Decision to improve access to budesonide with eformoterol inhalers

All-at-once dispensing of budesonide with eformoterol

Support for the proposal

Supportive, not having to collect budesonide with eformoterol every month and risk running out is very positive.

Monthly dispensing can be prohibitive for patients with transport, financial or mobility issues, and people run the risk of having no asthma reliever medication on hand.

Enhancing access to budesonide/eformoterol will facilitate the implementation of the New Zealand adolescent and adult asthma guidelines.

The widespread uptake of ICS/formoterol reliever and/or maintenance therapy in adolescents and adults with asthma in New Zealand has been temporally associated with a reduction in hospital admissions for asthma, particularly in Māori. The proposal will likely lead to further reductions in hospitalisations for asthma, and further reduce inequities in asthma outcomes.

We are pleased to be able to progress a decision that supports access to medicines and the implementation of the New Zealand adolescent and adult asthma guidelines,(external link) reduces inequities, and improves the health outcomes of New Zealanders.

Supportive, respondents suggesting following the Australian model and having these inhalers available over the counter with no requirement for a prescription.

We note that the Australian model for accessing budesonide with eformoterol inhalers differs to New Zealand model. However, making the suggested changes requires a change in prescription classification which is not the role of Pharmac. At this time, we are not looking to propose any additional changes to access.

Do not support all-at-once dispensing

Medical waste is likely to increase as a result of enabling all-at-once dispensing, as the number of unused inhalers that are dispensed will inevitably increase

We acknowledge there could be an increase in inhaler usage as a result of this decision and have taken this into account as part of our assessment.

Our assessment is that this decision will improve adherence to treatment helping to reduce the number of severe asthma exacerbations, which will benefit the health of many New Zealanders.

Monthly dispensing allows regular intervention to ensure adherence, inhaler technique and patient safety and this proposal would reduce this oversight.

Pharmac acknowledges the important role pharmacists have within the health system and appreciate the value that regular intervention has in ensuring someone can use their inhaler appropriately and effectively.

As part of this decision, we still expect nearly all dispensings will occur at community pharmacies. While we are not aware of any data that describe how frequently people currently receive support for their inhaler technique, we note that there will be an opportunity every three months to support adherence and safety.

Negative impact on financial operations of community pharmacies and poorer inventory control.

Stat dispensing would result in a loss of dispensing fees.

While we acknowledge that this change may result in a loss of revenue for community pharmacies, it will also likely reduce the workload required to dispense these medicines.

We note that there are many other medicines that are currently available dispensed as stat and/or on a PSO, including other inhalers, and consider that pharmacies are experienced at managing stock in these situations.

We have shared this feedback with HNZ, which is responsible for managing contracts with community pharmacies for dispensing funded medicines.

Other Funding Requests

Stat dispensing should be extended to all preventer inhalers

Pharmac is only making changes to some presentations of budesonide with eformoterol inhalers at this time. This is to align with and support implementation of the New Zealand adolescent and adult asthma guidelines,(external link) that outline the use of budesonide/eformoterol inhalers for symptom relief in a similar way to salbutamol (which is currently available on stat dispensing). This is in line with the clinical advice we have received.

Budesonide with eformoterol on a PSO

Support for the proposal

Supportive, respondents noted prescribers need to be able to access budesonide/eformoterol 100 mcg/6 mcg and 200 mcg/6 mcg inhalers in a clinical setting for a number of reasons: 

• Initiating AIR therapy and providing demonstration of the correct inhaler technique.
• Initiating AIR therapy in an After Hours/emergency setting if a patient is having a serious or life-threatening asthma exacerbation and is too unwell to travel to a pharmacy to have their inhaler dispensed.

We are pleased to be able to progress a decision for widened access to medicines that will improve the health outcomes of New Zealanders.

Do not support budesonide with eformoterol on PSO

Raised concerns with lack of individual patient records when medicines are supplied by PSO. Notes that shared digital records are fundamental for accessing vital information when required.  Considers that supply not being linked to an individual through a centralised patient record poses risks to patient safety and care continuity.

Pharmac recognises the important role pharmacists have in patient care, including clinical review, patient counselling, safety checks and adherence support.

The purpose of the PSO mechanism is to ensure that stock is available for all general practices for:

• emergency use,
• teaching and demonstration purposes,
• where an individual prescription is not practical

It is anticipated that only a small fraction of total use of budesonide with eformoterol (around 5%) will be from inhalers accessed via a PSO, largely for teaching purposes.

We note that salbutamol is currently available on a PSO and we consider that budesonide with eformoterol should be similarly available as it is the recommended reliever treatment for a considerable number of people with asthma as per the asthma guidelines.

Considers that there is currently no place for budesonide with eformoterol inhalers in the emergency management of acute severe asthma. Salbutamol via a metered dose inhaler or nebuliser remains the recommended treatment depending on severity.

We acknowledge that salbutamol offers a suitable treatment option for certain people in an emergency setting.

The evidence-based New Zealand adolescent and adult asthma guidelines, along with our clinical advisory committee, recommend budesonide with eformoterol as the preferred inhaler reliever therapy, rather than salbutamol inhalers or an alternative short-acting beta-agonist inhaler. Having this formulation available will not preclude the use of nebulised salbutamol where appropriate.

Dispensing via a PSO will result in a loss of dispensing fees and medicine margin.

We acknowledge that community pharmacies are reimbursed for dispensings and have discussed this issue with the Pharmacy Guild. Our analysis is that enabling PSO is likely to have a neutral financial impact as community pharmacy will still receive a dispensing fee.

The vast majority of inhalers are expected to be dispensed at community pharmacy.

Equity is a foundational principle of the health system, yet shifting inhaler access to clinics under PSOs could unintentionally disadvantage groups already experiencing barriers to care.

Pharmacies are often embedded within the communities they serve, allowing them to provide culturally appropriate, low-barrier services that support whānau in a way that traditional models of care may not.

Pharmac recognises the important role pharmacies hold within their communities and the health system. These changes are being made to provide people with greater access to their asthma treatments, with their community pharmacy still playing a critical role in providing care. Our clinical advisors have indicated that enabling ‘all-at-once dispensing’ and enabling access via a PSO will improve equity of access through reducing barriers, allowing people to better adhere to treatment guidelines.

Pharmac staff note the PSO form only allows for one inhaler to be provided at a time and isn’t intended to replace how people receive their regular prescriptions for budesonide with eformoterol inhalers.

Other Funding Requests

Propose that all ICS/LABAs be made available on PSO

Pharmac is making these changes to only some presentations of budesonide with eformoterol inhalers at this time to align with and support implementation of the New Zealand adolescent and adult asthma guidelines(external link), where our clinical advisors have recommended budesonide with eformoterol inhalers be funded for stat dispensing and on the PSO.