Controversy over asthma med restrictions in kids

The surprise PBS ban on GP-initiated scripts of fluticasone propionate 50 micrograms has ruffled feathers.

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GPs can no longer initiate fluticasone propionate 50 microgram on the PBS, with new rules requiring a specialist referral for pre-schoolers and a switch to other asthma medicines for older children.  

GPs and other specialists alike have raised concerns the change will delay and even restrict access to treatment for the most vulnerable children, and say the move was based on economics rather than the safety or efficacy of the drugs. 

From 1 April, the PBS will only fund fluticasone propionate 50 microgram/actuation inhalation, 120 actuations (Axotide Junior, Flixotide Junior)?in children under six years, for whom there is no alternative, when the drug has been initiated by a paediatrician or respiratory specialist. It is now an Authority Required drug.  

GPs and nurse practitioners can prescribe continuing treatment, and the treatment is still available with a private prescription and at the higher 125 microgram dose. 

In patients over age six, the PBS advises that GPs switch patients to alternatives such as budesonide, beclometasone dipropionate or ciclesonide.  

“We’re very worried,” Asthma Australia’s Anthony Flynn told TMR.

“Asthma is the leading cause of hospitalisations in children. If anything, we want to see more children using inhaled corticosteroids to better control their asthma and prevent symptoms and flare ups.”

“We need fewer barriers and more enablers.”

Dr Tim Senior, a GP at a clinic in Sydney’s south-western suburbs that services primarily Indigenous patients, told TMR the change took him and his colleagues by surprise.  

He said the decision “seemed odd” given that GPs manage most asthma patients, there are already long waiting lists to see paediatricians and most of them don’t bulk bill.  

Referring pre-schoolers who could otherwise be handled by GPs would delay starting asthma action plans for those children and make things harder for families who couldn’t afford the co-payments, Dr Senior said. 

The change was likely due to a lack of agreement on price between PBAC and the pharmaceutical company, said paediatric respiratory specialist Dr Ajay Kevat, one of the founding chairs of TSANZ’s Children’s Severe Asthma Working Party. 

“This move would see decreased PBS prescribing for this medication by limiting its availability to our frontline doctors, who are GPs, and that would reduce the cost for the government.  

“But that would be at the expense of patients and families. That might mean they can’t afford the medicine. And that leads to poor asthma control, which we know leads to increased hospital admissions. It leads to poor quality of life for children and families who are impacted, it leads to decreased school attendance,” Dr Kevat said.  

“While the government might save a penny here, they may pay pounds down the track for this decision in other areas.”  

Fluticasone is the most used inhaled steroid in children, and Dr Kevat said change was “disruptive” for asthma management and risky.   

The PBS still funds a higher dose fluticasone 125 microgram inhaler, but Dr Kevat noted this would expose children to greater risks of side effects.  

Additionally, the alternative inhalers were not necessarily the same shape as the ones children were already used to and might not fit the spacers that families already owned. All of this could disrupt their asthma management, he added. 

Dr Kevat said TSANZ is currently working on its official representation to PBAC and doctors are lobbying for reversal or alteration of the decision by making individual submissions to the PBAC secretary. 

Dr Shivanthan Shanthikumar, paediatric respiratory physician at the Murdoch Children’s Research Institute, said the decision was “purely economic” and nothing to do with the medication’s efficacy or safety.  

He supported the use of private scripts in people who wanted to continue with the inhaler: “It’s not a perfect solution, but it minimises the impact of this change.” 

Specialists would now have to start making room for young patients who were previously managed entirely by their GPs, Dr Shanthikumar said. 

“If we don’t step up and start seeing these kids, particularly the ones with concession cards, they’re not going to be able to get access to this medication without significant financial stress. We really should prioritise those families,” he said. 

Dr Shanthikumar said the children most affected by this change were concession card holders, particularly those in regional areas. Private prescription price varied across pharmacies, and access to specialists was restricted by distance, waiting time and cost. 

“This is just reinforcing the social determinants of health and the disparities in populations that are most affected by asthma,” he said.  

The highest prevalence of asthma was found in the lowest socioeconomic band. Likewise, Aboriginal and Torres Strait Islander population were more at risk than non-Indigenous population. “So the very populations who will be most impacted by this change are the people who have the highest rates of asthma,” he said.