This is fascinating. The insurance coverage piece is not surprising, albuterol is cheap and the newer medications are not. Dissemination of new best practices is rough especially when payors are not on board.
Right. Even if I have someone doing well on Symbicort or Dulera, the new year will bring a formulary change and now I have to switch it to Advair, which means a whole new conversation explaining why THIS one can’t be a rescue med even though I said the last one could be. Confusion on this can lead to real adverse events. So the ICS-formoterol rescue may actually be best but not worth the effort and potential negative consequences down the line.
My PCP just prescribed me Symbicort for a post-viral inflammation/reactivity/SOB that won’t go away. I was skeptical because albuterol has never worked at all for me, and I love my Breo. But man Symbicort is the bomb! I’m coughing up all the gunk that’s been stuck there for ages. All I ever get from albuterol is tachycardia.
In my experience as a patient, outside of albuterol, insurance makes asthma meds nearly impossible to afford without constantly jumping through hoops. Prior authorizations always running out, cost outrageous and always changing, constant demands to try cheap alternatives to the treatment that’s been working for ages. I finally gave up on a maintenance med that worked wonders and now use albuterol.
The US medical “ system“ is more like a patchwork quilt. It’s why I had to leave primary care all together, my brain just could not cope with it. It’s a shame. Thanks for hanging in there and doing the good work.
I had an asthma diagnosis as a (very skinny) preteen that magically resolved itself when my skeletal system started to mature a little and I got taller. Scheduled albuterol for a couple years in the meantime. When my oldest was almost 2, he was given emergency albuterol after a PICU stay with intubation to address coughing episodes…he’s needed it once in the 2+ years since then. As a PT and former academic, I’m somewhat shocked that guideline-based care is still taking so long to adopt shifts in guidance for common conditions like asthma.
As a college level lecturer, teaching public health courses, including Health Behavior Theory, I would edit slightly your question: "Why is CHANGE so hard?" External and internal factors, as you point out so well make changes like this complicated. You also need to take into consideration social factors like trusted messengers, lived experience, cultural norms. Then also the congruence of message - how many providers are and will continue to prescribe albuterol even after the best practice messages are being promoted and advocated?
This post is a great first step of many to get to the change needed. Raising awareness of an issue (as a person with mild asthma, I had no idea that albuterol should not be what I have for my occasional exacerbation). Advocacy leads to greater awareness and engagement, and turns into more advocates which will lead to more awareness and engagement. Additionally, your identification of the barriers to change is helpful so we can address and reduce/eliminate these. The easier it is to change behavior, the more likely people will do it. But only if they have to. :)
Oh, this frustrates me so much. Not for asthma per se, but for all medications. If my doctor recommends a medication, the insurance gatekeepers should not be allowed to say no because of cost or their own ignorance. Doctors are not frivolously prescribing medications! Grrrr . . .
With two asthmatics in the house I appreciate this info. For awhile there, with insurance a refill for albuterol and Flovent was well over $100. Last year we couldn't even get the nebulizer albuterol for 7 months (which was 7 months too late from when my family needed it). Time to push past status quo and start looking at other options. Thanks for the prompt.
The insurance coverage is absolutely the problem for me with ICS +LABA combo inhalers.... it's impossible to figure out the covered one and drives me mad, even when I prescribe what the insurance company states is covered, it usually is not!!! Ah!!!
I’ve heard that steroids exacerbate type 2 diabetes, so I worry when I’m prescribed meds such as Symbicort that include steroids. I wonder if that’s an element of some patients’ (and doctors’?) reluctance to make this particular change?
That's a great question! The inhaled steroids tend to have way fewer side effects than systemic steroids (i.e. Prednisone) and they help prevent the need for Prednisone.
Thanks so much for this! It is a beautiful example of how to explain something complex very clearly. Sharing it with my husband who has been on albuterol for 40 years.
I do have to say…I suffered an asthma attack while visiting NYC in 1997. It was late in the evening, and I did not know how to navigate in the city—didn’t even know where an urgent care or ER could be found—and I ended up buying Primatene at some all night drugstore.
It was f-ing awful. Like inhaling Lysol. Maybe slightly helped; maybe not. I do remember getting more relief from a cup of coffee.
Albuterol would have fixed all that.
Myself, I very rarely utilize my emergency inhaler. But I know for a fact that my totally miserable experience in NYC would have been resolved or even averted if I’d had an albuterol inhaler. So, the drug is not all bad, and we should not think of it as such.
Wow I’ve been going to conferences since 2019 and have not heard this recommendation but it makes sense to me. There’s just too many things to know as a generalist.
Why is change so hard in medicine?
Because pharmaceuticals don’t want to stop selling their old drugs.
This is fascinating. The insurance coverage piece is not surprising, albuterol is cheap and the newer medications are not. Dissemination of new best practices is rough especially when payors are not on board.
What is wild is that these combo meds aren't even new! The PBMs just keep changing which ones are covered...
