SMART Therapy and Other Patient Centered Approaches Towards Asthma Management (Recording)
This webinar was recorded on July 25, 2024
SMART therapy is for patients with moderate to severe asthma who need a combination treatment. This combined treatment consists of an inhaled corticosteroid and an inhaled long-acting beta-2 agonist (LABA). Under asthma guidelines, SMART therapy is recommended for people with moderate to severe asthma, including children ages 5 and older. It is considered an easier and patient friendly treatment plan to follow. In this webinar, learn about SMART therapy and other patient friendly asthma management strategies.
Speaker:
- Angela Hogan, MD
Dr. Hogan is double board certified in allergy and immunology and pediatrics. She practices at the Children’s Hospital of the King’s Daughter in Virginia. Dr. Hogan is passionate about community education in asthma and food allergies. She feels it is very important to not only get the correct diagnosis for food allergies but also important to understand the impact such a diagnosis has on the child and the family. She formed a regional food allergy support group called FASGOT.com, which helps healthcare providers, schools and families deal with food allergies. She is extensively involved in the education of the school nurses in the seven districts in her area and has organized outreach programs for community physicians. For Dr. Hogan, CHKD really is more than a hospital. It allows her to teach not only families but also future doctors in pediatrics and allergy. It supports her as she tries to work in the community, and it allows her to do clinical research. Dr. Hogan chairs the asthma committee of the American College of Allergy, Asthma, and Immunology.
This Advances webinar is in partnership with the American College of Allergy, Asthma & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for Advances webinars.
All attendees will be offered a certificate of attendance. No other continuing education credit is provided.
CME is available through ACAAI for this webinar.
Sponsored by the American College of Allergy, Asthma and Immunology
Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
Catherine: hello, everyone. We are going to get started in just a minute. We are going to give everyone a chance to get in. We have a lot of people trying to get in. In the meantime, while we wait, if you would not mind putting where you are calling from in the chat so I can see where you are in the world. That would be great. OK. Well, hello, everyone. Thank you for joining us today. I am the chief health equity officer for the Allergy and Asthma Network. We are in for a real treat today with Dr. Angela Hogan as today’s presenter. We have a few housekeeping items before we start today’s program. First, all participants will be on mute for the webinar. We will record today’s webinar and post it on our website within a few days. You can find all of our recorded webinars on our website at allergyasthmanetwork.org. Just scroll down to the bottom of the page to find our recorded an upcoming webinar set in case you would like to turn in to those. This webinar will be about an hour long, and that it time for questions. We will take those questions at the end of the webinar, but you can put your questions in the Q&A box at any time, and that is located at the bottom of your screen. We will have somebody monitoring the chat if you have questions or need some help. We will get to as many questions as we can but we conclude. This webinar is in partnership with the American College of allergy, asthma, and immunology. It offers CME’s for positions and attendance credits for all others. You can create a free ACPAII account. Attendees will be offered a certificate of attendance, and no other continuing education will be provided. A few days after the webinar, you will receive an email with additional information and a link to download the certificate of attendance. We will also try to add that link into the chat for you, so let’s get started. Today’s topic is smart — is SMART therapy and other patient centered approaches toward asthma management. SMART therapy is for patients with moderate to severe asthma we need a combination treatment. This combined treatment consists of an inhaled corticosteroid and an inhaled long acting beta two agonists. Under asthma guidelines, SMART therapy is recommended for people with moderate to severe asthma, including children ages five and older. It is considered an easier and patient-friendly treatment plan to follow. It is my esteemed pleasure to introduce our speaker, Dr. Angela Hogan. Dr. Hogan is double board certified in allergy immunology and pediatrics. She practices at the Children’s Hospital of the king’s daughter in Virginia. Dr. Hogan is passionate about community education in asthma and food allergies. She feels it is very important to not only get the correct diagnosis for food allergies but also important to understand the impact such as a diagnosis have on a child and family. She performed a regional food allergy support group which helps health care providers, schools, and families deal with food allergies. She is extensively involved in the education of the school nurses in the seven districts in her area and has organized outreach programs for community physicians. For Dr. Hogan, CHKD really is more than just a hospital. It allows her to teach not only families but also future doctors in pediatrics and allergies. It supports her as she tries to work in a community and allows her to do pinnacle research. Dr. Hogan chairs the asthma committee of the American College of Asthma and Immunology. I’m going to turn it over to you now.
