Key policies to support asthma medication management for children

Appropriate use of and adherence to asthma medications are critical components of controlling pediatric asthma morbidity. Guideline based asthma therapy recommends use of short acting nebulizers or inhalers to provide quick symptom relief and daily use of long term controller therapies, such as inhaled corticosteroids, to prevent inflammation and exacerbations.¹ However, children often lack access to controller and rescue therapies or have poor adherence to their therapies, leading to worse asthma control and health outcomes. As clinicians and researchers who aim to decrease the morbidity of pediatric asthma, we must advocate for policies that address improved use of and adherence to controller and rescue medications for children with asthma.

Recent data suggests that over a third of children do not have access to their prescribed controller or rescue therapies at home.² This is problematic as controller therapies such as inhaled corticosteroids have been shown to prevent asthma hospitalizations and deaths.³ Early access to rescue medications reduces treatment delays and prevents exacerbations from becoming severe. Therefore it is critical that our healthcare policies are designed to support families’ medication management.

There are a number of barriers that make medication management and adherence challenging for children. Caregivers may face difficulties in obtaining medications due to insurance coverage gaps and difficulties meeting authorization requirements. Children covered by Medicaid and the Children’s Health Insurance Program (CHIP) have greater difficulty accessing subspecialty care, such as asthma specialists, who may improve overall asthma medication management. Insurance formularies frequently change, making it difficult for clinicians to ensure patients have access to inhalers they can afford. In addition to difficulty accessing medications, children are unique in that they receive care in multiple settings, including school and daycare, and are often too young to carry medications between these locations. Thus, to have access to their medications, they require multiple inhalers, which are often not approved by insurance policies.

To begin to address these barriers, we propose advocacy for policies that promote improved access and adherence to medications for children with asthma. First, we believe that given the high and rising cost of prescription asthma medications, it is important to reduce barriers to generic medications and ensure that medications with clinical benefit are available in Tier 1 of insurance company formularies. Insurance companies should also cover medical devices, such as spacers, that allow children to appropriately take their medication.

To promote better adherence to asthma medications, formulary changes should be limited. Insurance companies often engage in non-medical formulary switching (NMFS), when coverage is changed to similar medications for which a lower price can be negotiated. This practice may result in short term promotion of a brand name medication rather than promotion of generic medication, and lead to additional future formulary changes when short term promotion ends.⁴ Children with asthma who are responding well to their long-term medication regimen are challenged by these formulary changes as they are forced to transition to medications they are unfamiliar with that may not have the same dosing or delivery mechanism. Caregivers, health care providers, and pharmacists may also be unfamiliar with the new inhaler’s mechanism of delivery, resulting in difficulties in communication with children regarding proper inhaler use and resulting in poor adherence. Physicians can help prompt change in insurance company actions by collecting quality improvement data within their practices to show how formulary changes impact children’s asthma medication management and sharing this data with insurance companies.

In addition to limiting changes to formularies, insurance companies should eliminate restrictions on the number of canisters of medications that can be dispensed for children. Medication safety is quoted as a rationale to limit the number of rescue and controller medication canisters that can be dispensed monthly. We believe that the risk of a child not having medication available during an acute exacerbation of his or her asthma far outweighs the risk of having access to additional inhalers. By allowing for multiple canisters to be dispensed, we ensure that children have access to their medications at home, at daycare, and at schools. Evidence has supported the use of directly observed therapy (DOT) of daily asthma preventative therapy by school nurses to improve asthma outcomes. Preschool and elementary school aged children receiving DOT were found to have a higher number of symptom free days, reduced rescue inhaler use, and decreased risk of having an asthma exacerbation requiring treatment with prednisone among preschool and elementary school aged children.⁵ The success of such programs depends on students having multiple refills of medications available and having nurses or trained medical assistants available in schools to assist with medication administration.

Finally, we believe that policy support for school-based programs will lead to improved medication access and adherence. As children spend a significant amount of their time in school each week, schools serve as a location to provide delivery of care for children, especially vulnerable children who may have less access to health care. In addition to previously discussed DOT programs, data also supports the implementation of stock albuterol programs to improve asthma outcomes. Pediatricians consult with schools to create policies to allow for multiple students to share a single albuterol inhaler that has a reusable holding chamber, eliminating the need for a child to have his or her own personal inhaler. Implementation has shown to lead to decreased 9–1-1 calls and fewer emergency transports for asthma emergencies.⁶ Legislative support is needed to promote stock albuterol policies and support good faith use of the medication.

Improved medication management for children with asthma has the potential to impact child health and wellness. Improving access to controller therapies is a critical step to prevent asthma morbidity and mortality and early access to rescue medications reduces treatment delays. In addition to health benefits, improved medication management may also help to reduce school absences, which are higher in children who have asthma. By supporting policies that address improved medication management in children with asthma, we help to promote improved child wellbeing.

Table 1.

Key policies for pediatric asthma management

Avoid insurance coverage gaps for children.

Ensure children with Medicaid-CHIPS have equal access to subspecialty asthma care.

Ensure that medications with proven clinical benefit for asthma are available in Tier 1 of insurance company formularies.

Ensure medical devices to support appropriate inhaler use, such as spacers, are covered by insurance.

Limit insurance company formulary changes.

Eliminate restrictions on the number of canisters of asthma medications that can be dispensed.

Ensure all schools have trained personnel, especially school nurses, that can assist with provision of asthma medication to children.

Support the implementation of stock albuterol programs within schools.