It is now more than 12 years since the long-acting beta agonists (LABAs) became available in Canada for the management of asthma. When these medications, which include salmeterol (Serevent) and formoterol (Oxese), were first assessed by Pharmacare, they were made available for physicians (other than respirologists and allergists) only with Special Authority approval. At that time, the reason given for this restriction by Pharmacare was that there were not sufficient data to approve full coverage.
Since that time evidence of the efficacy of LABAs in the management of all but the mildest asthma has been demonstrated in dozens of studies, including a Cochrane analysis. The data and experience is so persuasive that their use is recommended in almost every set of asthma guidelines available, including the Canadian ones and the GINA international ones. Research has shown that the “number needed to treat” to prevent a hospital visit is as low as four!
Over the last 10 years or so there has been an increasing body of research demonstrating efficacy of these medications for COPD as well. Recently the results of the TORCH trial were published in the New England Journal of Medicine. This was a large 3-year trial of fluticasone/salmeterol (Advair) in patients with moderate to severe COPD. This trial showed a clear benefit for patients in quality of life, preservation of lung function, and decreased exacerbations, plus a trend to decreased mortality. Since exacerbations are the major cause of decreased quality-of-life for individuals with COPD, anything that can decrease there frequency is welcome. Recovery from an exacerbation takes 2 to 4 months, and 10% to 20% of individuals hospitalized for an exacerbation never leave hospital. Exacerbations of COPD are a major cause of hospitalization, with the average length of stay being 10 days—at a cost of $8000 to $10 000 per day. In recent years, there have been approximately 7000 admissions for this in BC alone. Therefore, decreasing their frequency also has a large economic benefit for the medical system.
Why then, are the LABAs still not a full Pharmacare benefit? When I asked a Pharmacare official recently, I was told that it was because the companies likely had not reapplied for coverage since the drugs were first marketed in BC. Having difficulty believing this, I asked one of the companies involved and was told that they had reapplied many times over the years, most recently in October 2006. Since the company has an inherent advantage to having the medications covered and Pharmacare has a financial incentive to keep their coverage limited, I tend to believe the company’s side of the story. Unfortunately, the money saved by Pharmacare not covering the LABAs is spent many times over elsewhere in the medical system.
I call on Pharmacare to respond to the large body of scientific evidence and provide coverage for LABAs to patients with asthma and COPD. If the benefits in improved quality-of-life for patients and decreased use of scarce hospital resources are not sufficient, surely the financial benefit for the medical system as a whole should be sufficient reason to make this change.
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