Pediatric Asthma Puerto Rico · 2020-05-20 · Pediatric Asthma Pediatric Asthma Epidemiology in...

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May 2019 | Page 1 Pediatric Asthma Pediatric Asthma Epidemiology in Puerto Rico According to the Department of Health in Puerto Rico, in 2008 an estimated 143,080 children had asthma. Current asthma prevalence in children is 13.8%, compared with U.S. rates of 9.0%. 1 What is Bronchial Asthma? 2,3 Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms which may lead to airway obstruction, bronchial hyper responsiveness and an underlying inflammation. Acute asthma occurs when there is inflammation, mucus accumulation, bronchospasm and airway narrowing. It is commonly progressive but can be of rapid onset. Chronic / persistent asthma occurs when there is a cycling of exacerbations and remissions. Diagnosis is based on characteristic signs and symptoms. Asthma Triggers 4,5 Is important to identify and avoid asthma triggers. Successful avoidance or remediation may reduce the patient's need for medications. The following are examples of asthma triggers: Inhaled allergens symptoms triggered by common inhaled allergens, at home, daycare, school, or work. Examples of indoor allergens are dust mites, animal dander, molds, mice, and cockroaches. Outdoor allergens include grass and ragweed pollen. Respiratory irritants inhaled irritants include tobacco smoke, wood smoke from stoves or fireplaces, strong perfumes and odors, chlorine-based cleaning products, and air pollutants. Others stress, getting sick with a cold, the flu, or a lung, ear, or sinus infection, exercise, use of certain medications (e.g. non-selective beta-blockers, aspirin), temperature and weather. Environmental controls at home (e.g. avoidance of tobacco, air pollution, among others), and active management of comorbidities (e.g. obesity, gastroesophageal reflux) that may contribute to symptom burden and poor quality life will lead to an improvement in the management of asthma. For persistent symptoms and/or exacerbations, the practice guidelines recommend the evaluation of inhaler techniques, adherence, persistent allergen exposure and comorbidities prior to stepping up treatment. If no improvement is seen after addressing these issues, consider referring the patient to a specialist. Prevention and Control Strategies 3 In its Guidelines for Diagnosis and Management of Asthma, the National Institute of Health (NIH) establishes that the goal of asthma therapy is to maintain control of asthma with the least amount of medication and hence, minimal risk for adverse effects.

Transcript of Pediatric Asthma Puerto Rico · 2020-05-20 · Pediatric Asthma Pediatric Asthma Epidemiology in...

Page 1: Pediatric Asthma Puerto Rico · 2020-05-20 · Pediatric Asthma Pediatric Asthma Epidemiology in Puerto Rico According to the Department of Health in Puerto Rico, in 2008 an estimated

May 2019 | Page 1

Pediatric Asthma

Pediatric Asthma Epidemiology in Puerto Rico According to the Department of Health in Puerto Rico, in 2008 an estimated 143,080 children had asthma. Current asthma prevalence in children is 13.8%, compared with U.S. rates of 9.0%.1

What is Bronchial Asthma? 2,3 Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms which may lead to airway obstruction, bronchial hyper responsiveness and an underlying inflammation.

Acute asthma occurs when there is inflammation, mucus accumulation, bronchospasm and airway narrowing. It is commonly progressive but can be of rapid onset.

Chronic / persistent asthma occurs when there is a cycling of exacerbations and remissions. Diagnosis is based on characteristic signs and symptoms.

Asthma Triggers 4,5 Is important to identify and avoid asthma triggers. Successful avoidance or remediation may reduce the patient's need for medications. The following are examples of asthma triggers:

Inhaled allergens – symptoms triggered by common inhaled allergens, at home, daycare,school, or work. Examples of indoor allergens are dust mites, animal dander, molds, mice,and cockroaches. Outdoor allergens include grass and ragweed pollen.

Respiratory irritants – inhaled irritants include tobacco smoke, wood smoke from stoves orfireplaces, strong perfumes and odors, chlorine-based cleaning products, and air pollutants.

Others – stress, getting sick with a cold, the flu, or a lung, ear, or sinus infection, exercise,use of certain medications (e.g. non-selective beta-blockers, aspirin), temperature andweather.

Environmental controls at home (e.g. avoidance of tobacco, air pollution, among others), and active management of comorbidities (e.g. obesity, gastroesophageal reflux) that may contribute to symptom burden and poor quality life will lead to an improvement in the management of asthma. For persistent symptoms and/or exacerbations, the practice guidelines recommend the evaluation of inhaler techniques, adherence, persistent allergen exposure and comorbidities prior to stepping up treatment. If no improvement is seen after addressing these issues, consider referring the patient to a specialist.

Prevention and Control Strategies3 In its Guidelines for Diagnosis and Management of Asthma, the National Institute of Health (NIH) establishes that the goal of asthma therapy is to maintain control of asthma with the least amount of medication and hence, minimal risk for adverse effects.

