Microsoft word - olenic_asthma.doc

Asthma Medications for the Workers Compensation Patient Population
According to the very widely recognized GINA (Global Initiative for Asthma) guidelines, the treatment of occupational asthma is identical to other forms of this condition.1 Therefore, when considering which medication are appropriate for treatment of occupational asthma, the GINA guidelines as well as a number of other guidelines were reviewed. The list provided by Work Loss Data Institute was used as a starting point for documenting information related to pharmacotherapy of occupational asthma. Additions have been made as well as one deletion to the initial list. Specifically, tiotropium was deleted as it is indicated for COPD only. Table 1 of this document lists products by brand and generic names, indicates generic product availability and provides current average wholesale prices. AWP (average wholesale price) may be higher than retail pricing; however, it is a means of comparing relative costs regardless of drug plan, pharmacy pricing or other factors that may impact actual retail pricing. Tables 2 and 3 summarize the various guidelines’ recommendations for outpatient rescue and maintenance/prevention drugs to allow the reader to compare similarities and differences among treatment recommendations. Please note: medication therapy for acute exacerbation requiring hospital treatment is not addressed in this report. Asthma is classified according to severity and persistence of symptoms. GINA and British guidelines use a five step classification system. The NHLBI uses a six step algorithm for treatment guidelines. In all cases, Step 1 is considered mild, intermittent asthma and Step 5/6 is considered severe and difficult to control asthma. The medication recommendations in guidelines are associated with specific levels of severity. The ratings indicate the preference of a medication for the appropriate level of treatment needed. The reader is directed to the guidelines for details. It appears that there are no distinct advantages among medications in the same drug class within the same recommendation level. Therefore, patient-specific considerations and cost may be primary considerations when selecting medications. 1 Global Strategy for Asthma Management and Prevention. (GINA) 2011. Available at: . Accessed March 7, 2012. Table 1: Medications included in this report
Generic Name
Brand Name
Dosage form
Available (Y/N)
44 mcg-$116.10 110 mcg-$165.00 220 mcg-$255.60 100/50-$$225.60 250/50-$280.20 500/50-$368.40 Asthma Medications – Workers’ Compensation Drug Plan Recommendations
NOTE: Unless otherwise specified, the dosage form is via oral inhalation and may be via a metered dose inhaler or powder inhalation device. Key to acronyms and recommendation levels used in tables
3 = third-line, if other medications not tolerated AAAAI = American Academy of Allergy, Asthma and Immunology ICSI = Institute for Clinical Systems Improvement NHLBI = National Heart, and Lung and Blood Institute Table 2: Rescue Medications Recommendations per Guidelines
Brand Name
Drug Class
VAii§ Britishiii ICSIiv∞ NHLBI AAA
(aerosols and oral inhaler) Pirbuterol Maxair® SABA lone (severe exacerbation) §Based primarily on NHLBI and GINA; ∞Based primarily on NHLBI Table 3: Maintenance / Preventative Medications Recommendations per Guidelines
NOTE: Unless otherwise specified, the dosage form is via oral inhalation Medication
Brand Name
Drug Class
Formoterol/budesonide Symbicort® LABA/LACS 1 2 1 1 1 1 Formoterol/mometasone Dulera®
1 Cromolyn is listed for use as a pre-exercise prophylaxis agent by ICSI and NHLBI
Note: Inhaled LABAs are not to be used alone for management of asthma. Therefore, the single agents are listed as N.
However, they may be used in combination with a corticosteroid.
Other medications not included in Maintenance / Preventative therapies include methotrexate, cyclosporine, macrolide
antibiotics, tumor-necrosis factor-alpha monoclonal antibodies, and gold compounds. Although these agents have been
studied, there are insufficient data to recommend these agents. Further, the clinical data that are available suggest that the
risks may outweigh only minor benefits. vii
With regard to formulary/drug plan considerations, medications rated 1 or 2 by most guidelines are appropriate for
inclusion. Medications rated as 3, 4, N or N/A should be considered only with pre- or prior authorization with
documentation demonstrating medical necessity. Table 4 summarizes drug plan recommendations.
Table 4: Formulary/Drug Plan Recommendations
Generic Name
Levalbuterol (aerosols and oral inhaler) i Global Strategy for Asthma Management and Prevention. (GINA) 2011. Available at: . Accessed March 7, 2012. ii Management if Asthma Working Group. VA/DoD clinical practice guideline for management of asthma in children and adults. Washington, DC: Department of Veteran Affairs, Department of Defense; 2009. Available at: . Accessed March 7, 2012. iiiBritish guideline on the management of asthma. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2011 May. (SIGN publication; no. 101).). Available at: . Accessed March 7, 2012. iv Health Care Guideline: Diagnosis and Management of Asthma. Bloomington, MN :Institute for Clinical Systems Improvement; June 2010. Available at: . Accessed March 7, 2012. v The Expert Panel Report 3 (EPR—3) Summary Report 2007: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 2007. Available at: . Accessed March 7, 2012. vi Li JT, Oppenheimer J, Bernstein IL, et al. Attaining optimal asthma control: a practice parameter. J Allergy Clin Immunol 2005; 116(5):S3-11. vii Global Strategy for Asthma Management and Prevention. (GINA) 2011. Available at: . Accessed March 7, 2012.


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