CHEST 2019 — Decreased asthma control in children following an insurance formulary change

  • Keren Landman, MD
  • Conference Reports
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  • Children taking inhaled steroids for asthma had reduced lung function when a Medicaid formulary change led to a switch from metered dose inhalers (MDIs) to dry powder inhalers (DPIs).

Why this matters

  • Insurance formulary coverage changes are an important reason for medication changes in otherwise stable patients, and may lead to changes in health status.

Study design

  • Retrospective chart review of 68 children with asthma ages 6-18 years at an academic medical center's general pediatric clinic.
  • Subjects had all been clinic patients during a major regional Medicaid provider's formulary change and had spirometry before and after the change.
    • The change resulted in discontinued coverage of beclomethasone dipropionate delivered by an MDI in favor of mometasone furoate, available as both an MDI and a DPI.
  • Funding: None.

Key results

  • 98.5% of patients on inhaled controlled therapy took an MDI prior to the formulary change, compared with 60% after the change.
  • Among 24 patients who changed to a DPI:
    • Average FEV1 decreased from 99% to 89% postchange.
    • FEF25%-75% decreased from 89% to 77% postchange.
  • No statistically significant changes in lung function were observed among children who remained on an MDI.


  • Retrospective review.
  • Physicians not blinded to patient's medication list.

Expert commentary

  • In a press release, Victor Test, MD, Co-Chair of the CHEST Scientific Program Committee and Professor at Texas Tech University Health Sciences Center, was quoted as saying, “This study demonstrates that formulary-dictated changes in inhaled corticosteroids decreases control of asthma and raises the following question: Are changes in formulary driven only by financial concerns appropriate in patients with asthma?” Dr. Test was not involved in the study.