Paediatricians, respiratory specialists, GPs, and parents have been left wondering why the Pharmaceutical Benefits Advisory Committee’s sudden decision to restrict access to fluticasone propionate inhalers for children under six has not been rescinded.
From 1 April 2023 children under six could no longer be prescribed fluticasone products, including Axotide Junior and Flixotide Junior, by their local GP, and patients over 6 years were no longer eligible to collect a PBS subsidy for their fluticasone preventatives.
GPs could continue treatment for children already prescribed these products by a paediatrician or respiratory specialist but now need prior approval by the PBS when issuing repeats or requesting an increase in dosage.
Yet as fluticasone preventatives should be used daily to be effective, even in people without current symptoms, the move was labelled a financial rather than clinical decision by groups such as the National Asthma Council (NAC) and Asthma Australia – especially considering that Asthma is the leading cause of burden of disease for people aged 5–14 years.
“I don’t fully understand why the change has been made,” Professor Nick Zwar, the chair of the NAC’s Guidelines Committee, told AusDoc on 6 April 2023.
“It’s not a realistic, practical way of getting access for people who need this medicine.”
For example, according to the latest data from the AIHW, nearly 460,000 Australian children aged 0-14 (10%) were estimated to have asthma, with the condition most prevalent among children aged 5 to 9 – yet Flixotide Junior and Axotide Junior were only dispensed nearly 87,000 times through the PBS between March 2022 and February 2023, meaning that less than 1 in 5 children accessed at least one script of these preventatives.
To help manage their asthma, children aged 4 to 11 years were advised to use 30 -55mcg of fluticasone twice a day, and the clinical guidelines for children younger than 4 years of age stated that usage and dose should be determined by the child’s GP.
But by limiting authority to respiratory specialists and paediatricians, a very real concern exists that waiting times will implode under increased demand for these comparatively limited services, placing further strain on emergency healthcare due to a subsequent increase in presentations with asthma.
Asthma mortality and hospitalisations in Australia are high by international standards and according to Asthma Australia’s 2023-2024 Federal Pre-Budget Submission, each ED presentation for asthma cost $443, an uncomplicated hospital admission cost $2,591 (approximately 1.5 hospital days) and a complicated admission cost $5,393 (approximately three hospital days).
The advice issued by the PBS also noted that existing patients aged 6 years and above would be required to “see their GP or primary prescriber to switch to an alternative PBS reimbursed medicine” or “consider swapping to private prescriptions” – increasing the price from under, to just over $11.
Dr Tim Senior, a member of Asthma Australia’s Professional Advisory Council, spoke with the RACGP’s newsGP on 5 April 2023, and highlighted that there were real health equity consequences for families because of the restrictions.
“For any patient who can’t afford the co-payment to see a paediatrician, essentially that means that they are unlikely to be able to afford a private prescription for fluticasone – and so they’re just blocked off from receiving that medication at all,” Dr Senior said.
“Asthma that is not managed well enough can be a serious condition… we are managing this routinely and this puts significant barriers in the way of doing that.
“And the paediatricians I have spoken to say the same thing; they do not want their lists to be filled with things that they do not need to be managing – it is not great use of their time either.”
In other Asthma news, the NAC released the new ‘First Aid for Asthma chart for combination inhalers with Formoterol’ (FAFA chart) on 14 April, which provides guidance for their use in the event of an asthma attack – provided it is that person’s usual medication.
Respiratory physician and Chair of the FAFA Working Group, Professor Peter Wark, said the development of combined preventer and reliever medication was an important advance for asthma care and noted that the NAC wanted all health professionals to reinforce with their patients that the treatment was “very effective and safe.”
“This new chart is designed for patients using a combination preventer and reliever medication that uses formoterol as the reliever, which could help to prevent an asthma attack from becoming an asthma emergency,” Professor Wark said.
“The FAFA charts are the backbone for the management of acute asthma by GPs and other health professionals and the steps followed in the chart are as relevant on the sidelines of the sporting field as they are in a doctor’s surgery.
“For those with mild and moderate disease who are aged 12 and above and there is very good evidence that it is more effective and safer than using a reliever alone.”