Pediatric Asthma

Sonya Collins

In January 2024, GSK discontinued sales of its Flovent HFA and Flovent Diskus inhalers. The company attributed the change to the availability of generic alternatives that work just as well but for a potentially lower price. However, few insurance companies cover the authorized generics, leading to serious challenges in finding an acceptable replacement for the drug, particularly for parents of some small children.

Pharmacists will need to be aware of the alternatives that are available for patients.

“Pharmacists are in a strong position to educate both parents and prescribers,” said Leslie Hendeles, PharmD, professor emeritus at the University of Florida College of Pharmacy in Gainesville, FL.

Know the facts

Generic fluticasone is manufactured by Prasco Laboratories. But most insurance companies don’t cover it.

In the absence of a generic alternative on their formulary, some payers are pointing patients toward dry-powder inhalers, such as Advair Diskus, Wixela Inhub, QVAR Redihaler, and Trelegy Ellipta. These require forceful inspiration and a breath-hold, and they have not been studied for safety and efficacy in patients under 5 years old.

“With children under the age of 8, it’s variable as to whether you could teach them to inhale fast and hold their breath for 10 seconds, and those two things are key to using a dry-powder inhaler device,” said Hendeles.

The only inhaled corticosteroids that have been studied in children under 5 years are budesonide nebulizer solution and the Flovent metered dose inhaler. For small children, or anyone who cannot use a metered dose inhaler properly, Hendeles said, “We can attach a chamber with a mouthpiece or a mask, and that way they won’t have to inhale slowly or hold their breath.”

The metered dose inhaler with a chamber may be preferable to a nebulizer for several reasons:

• Patients must pay an additional out-of-pocket cost for a nebulizer.
• The device takes 10 to 15 minutes to deliver a dose, during which time small children often fight the device.
• Parents must disinfect the devices after each use.
• Nebulizers require electricity, which limits where they can be used.

Understand the challenges

Under most insurance plans, generic fluticasone may come with a high out-of-pocket cost to parents. Depending on the plan, there may not be another metered dose inhaler in the formulary.

“They have changed their preferred drugs to dry-powder inhalers without taking into account the fact that children and some adults can’t use a dry-powder inhaler,” Hendeles said.

For patients who cannot use a dry-powder inhaler, a nebulizer might be recommended, but small children may refuse this device. The patient would have to fail the nebulizer before gaining access to generic fluticasone.

“But in the meantime,” Hendeles said, “they had to spend the money for the compressor. This is a real problem.”

Possible actions for pharmacists

Community pharmacists can help streamline the path to effective inhaled corticosteroids for their youngest patients.

When a payer denies a claim for generic fluticasone and offers a list of alternatives, pharmacists can send the list to the prescriber for them to choose. Pharmacists should be prepared to make suggestions regarding which medication would be appropriate for the patient.

“One of the roles for the community pharmacist is to recommend something that would be appropriate,” Hendeles said. “Asthma specialists will have knowledge about the different options, but primary care doctors and pediatricians certainly will not.” ■