Dr. Hogan: Thank you all for joining us this afternoon. Our learning objectives — we will talk mostly about SMART, but we will also discuss how to practically implement these into your practice and why that is important, and then we will talk a little bit about focusing on patient-centered treatment and how that can improve the quality of care that we deliver to our families. Let’s review first again what is asthma. It is a chronic disorder. It has a couple of main components. Most important is airway inflammation and the second is bronchial hyperresponsiveness. In order to be asthma, we know that airway obstruction needs to be reversible. We know that asthma is not just one disease. We talk about it as if it is, but there are multiple different risk factors for the development of asthma. There are differences in triggers, differences in symptoms and severity, and even responses to therapy. One therapy does not necessarily fit all asthmatics. We know what other conditions patients may have may also impact their sponsorship therapy and the severity of their asthma. We know asthma is a really big deal financially in this country. It is the most common chronic disease of childhood. In children, we know that about 50% of them have uncontrolled asthma, and if they have uncontrolled asthma, it may cost a lot more health care dollars. They over utilize the health care system when they are poorly controlled, and actual severe asthma in children only makes up about 5% of pediatric asthmatics, but that accounts for about 50% of health care that are spent economically in this country, asthma costs about $56 billion, which, obviously, has a big impact on our health care system. In terms of speaking briefly about asthma and epidemiology, we know there are different prevalences across the different populations. It does vary by race and ethnicity, and we know that asthma disproportionately affects the black population. As you can see from this graph from the CDC looking at age and sex and ethnicity, there are some disparities noted here.
We also know that asthma mortality has overall been pretty stable. We know that about 11 people in the U.S. die each day from asthma. We did see when we looked at asthma mortality trends that we were on a downward slope, but in 2020, we saw the first to rise in asthma deaths, and most recent statistics say that this trend may be ongoing. We also know that adults are six times more likely than a child to die from their asthma and that, again, there is a disproportionate effect. Black individuals are three times more likely to die from their asthma than white people. We know that the death rate is the highest among individuals who are 65 years old or older compared to the other age groups. We know that asthma really impacts utilization. There are 750,000 80 visits per year for asthma, 200 thousand hospitalizations annually, and we know currently the mainstay for ER visit or hospitalization is still in bronchial dilators and systemic corticosteroids. The biggest place to make an impact on asthma improvement in health care is — can we do that as an outpatient and try to keep them from needing to go to the emergency room and being hospitalized? What we have found most recently is that our thinking about asthma is probably all wrong. We have been thinking about asthma as a disease that involves predominantly bronco did not — bronco dilation and that the airways are restricted, and we really under-understand the problem that airway inflammation plays a huge role in this and that asthma morbidity and mortality are actually very preventable when we understand the importance of addressing airway inflammation. When we think about what resources you could go to to understand asthma a little bit better, there are two main resources available for most people. There are the national asthma guidelines put out from the NHLBI. The most recent update was published in 2020. Then there is the international guidelines or initiative that people use as a resource called the global initiative for asthma, and they update yearly, and the most recent publication for 2024 is already published now. The global initiative for asthma , as I said, do not necessarily consider themselves a guideline but more a global strategy, and those are geared towards PCP’s and focus very much on the newest evidence-based medicine.
The NHLBI guidelines were first published way back in, like, 1997. One of the biggest asthma updates was in 2007 where we used a lot of our resources, but in 2020, they did put out a new updated focus on five or six different areas of asthma that we currently are following also. How do these guidelines differ from each other? They are minor things overall. Also when they assess asthma severity is different. In our national guidelines, severity determines the initial visit. So what are the goals of our asthma management? It depends on a lot of things. It depends on what the patients are able to understand and also what are their preferences in terms of how they want to manage their asthma, but GINA feels like all patients should have few to no symptoms and should be able to sleep and work and play without any impairment. It would be nice if they could maintain normal lung function. We would like for them to have no flares at all and we would like for whatever medications we pick for them to have minimal side effects. An overall, whenever possible, we would like to avoid neural corticosteroids because they have such long-term impacts. They can be helpful but in the long run lead to a lot of morbidity. When we think about our asthma management, we need to think about what is the asthma phenotype we are treating, how well a patient can adhere to what we are asking them to do. Are they current smokers? We also want to make sure that what we pick is cost effective for that family and that it is available. Again, we want to constantly review what we put them on, reassess how they are doing on it and adjust those therapies.