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Control of asthma is determined by assessment of both impairment and risk. The reduction of these factors will help the patient obtain a better management of the disease and prevent future damage.

Recommendations for the Diagnosis and Classification of Asthma in Pediatric Population6

Asthma in the pediatric population can be classified as mild, moderate and severe. Assessment of patient and family history, physical examination, and lung function testing are key components for the initial diagnosis of asthma.

FEV: Forced Expiratory Volume in 1 second; PEF: Peak Expiratory Flow (highest of three readings)

Four Components for the Treatment of Pediatric Asthma

Evaluation, Monitoring of Severity 5

Assess symptom control over the last 4 weeks

Reducing Impairment Reducing Risk

Prevent chronic and troublesome symptoms Prevent recurrent exacerbations of asthma and minimize Emergency Department visits or hospitalizations

Require infrequent use (< 2 days a week) of inhaled short acting beta2 agonists (SABA) for quick relief of symptoms

Prevent progressive loss of lung function

Maintain normal (near) pulmonary function and activity levels

Provide optimal pharmacotherapy with minimal or no adverse effects

History of Variable Respiratory Symptoms

Confirmed Variable Expiratory Airflow Limitation

Wheeze, shortness of breath, cough, and chest tightness

Symptoms occur variably over time and vary in intensity

Symptoms are often worse at night or on waking

Symptoms are often triggered by exercise, laughter or allergens

Documented excessive variability in lung function AND documented airflow limitation

Lung function can be assessed by one or more of the following: - Positive bronchodilator reversibility test

Children: increase in FEV1 of 12% predicted

- Excessive variability in twice-daily PEF over 2 weeks - Children: average daily diurnal PEF variability >13%

- Positive exercise challenge test Children: fall in FEV1 of 12% predicted, or PEF > 15%

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Identify other risk factors for exacerbation

Measure lung function at diagnosis/treatment initiation, 3 - 6 months after controller treatment, then periodically

Assess treatment issues (e.g. inhaler technique, adherence, side effects, patient goals)

Assess comorbidities (e.g. rhinitis, gastroesophageal reflux, obstructive sleep apnea, depression, and anxiety)

Asthma severity can be assessed when the patient has been on regular controller treatment for several months

- Mild asthma: asthma that is well controlled with “as needed” reliever medication alone

or with low intensity controller treatment (e.g. low dose inhaled corticosteroid [ICS]) - Moderate asthma: asthma that is well controlled with low dose ICS/LABA - Severe asthma: asthma that requires a high dose of ICS/LABA to prevent it from

becoming uncontrolled, or asthma that remains uncontrolled despite this treatment.

Education for the Doctor-Patient Relationship5 Provide inhaler skills training; technique is often incorrect

Encourage adherence with controller medications, even when symptoms are infrequent

Provide training in asthma self-management to control symptoms and minimize the risk of exacerbations and need for healthcare utilization

Medical Treatment 3,5 Asthma medications are categorized in two classes: long-term control medications taken daily on a long-term basis to achieve and maintain control of persistent asthma, and quick-relief medications taken to provide prompt reversal of acute airflow obstruction and relief of bronchoconstriction.

Long-term Medications Treatment with regular daily low dose inhaled corticosteroids (ICS) is highly effective in reducing asthma symptoms and reducing the risk of asthma-related exacerbations, hospitalizations and death. In patients with persistent symptoms and/or exacerbations despite low ICS, consider a step up after reviewing inhaler technique, adherence, persistent allergen exposure and comorbidities. In children 6-11 years, increasing ICS dose is preferred over a combination of ICS/LABA. Consider a step down once good asthma control has been achieved and maintained for about 3 months. Inhaled long acting beta2 agonists (LABA) are not recommended for use as monotherapy for long-term control of persistent asthma; must be used as an adjunct to ICS therapy.

Quick-relief Medications National Institute of Health guidelines recommend inhaled short acting beta2 agonists (SABA) as the drug of choice for treating acute asthma symptoms and exacerbations and for preventing exercise-induced bronchospasm. For further management of asthma in pediatric patients, a stepwise approach is recommended (as shown below). This is meant to assist - not replace - clinical decision making required to meet individual patient needs.

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Guidelines for the Diagnosis and Management of Asthma National Asthma Education and Prevention Program of the National Heart, Lung and Blood Institute, Expert Panel Report 3, 2007

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Guidelines for the Diagnosis and Management of Asthma National Asthma Education and Prevention Program of the National Heart, Lung and Blood Institute, Expert Panel Report 3, 2007

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Drug Utilization Data A retrospective observational review of asthma medications usage was conducted for:

All Administración de Seguros de Salud de Puerto Rico (ASES) beneficiaries, including Molina Health population

Period: July 1, 2018 - December 31, 2018

Focused on patients 0-11 years of age or older that had been prescribed an asthma medication (refer to Table 1).

