cost for the patient.

So, I wouldn't have immediately thought of inhalers as an expensive medication. Is there really a big difference in terms of costs between a combination inhaler and inhaled corticosteroids by themselves?

Yes there can be so it depends how you prescribe it but what we show in this article is that you can prescribe a low daily dose of inhaled corticosteroid alone for as little as one-sixth of the cost of almost all of the combination inhalers. There's a table in this article which shows exactly how you can prescribe it in this way, and it's a little bit complicated so that's why we did put it into a table because it depends on the dose of the inhaler, the number of doses in one prescription, and the number of times that it's able to be prescribed. So that's not something that I could normally calculate in my head.

This probably isn't just limited to asthma medications really is it? Do you think this is something that extends beyond asthma medications?

Yes I do. I think it's very important for prescribers to understand that cost matters, to find out how much a patient pays per month for the medications that they would typically prescribe, and then consider giving the patient a choice. If cost is something that bothers them or can mount up then you can offer an alternative rather than just routinely prescribing a combination inhaler. There was an interesting study from Perth round about ten years ago when instead of the usual cost-of-living increase in the PBS co-payments there was 25% increase and even though for a concession card holder that amounted to I think it was 70 cents or 90 cents, something like that, per month. There was a sustained step down in adherence as indicated by dispensing rates. Now interestingly the conditions for which that stepped down was most marked were conditions that were either asymptomatic like osteoporosis or conditions for which there was an over-the-counter alternative such as airways disease. Well I guess what I've been talking about is shared decision making, to think about cost as a possible factor, to think about how often the patient's taking it, and to think about whether offering a more affordable medication might help keep them safer with the ability to take it more regularly. So this is not going to be the answer for everyone, but it's adding choices to the conversation about asthma preventers.

So presumably when you say that there are over-the-counter alternatives for example for asthma, do we know if people are taking salbutamol inhalers instead of their preventer medications, because that's a cheaper option. Is that what's happening?

Yes that's right .You know in the media the blue inhaler is very strongly associated with being the treatment for asthma and it's not surprising that from a patient's perspective the blue inhaler would seem like the perfect answer to asthma because it's cheap in Australia, you can buy it over the counter without a prescription, and when you take it, it works remarkably well, so within a few minutes the patient is feeling better. So from the patient's perspective that is a pretty good solution so part of what we need to talk about in having an asthma consultation is that, although that seems to be working well, it's a band-aid solution that doesn't reduce your risk of having a nasty flare-up in the future and it doesn't reduce your risk of having symptoms tomorrow or the next day. What we see is when patients really get scared is when for example they have a cold, with a viral infection your response to your blue inhaler tends to go down quite dramatically and that's very frightening for someone with asthma when the blue inhaler no longer works as it should. But the other thing that I find in my practice helps is that we emphasise that the aim is to find the least amount of preventer medication that will keep them well and keep them safe. For most people a low-dose preventer inhaler, as long as it's taken regularly and correctly, would be very effective.

So what would your final message be to our listeners?

So I'd emphasise the importance of thinking of asthma prescribing as an opportunity for shared decision-making, finding out what's important for your patients, what are the barriers or facilitators to them for using a regular preventer and then seeing what choices you can offer them.

Yeah, that's a really important thing to think about. So thank you very much once again for joining us today.

Thank you David.

[Music]

Professor Reddel’s full particle is available online at nps.org.au/australian-prescriber and like our whole journal it's free. The views of the hosts and the guests on this podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm David Liew and thanks once again for joining us on the Australian Prescriber a podcast.