The little circle on the bottom is taken from GINA, and GINA says every visit we see asthmatic patients, we should be reviewing and assessing and adjusting their asthma care. First, let us talk about albuterol or short acting beta agonist in a very new light. Albuterol used only by itself can be dangerous. If we use a regular short acting beta agonist for only one to two weeks a couple of times a day, then we actually lead to tolerance in the airways to responding to that short acting beta agonist, and we see reduced effectiveness and increased airway hyperresponsiveness, so we need to quit thinking that all we need to respond for a patient is albuterol because actually, short acting beta agonists have been shown to have a lot of risks associated with exacerbation. We propagate this response because albuterol is an expensive and does provide rapid relief, so it — the family focus is back on the fact of let me grab that rescue inhaler, and we always ask those questions — where is your rescue inhaler? How much are you using your rescue inhaler? We don’t talk about the other part which is addressing airway inflammation. What we know is that we should be thinking and talking a lot more about inhaled corticosteroids. We know and him corticosteroids decreased that airway hyperresponsiveness and the risk for an asthma flare. They decrease mortality. They decrease the build up in the air were also which we know is important to address when we think about the best management of asthma inflation, and they also keep us from remodeling our airways. Inhaled corticosteroids play a very important role when you think about asthma. Even mild asthma does not necessarily mean that you are safe. We know individuals who do have mild asthma can have a very severe asthma attack and possibly even a fatal exacerbation.
Part of the problem with asthma being mild is everybody thinks it is mild asthma, so they do not always think — take their medicine the way it is prescribed and when they start having symptoms, the inhaler they reach for is that short acting beta agonist, so they may be at risk for developing tolerance to their response to that. Even when we do prescribed and inhaled corticosteroid for patients, oftentimes, that maintenance medication is only consistently taken about 30% to 40% of the time. In a recent systematic review, and found that 24% of hospitals — sorry, 24% of exacerbations were related to poor adherence to their controller therapy and 60% of hospitalizations were because patients were taking their inhaled corticosteroid. There’s strong evidence to suggest we need a safer way of teaching patients to manage their asthma than just a acting beta agonist. That’s where we are going to come in with SMART smart –SMART Mart therapy. The terms are interchangeable. Mart is actually using a particular type of medication that is two in one inhaler’s, and it uses an ICS, and it uses formoterol, and long acting beta Venus that has the ability to act a lot like a short acting beta agonist also because it has very rapid onset. Mart is using both of these medications today in one inhaler, so we are going to spend a fair amount of time reviewing that and talking about how we should apply those. For MAE RT with SMART therapy, you have an inhaler and you increase the use of it when you are sick and when you are well, we dial it back down. In this particular country, there are two preparations that are available. There is a budesonide for Motorola had inhaler — formoterol inhaler.
Again, it has to be formoterol or it does not count for all the studies and things we will talk about that make SMART helpful. There’s another product on the mark that can be used — on the market that can be used but should not be used for maintenance. In the 2023 GINA, they sort of re-changed our terminology, and that is where the word MART came from. The terms I want you to know and understand today are first, we talk a little bit about air, and AIR is just using anti-inflammatory as a believer. You will have this combination of products, and they are used only when the need, so they are just rapid relief. The thinking is if you are using a short acting beta agonist by itself for symptom relief, something made you need to use that for symptom relief, so when we put the two medicines together, and inhaled steroid will help chase away whatever it was that made you need to use that inhaler, so it is better to have both the cost and symptoms addressed — the cause and the symptoms addressed together in one inhaler, and that is what we are moving towards. This particular combination of medicines, they can be used before exercise, also. When we talk about asthma therapies, we use them in steps one and two. MART or SMART uses them for both maintenance and relief therapy.