Table 1: Names of Drugs that were categorized by therapeutic group

SABA Alternatives Inhaled Corticosteroid Combination (LABA +ICS)

Albuterol tablet Albuterol inhalation solution Albuterol sulfate inhaler Levalbuterol inhalation solution Levalbuterol inhaler

Montelukast Montelukast Chewable

Flovent HFA Flovent Diskus Budesonide Suspension

Advair Diskus Advair HFA Symbicort

SABA= Short Acting beta2 Agonists; ICS= Inhaled corticosteroid; LABA= Long acting beta2 agonist

40.04%

0.35%

45.50%

0.11%

14%

Graph 1: Percentage of Patients 0-4 Years Old Utilization by Therapeutic Class

SABA Combination (LABA + ICS)

Inhaled Corticosteroid Oral Corticosteroid

Alternatives

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Of a total of 19,739 claims, Budesonide Suspension, a high priced generic, had the highest number of pharmacy claims, followed by Albuterol Inhalation Solution and Montelukast Chewable in patients 0-4 years old (See Graph 2). Note that the diagnosis of these patients is unknown, and therefore, the use of Montelukast could be due to other indications.

Graph 3 shows the top 10 asthma medications by total amount paid by the ASES Health Insurance during the evaluated period. Budesonide suspension appears in first place, as the drug with highest total amount paid out of a $1,011,103.40 total, followed by Flovent HFA and Albuterol Inhalation Solution.

7,504

6,057

3,000

1,707 1,227107 106 6 4 4 1 1

01,0002,0003,0004,0005,0006,0007,0008,000

Graph 2: Amount of Prescriptions in Patients 0-4 Years Old

$463,923.6

$328,055.4

$86,699.28

$70,496.40

$41,448.92

$18,935.44

$492.57 $384.17 $329.70 $190.05 $0.00

$50,000.00$100,000.00$150,000.00$200,000.00$250,000.00$300,000.00$350,000.00$400,000.00$450,000.00$500,000.00

Graph 3: Paid Amount by Drug in Patients 0-4 Years Old

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SABA= Short Acting beta2 Agonists; ICS= Inhaled corticosteroid; LABA= Long acting beta2 agonist

Of a total of 19,301 claims in the 5 – 11 years of age group, Montelukast chewable shows the highest number of pharmacy claims, followed by Albuterol Inhalation Solution (See Graph 5). Note that, since the diagnosis of these patients is unknown, the use of Montelukast could be due to other indications.

36.40%

0.88%29.54%

5.63%

27.55%

Graph 4: Percentage of Patients 5-11 Years Old Utilization by Therapeutic Class

SABA Combination (LABA + ICS) Inhaled Corticosteroid

Oral Corticosteroid Alternatives

5,649

4,673

3,323

1,987 1,736

411 213 146 138 96 5 4 20

1,000

2,000

3,000

4,000

5,000

6,000

Graph 5: Amount of Prescriptions in Patients

5-11 Years Old

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Graph 6 shows the top 10 asthma medications in terms of the total paid amount by the ASES Health Insurance. Flovent HFA appears in first place, as the drug with highest total amount paid out of a $968,113.78 total, followed by Budesonide Suspension and Ventolin HFA. In summary, this data illustrates that short acting beta agonists (SABA) and inhaled corticosteroids (ICS) are among the most frequently prescribed in this population. These two therapeutic classes also tend to have the highest costs paid by the health insurance. The evaluated data did not allow to categorize ICS in low, medium and high doses, which could have allowed for a classification of asthma severity.

References 1. National Center for Environmental Health: Asthma in Puerto Rico. Center for disease Control and Prevention

(CDC) https://www.cdc.gov/asthma/stateprofiles/asthma_in_pr.pdf 7. Updated 2008. Accessed January 2019 2. Kelly H, Sorkness CA. Chapter 26. Asthma. In Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L.

eds. Pharmacotherapy: A Pathophysiologic Approach, 9e Ney Work, NY: McGraw-Hill; 2014, https://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146058008. Accessed April 2019.

3. National Institutes of Health, National Heart, Lung and Blood Institute. National Asthma Education and Prevention Program. Full Report of the Expert Panel: Guidelines for the Diagnosis and Management of Asthma (EPR-3). July 2007, https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf. Accessed April 2019.

4. Miller, R. (2018). Trigger control to enhance asthma management. Up-to-date. Retrieved April 18, 2019. 5. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA).

https://ginasthma.org/gina-reports/. Retrieved April 2019.

$406,970.58

$218,000.90

$99,761.46

$56,176.51

$56,143.06

$44,478.78

$42,198.59 $35,254

$2,142 $1,700

$0.00$50,000.00

$100,000.00$150,000.00$200,000.00$250,000.00$300,000.00$350,000.00$400,000.00$450,000.00

Graph 6: Paid Amount in Patients 5-11 Years Old