Right. Even if I have someone doing well on Symbicort or Dulera, the new year will bring a formulary change and now I have to switch it to Advair, which means a whole new conversation explaining why THIS one can’t be a rescue med even though I said the last one could be. Confusion on this can lead to real adverse events. So the ICS-formoterol rescue may actually be best but not worth the effort and potential negative consequences down the line.
agree. inhaler confusion is so real.
My PCP just prescribed me Symbicort for a post-viral inflammation/reactivity/SOB that won’t go away. I was skeptical because albuterol has never worked at all for me, and I love my Breo. But man Symbicort is the bomb! I’m coughing up all the gunk that’s been stuck there for ages. All I ever get from albuterol is tachycardia.
I'm so glad you're feeling better!
P.S. I love Cait Van Damm! So excited for that conversation!
😍😍😍
In my experience as a patient, outside of albuterol, insurance makes asthma meds nearly impossible to afford without constantly jumping through hoops. Prior authorizations always running out, cost outrageous and always changing, constant demands to try cheap alternatives to the treatment that’s been working for ages. I finally gave up on a maintenance med that worked wonders and now use albuterol.
Yep. Insurance actively causes harm to my asthma patients.
The US medical “ system“ is more like a patchwork quilt. It’s why I had to leave primary care all together, my brain just could not cope with it. It’s a shame. Thanks for hanging in there and doing the good work.
❤️
I had an asthma diagnosis as a (very skinny) preteen that magically resolved itself when my skeletal system started to mature a little and I got taller. Scheduled albuterol for a couple years in the meantime. When my oldest was almost 2, he was given emergency albuterol after a PICU stay with intubation to address coughing episodes…he’s needed it once in the 2+ years since then. As a PT and former academic, I’m somewhat shocked that guideline-based care is still taking so long to adopt shifts in guidance for common conditions like asthma.
So sorry to hear about your kiddo! Sounds so difficult
As a college level lecturer, teaching public health courses, including Health Behavior Theory, I would edit slightly your question: "Why is CHANGE so hard?" External and internal factors, as you point out so well make changes like this complicated. You also need to take into consideration social factors like trusted messengers, lived experience, cultural norms. Then also the congruence of message - how many providers are and will continue to prescribe albuterol even after the best practice messages are being promoted and advocated?
This post is a great first step of many to get to the change needed. Raising awareness of an issue (as a person with mild asthma, I had no idea that albuterol should not be what I have for my occasional exacerbation). Advocacy leads to greater awareness and engagement, and turns into more advocates which will lead to more awareness and engagement. Additionally, your identification of the barriers to change is helpful so we can address and reduce/eliminate these. The easier it is to change behavior, the more likely people will do it. But only if they have to. :)
Oh, this frustrates me so much. Not for asthma per se, but for all medications. If my doctor recommends a medication, the insurance gatekeepers should not be allowed to say no because of cost or their own ignorance. Doctors are not frivolously prescribing medications! Grrrr . . .
😬
If you did have a nationalised health-care system, beneficial change might become impossible.
I don't know.. our current system isn't doing us any favors…
With two asthmatics in the house I appreciate this info. For awhile there, with insurance a refill for albuterol and Flovent was well over $100. Last year we couldn't even get the nebulizer albuterol for 7 months (which was 7 months too late from when my family needed it). Time to push past status quo and start looking at other options. Thanks for the prompt.
Sending love! It shouldn't be this hard.
The insurance coverage is absolutely the problem for me with ICS +LABA combo inhalers.... it's impossible to figure out the covered one and drives me mad, even when I prescribe what the insurance company states is covered, it usually is not!!! Ah!!!
(hyperventilating)
Yes hyperventilating too 😬
I’ve heard that steroids exacerbate type 2 diabetes, so I worry when I’m prescribed meds such as Symbicort that include steroids. I wonder if that’s an element of some patients’ (and doctors’?) reluctance to make this particular change?
That's a great question! The inhaled steroids tend to have way fewer side effects than systemic steroids (i.e. Prednisone) and they help prevent the need for Prednisone.
Good to know, thanks!
Thanks so much for this! It is a beautiful example of how to explain something complex very clearly. Sharing it with my husband who has been on albuterol for 40 years.
I'm so glad!
I do have to say…I suffered an asthma attack while visiting NYC in 1997. It was late in the evening, and I did not know how to navigate in the city—didn’t even know where an urgent care or ER could be found—and I ended up buying Primatene at some all night drugstore.
It was f-ing awful. Like inhaling Lysol. Maybe slightly helped; maybe not. I do remember getting more relief from a cup of coffee.
Albuterol would have fixed all that.
Myself, I very rarely utilize my emergency inhaler. But I know for a fact that my totally miserable experience in NYC would have been resolved or even averted if I’d had an albuterol inhaler. So, the drug is not all bad, and we should not think of it as such.
Wow I’ve been going to conferences since 2019 and have not heard this recommendation but it makes sense to me. There’s just too many things to know as a generalist.
It's definitely an outpatient thing. 😅