That is what SMART stands for, single maintenance and reliever therapy. Or MART, maintenance reliever therapy — maintenance and reliever therapy. A couple other terms that they also redefine in 2023 is they like the word maintenance to replace the word controller, and I also like the word reliever to reflect what your as needed medication is for quick relief. Now that you know all the terms, how do they work? Let’s first attack asthma in adolescents and in adults 12 years of age and older. One of the huge points from GINA is that they feel like no patient should ever be prescribed a short acting beta agonist alone ever. Again, because the short acting beta agonist gives you relief of the symptoms but does not address whatever the cause was, so the feeling is that there should always be two medications together according to GINA. What we know is that this particular combination can be used a couple of different ways, and in GINA, they proposed certain asthma tracks on how we look at treating asthma. This is what the GINA 2024 guidelines look at, and I want to spend a minute to go over these and understand them. There are basically two tracks. There’s the top track, which is track one, and the bottom track, which is track two. Track one is the preferred track. We see there are basically five different steps for asthma . Current guidelines recommend we just use an as-needed low-dose ICS formoterol in mild asthma. As it gets a little worse, we step it up and at maintenance and rescue, and a little bit higher dose in step four. In step five, it becomes a little more difficult to manage asthma, and we start looking at additional ad-on medicines and start considering asthma phenotypes that we might consider for Biologics, which is beyond the scope of the lecture that we want to talk about today. Again, I want to point out track one here, which is again, using ICS formoterol as both the primary reliever medication and also as the controller. What we know is that this particular way is a very good way of managing asthma because what we know is that this particular way allows you to step up and step down without having any particular issues. You dial up for increased symptoms. It avoids confusion about different inhaler techniques with different devices and that a single medication can be used for both symptom relief and maintenance, so patients are not trying to jumble or figure out which inhaler they should be using win. They just have one single inhaler. Sometimes the insurance companies, as you know — one month they like one particular inhaler in the next month a different device. Sometimes I have patients who will bring in their bag of medicine and have three or four different things, and each of them may have a different technique of how they are supposed to use those medicines, and it can become very confusing, and patients can do them improperly, and then they will not get optimal asthma control either. With this particular method, it allows them to dial up and dial down. We also know there is a great amount of science that shows that GINA does have good evidence-based medicine to support that this works. We know that in steps one and two, when ICS formoterol is used alone as rescue, that there are more than 10,000 patients in these long-term 12-month studies that show that this is superior than just using albuterol alone or even using an ICS-plus — ICS plus albuterol if the ICS is used every day. We also know that for MART in steps three to five that there are more than 30,000 patients in the studies that demonstrate that not only is this superior in terms of effectiveness, but it is also very safe. So we have many studies that demonstrate that this is the preferred method for asthma treatment.
So when we look at our national guidelines from 2020, they actually adhere to what GINA recommends in steps three and four. Our guidelines from 2020 are based on some outdated information, and they still prefer as needed albuterol for intermittent asthma, and then every time you get an inhaled steroid or every time you get a sawbuck, they want you to match it with an inhaled steroid in step two, but you can see in steps three and four that they actually parallel GINA exactly. You want to have a little science behind this to say why it is the preferred way, and I have that in the next slide. What I want to show you is a Cochrane database systematic review from 2021. In this particular slide, what I am demonstrating for you is that ICS formoterol when compared to albuterol alone is able to demonstrate a 52% reduction in the use of oral steroids in patients with mild asthma and ICS-formoterol when compared to albuterol alone has a 65% reduction in usage of the emergency department or hospitalizations. Most people think that Cochrane analysis is a very good way to demonstrate evidence-based medicine. If we also look at the Cochrane review for how does ICS-formoterol compared to people that are on daily ICS and as hyphenated SABA — and as-needed SABA, there is a significant reduction in oral steroid use and 37% reduction in emergency room visits and hospitalizations when the one inhaler is used instead of two separate inhalers. In addition to that, we know that GINA doesn’t say sometimes insurance does not allow you to use the ICS-formoterol product. What they are recommending is that in step two, perhaps we consider using an ICS-SABA so that we don’t have abuse or overuse of albuterol alone, but it doesn’t recognize there will still be some insurance plans and individuals who will still be using other ICS SABA’s and ICS LABA’s. We usually don’t recommend using two different LABAs together because there’s no evidence it is safe. In January 23, we had a product that links an inhaled corticosteroid to albuterol, and the product is available on the market now, and it is available for 18 and up, so if you had someone that traditionally might have just prescribed albuterol alone for, they would say don’t do that. You should make it albuterol and budesonide together in one inhaler because that will be much safer for those individuals. This is what it looks like together. Both tracks are there. As you can see again, step three and step four talk about MART, and that is what we will focus on for just a minute.
Again, MART is the same as SMART , and it means maintenance and reliever therapy. The previous slides were for steps one and two and now we move on to steps three and four. Let’s talk just a minute, again, why we think SMART is better, not only because it is simpler, but be because — because we have only one inhaler the patient needs to deal with and there’s good evidence to show putting together one inhaler also reduces the risk for them to use oral corticosteroids and also reduces exacerbations, so there is even some data that shows using ICS-formoterol products actually improves blood eosinophils levels. Dexamethasone was the ICS used with ICS in the study and showed it was effective in reducing the number of a sinner fills — eosinophils in the blood and seem to have an even bigger impact on those patients that had more eosinophils. It is important to note that not only is it helping symptoms, but even at cellular level. When we look at national guidelines, again, by step three and step four, this particular age group, it looks very much like GINA. You can see that again, they talk about using the combination of an ICS formoterol basically as a maintenance medicine and also as a rescue medicine, use a lower dose at stage three and at step four, we increased to a higher dose of that medicine, meaning more puffs, so that we can control their asthma better. So what do you need to tell patients? One of the things you need to tell patients is that this combination product will work just as well as albuterol. Occasionally, patients are so dependent on albuterol and they are anxious to give it up, and they are afraid, what if it does not in fact help me as quickly? But you can reassure patients that it has both the ability to have a rapid onset, and also like long-acting beta agonist, it has the ability to have a long-acting effect also. And the question comes up — what do you do for school? Are we going to send an albuterol inhaler to school and have them have their controller medication at home? It is a combination therapy, and the current recommendations are actually we should be giving the multiple combination ICS formoterol products all in the same month so they can have one to bring to school. In our state of Virginia, we have been able to get state Medicaid to improve three inhalers for our patients per month so they can have one to send to school, one in the soccer bag, and also 14 home because that is what we will need to do. Oftentimes, we will even have patients who go to the emergency room, they are treated there, and then the ER physician or ER provider will want to immediately prescribe them albuterol if they leave. We need to quit confusing the picture and continue to focus on the fact that they need to have combination therapy available in multiple places and that they just need the one medication.
Then, the question always comes up with previous inhalers, and we have always said to brush her teeth right after you take it and rinse and spit and drink something. What we are really finding is that with most of these medications, specifically budesonide and formoterol products, we are seeing very little thrush. Current recommendations are that maybe if you are doing two puffs and it is your maintenance medication for the day, you may want to go ahead and rinse and spit, but if you are doing pretreatment with exercise or doing and as-needed dose, you probably don’t need to rinse and spit. Again, the rich — the risk of thrush is very low. We know it is important for patients to have an active asthma plan. That is not anything new. It has been in our guidelines for lots of years, but as we start to explain to them, it can be a little confusing, so we want to make sure we spell out very clearly what an action plan would entail if they are going into the yellow or red zone. First, let’s talk a little bit about how many puffs we use for each part of it, and then we look a little bit about action plans. When we look at GINA, GINA says if we are using the combination product in step one or two, they probably only need to have probably just one inhaler and one pup should be fun — fine — one puff should be fine. They were to step three, it is the same inhaler and they can take one puff as their maintenance medicine once or twice daily and as a rescue, they would take an additional one puff, and as they moved to step 4, maybe having more significant asthma, again, the same inhaler, but they would take two puffs twice a day and one additional puff as a rescue inhaler. It is a little bit tricky because the way that we looked at asthma inhalers in the U.S. and what is currently FDA approved for these inhalers is not the same way that GINA says we should be using it. Puff the Magic Dragon on this slide basically says a rescue puff is all that would be needed, but most of are MDI’s in this — most of our MDI’s in this country, when you look at their wording, it says it is not approved for rescue, and it also says that most of those inhalers should be given with two puffs.
That is kind of based on old information. Some of our early NDI — NDI — M DIs but like the medicine was not going all the way through the inhaler, so they would do two puffs to push it through. We found that one puff can effectively get all the way through the device and be delivered effectively. As stated, GINA says we really only need one inhalation for symptom relief and if we are not seeing significant improvement after a few minutes, we could do a second puff. The other thing again that GINA says his other ICS-formoterol products available have not really been studied as well internationally and in most of the trials, so when we talk about it in this country, the only combination therapy that has been studied well and is available on the market is the budesonide formoterol product. There is also the mom met his own — then that his own product available in this country. In Europe, there is a Beckley Methodism — beclamedisone product, but that is not available in the U.S.. What strength are you going to try for a patient and how many puffs are you going to give them, both for maintenance and rescue. Let’s walk through this table for a moment. If you have a patient over 12, current recommendations from GINA are you should prescribe the 160/4.5. They would take one puff as needed for exercise or for reliever. If they are going to be on SMART or MART, depending on severity, they would start with one puff once a day or twice a day, in step three with one puff as a believer and if they had more significant disease, they would get two inhalations twice a day with one puff to rescue. I want to note for you that the maximum daily number of puffs in someone over 12 should be getting his 12. That’s how I always remember, 12 for 12. Beyond that, it is not recommended to go beyond that. If you have an asthmatic that is younger than that, we know six to 11 you will groups, if we were using this particular therapy, we would want 80 per 4.5 budesonide formoterol.
Currently, there is no evidence, although there are ongoing studies, there is not enough evidence for GINA to recommend air therapy in patients six to 11, but they do endorse MART therapy at steps three and four, and the appropriate way to begin in step 3, 1 inhalation once daily with one rescue puff, and in step 4, 1 inhalation twice daily with one inhalation as a rescue. You can see the number of total puffs in this particular age group is eight. I have gone ahead and put on this table for you if you were going to use them that his own formoterol, which is a product available in this country and want the — what the standard dosing would be for SMART or MART if that is the inhaler the insurance company wants to pay for. Let’s talk about asthma in six to 11-year-olds. There are some things that again are a little bit different. As I mentioned, we do not have air therapy improved, but if they had to use a SABA, you would want to match that with an inhaled corticosteroid, and you can see at step three and four, we then can begin using more as we mentioned in the previous table. You can see here when it is all put together in the GINA 2020 for schematic for six to 11-year-olds, I, prior to that, SABA would be used for step one and two and in three and four, we would make it a combination product. The dosing, as I mentioned, is very simple. Again, we do not want to use ICS formoterol with other ICS LABA ‘s. This is what it looks like in our NHLBI guidelines. In terms of matching GINA in steps three and 4. And then, bringing to you that I just mentioned about the Mometasone. Let’s spend a few minutes talking about what we can do to have patient-centered asthma care. One of the most important things we need to do is have shared decision-making. When I am meeting with my families, I talk about for them what they use in the past and how it is working. We spent a lot of time talking about our new understanding that if we use albuterol excessively that that can be dangerous, and I have tried to mention how we dose their ICS-formoterol combination once a day, easier in the morning or at night, and make sure we have the appropriate inhalers available at school, so we discussed the pros and cons of different treatment options, because I think it is important we give them a say in what they’re looking for. I think it is important to have personalized asthma action plans. It is very important that patients know what to do on an everyday basis and also what to do when things are not going well. Here is an example of an asthma action plan that is available on the Allergy and Asthma Network. You can see SMART is incorporated in that. We would tell patients how many puffs to take when, how many would be their rescue, remembering again it is 12 above 12, and under 12, it would be eight, and then there’s also a certain number of puffs when they are in the red zone. In this particular example, if they are in the red zone, they would take one puff of an S&L formoterol product. Weight one to three minutes. If they are no better, they can take an additional one 23 puffs. This is what our action plan looks like in the state of Virginia. This is an example. It again incorporates both the ability to use SMART and also more traditional asthma combination medications.
This is the asthma action plan from NHLBI, so I recommend you get an action plan that fits your community, that can easily be utilized, and I think it is very important. In our particular pediatric asthma plan, we wanted one that could populate our EMR so it could stay there and parents could go on the portal and pull off the action plan and use it at the YMCA or somewhere else. I think it made it very helpful for patients to be able to have their action plans. I think it is also important, as we mentioned, from the little circular things at the top of the screen. I think each time we see an asthma patient in follow-up, we need to see what is working and what is not. We need to try to teach them again the importance of their inhalers and encourage self-monitoring of symptoms. There are lots of apps that are available that patients can go in and rate their asthma for the day. I have ACT scores built in the apps. Some cactuses that are very savvy with electronics, they even have those communicate back with their provider. I think it is important that we utilize all the people in our facilities to help provide patient care. It may be that we need to have a team approach. I think it is important that specialists are talking to primary care so everybody is on the same page. As we involve the emergency room, people also need to understand what SMART is and how that works, and I think things like clinically integrated networks can be helpful also. Everybody is helping to provide the vision and understanding of asthma management. In addition to that, I think it is important to have regular follow-ups. Some individuals have difficulty managing asthma and should probably be seen at least every three months, and it is good to see them when they are well just as it is to see them when they are not well. Again, I’m amazed every time I try to review asthma techniques. People can forget how to use their spacer, and we have to review that over and over again. And also, telemedicine, for those of you that have the ability to use that, can be very helpful in establishing a routine care and follow-up. We just checking in and seeing how you’re doing with your asthma. I also find being able to subtract how often they refill their medications is helpful and also lets me tell them how — tell them I know how often they are refilling their medications. It is an opportunity for me to stress to them the importance of refills on medications. I think it is important when we see patients that we also addressed health care disparities. It is difficult to want to manage asthma from my seat if when they go home they are having difficulties getting transportation or they do not feel safe or potentially do not feel supported by their family in terms of the adjustments that need to be made for families with chronic illness. We want to provide things that build independence, so patients see we want to address asthma disparities as they occur across the health care system, and I think it is important that we think about medication costs. It is difficult to say go get this wonderful new asthma medication and I want you to have three of these inhalers, one for every word though, and the cost of those inhalers is prohibitive. We also need to make sure the action plan we use and the information we communicate to the families is understandable to everyone, including the kids need to understand a little bit about the importance of their asthma medications if they are old enough to understand that. I think having resources at each point of care can help address — that can help some of these barriers is important. There was good news that came out on June 1. At least three different pharmaceutical companies place a price cap on several of their brands of asthma inhalers.
They are to be no more than $35, so what I found in my particular area is that I have been able to print a coupon for certain brands to hand to the families to give to the pharmacies or in the state of Virginia, as I mentioned, we have been very fortunate, and Medicaid have embraced that inhalers are important and are covering them. Additionally, sometimes I will tell them that they should — if the insurance says it’s going to be $60 or $160, I tell them to have the pharmacy just take the insurance out and run their prescription through as if they had no insurance, and what I’m finding then is it is popping up at $35, so I think this price cap from these pharmaceutical companies will have a very good impact on patients’ accessibility to be able to get these inhalers, so I think that there are many, many hurdles we still have to overcome. There are still a lot of people really hung up on the fact that here we are advocating this is the way to treat asthma, and the FDA has not approved that these inhalers can be used as a rescue inhaler, but I think that if it comes, it will come in due time and that we need to follow where the evidence or science is. We have two great asthma documents that say this is how we should be managing asthma. This is how we provide safe asthma care for patients. We need to throw out our old view that asthma is just a disease of bronco restriction, and we need to make these available and we need to focus on health care system integration, and we need everyone to understand, and I think that somewhere I read recently that any time new guidelines are written, that it can take up to 12 years before new guidelines in any chronic disease actually take hold and that everyone learns about it and is able to implement those for patient care. What I’m hoping is that we don’t take 12 years to be able to implement our new understanding of asthma, that it is really important that we prevent disease, prevent exacerbations, and make one inhaler available for most patients in step three and step four that makes it easier for them to manage their asthma. I think that is all I want to say other than here are some additional resources from the Academy of allergies, the College of allergy, the allergy and asthma network, and the asthma and allergy foundation of America. They all have great websites with lots of information about SMART.
Catherine: Dr. Hogan, thank you so much. That was a lot of great information. We need more time. I wish you could see all the questions. We have a lot of questions in the Q&A but also in the chat. I’m going to do my best to summarize everything so we can answer everybody’s question. There were a lot of questions, as you can probably imagine, about the insurance issue, about insurance not being familiar with GINA, and because of that, they are not able to process the prescription. Someone was saying they are having a difficult time with insurance coverage for ICS for Motorola inhalers and that insurance companies often will not cover these inhalers. A lot of the patients are unable to afford the out-of-pocket cost . Basically, this is what I have been hearing throughout the webinar with all the questions, do you have any suggestions on how to educate insurance companies regarding guidelines, SMART/MART and changing the coverage.>> yes, I do. First of all, if you are a member of a college or have access to the ACAAI website, there is a letter that was recently written that helps the get authorization. It is a multifaceted level with good evidence-based medicine, and you could adapt that to your individual patient and argue why this particular medication could be or should be covered. I think that there are many people working across the country to try and overcome obstacles. I know in our particular area, I have recently written a five-page letter to some of our insurance providers discussing why this is the superior way. I think things are going to get better, but on a practical note, I so far — knock on wood — have been able to tell my families again because of this recent price cap, to tell the pharmacy to take their insurance completely out and run it through as if they had no insurance, and so far, from what I have heard, and hopefully, I’m still right, then it is $35 because of the price cap, so that may enable them to at least get one inhaler for $35.
Catherine: OK, there was another comment and question. At a recent conference, we were informed that the shelf life of an inhaler decreased drastically once and inhalers open, that the expiration date on the box is the date of expiration if the inhaler has not been used. How do we assist families if they need inhalers for school or home every 30 to 90 days due to shelf life?>> I’m not sure that the shelf life is the same for all of those inhalers. I think it depends on what the preparation is. Certainly for dry powdered inhalers, we know that the moisture can get into those, and they may have a shorter half-life. In NDI has a longer shelf life, as clearly evidenced on the box, so I’m not sure that applies universally across all inhalers.>> OK, there’s a question about ICS and Perry oriole dermatitis for patients with asthma five to six years old. How do you successfully manage someone’s asthma when that her face is constantly battling this rash on their face?>> we do see that less with the budesonide for Motorola — budesonide formoterol. Also, you see less thrush. That is what my experience has been. I make sure the spacer is clean. It is usually patients that have a mask spacer. If it is someone I can switch to ML these spacer, that sometimes will overcome it. We know that topical steroid creams do not make that any better, so don’t apply topical steroid creams. Sometimes you can use — a little can sometimes be helpful. Sometimes we will use MetroGel. That can also help with the Perry oral dermatitis.
Catherine: There was a question — are you currently writing prescriptions S two puffs per day?
Dr. Hogan: Actually, especially if they are an AIR patient, I write it as two puffs twice a day because that is what the description says, and then I tell them to use their action plan. We all are hopeful. We cannot wait until the system changes. We have to do our work around that we need to do because this is too important to wait until the FDA decides, oh, yeah, I think it is a good idea. So, yes, I’m not quite saying on the prescription what I am actually having them do in real life.
Catherine: OK. Let’s see here. Are there equity studies on who is being prescribed SMART versus just albuterol so we can learn more about access and how we can improve it?
Dr. Hogan: I’m sure there are. I am probably not able to answer that at this moment, but the current thinking is, again, this particular way of treating asthma, because it is so much more accessible across a large population, could potentially, especially if you don’t need to have an inhaler every day, that you can dial up when you are having symptoms for AIR or when you are having mild, persistent asthma, the number of puffs you need on a daily basis is much less than what is contained in the inhaler, and we probably will be able to level — or not level, but at least decreased some health care disparities at least in terms of access to quantity of medication.
Catherine: OK. I am sorry. We’re at the top of the hour now. There were a lot of questions we did not get to, and we are sorry for that. Thank you so much. This has been really informative. We have two webinars coming up in August. First, we will welcome back Dr. David stuck us. He will talk about childhood asthma and how to teach children to use inhalers properly. On August 27 at 12:00 p.m. Eastern, we will welcome Dr. and Maitland to discuss seasonal allergies and optimizing treatment for each patient. You will receive an email from Zoom in a few days with a link to the recording and an evaluation. That is really important to give us feedback, and some additional resources. Again, thank you so much, from all of us here at the allergy and asthma network. Join us as we work every day to breathe better together. Have a good evening, everyone, and we will see you at the next webinar.
