Leah J. Witt, MD: Hello. I'm Dr Leah Witt. Welcome to season one of Medscape InDiscussion, chronic obstructive pulmonary disease (COPD) podcast series. Today we're talking medications, especially inhalers and COPD; everything from correct use, cost, and tips for prescribing. I am beyond excited to welcome my friend and today's expert guest, Dr Amber Lenae Martirosov. Dr Martirosov is an ambulatory care clinical pharmacist at Henry Ford Health and an associate clinical professor at Wayne State University. She describes herself as a huge advocate for patients. She practices in an outpatient clinic, where she improves patient outcomes by focusing on getting patients the right inhaled medication at the right price. Welcome to the Medscape InDiscussion podcast, Amber.
Amber Lenae Martirosov, PharmD: Thanks for having me, Leah. It's great to be here.
Witt: We've talked a lot about this topic, and we're going to get into it. Before we do, I want to kick off the episode by getting to know you. What is on your mind outside of medicine?
Martirosov: I've been doing this new thing that I call revenge reading, where I stay up too late reading books because I want to be able to read books. I'm currently reading The Wager, which is a really fascinating book about potential mutiny aboard a ship. It's a really good book. I would recommend reading it.
Witt: I'm revenge listening. I haven't gotten to reading because I fall asleep too fast, but I love podcasts. I started listening to Emily Oster's ParentData podcast. She's an economist who dives into the data about pregnancy and parenting. She has a podcast, and I was just listening to the episode where she interviewed Eve Rodsky, who wrote Fair Play. I highly, highly recommend. She takes such a scientific approach that I think anybody who's in medicine could really appreciate that approach.
Let's get into our case. I'm going to keep our patient the same as in the last episode, and we're going to talk about Mr Rivera. Today, we're talking about medications, especially inhalers. He's a 78-year-old man. We diagnosed him with COPD last episode. He was hospitalized with a COPD exacerbation.
You're seeing him for the first time in your pulmonary clinic to talk about medications. He was discharged from the hospital with a tiotropium soft-mist inhaler (SMI) and albuterol. There was a meds-to-bed initiative. He got the medications, but he doesn't know how to use them. I want to start by asking you, how do you approach that first post hospital follow-up visit?
Martirosov: This is an important question to consider, especially from a provider perspective. One of the things that we see commonly with inhalers is that patients will get inhalers, and either the provider doesn't educate the patient or believes that the patient will be educated when they get to the pharmacy.
This is a missed opportunity for education. We're often seeing these patients say, "I don't know how to use these devices." It's important to understand with this patient specifically that tiotropium SMIs requires the patient to put it together.
It's not packaged in a box that's ready to go. The patient must do some work to assemble it. When I first see these patients, the first question that's always important to ask is, "What inhalers have you used in the past? Can you tell me about how you use them?" If they have not used inhalers, then the next question I ask is, "What do you think you should be doing with this inhaler?" We can start with the knowledge they have and build on that. We then systematically go through the different steps of appropriate use of the different types of inhalers. We go into those nuanced details. When should they be holding their breath? When should they be blowing out their nose? We talk about things like that.
Witt: We have a secret love of both inhaler technique and Medicare Part D. We'll get into that in a second. I want to talk about the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, the holy grail of COPD management, which now recommends for group E, that's the high exacerbation group that he's in because he was hospitalized for an exacerbation, to start a long-acting beta-agonist (LABA)–long-acting muscarinic antagonist (LAMA). This is the same as group B, which is defined as high symptoms and a moderate number of exacerbations. Why do you think that is? Why do the GOLD guidelines suggest going right for the LABA-LAMA initially?
Martirosov: This taps into the pharmacist brain because we're going to talk about pharmacology. When you think about the way that LABAs work and the way that LAMAs work. They are both bronchodilators by nature, but they are targeting different receptors. The LAMA has an added benefit of targeting muscarinic receptors, which then would cause a little bit of anticholinergic effects.
When we combine a LABA with a LAMA, we get this phenomenon known as dual bronchodilation with the added bonus of a little bit of that antimuscarinic effect. This is fantastic for your patients with COPD who we know are going to have some limitations in their breathing and need that bronchodilator to open those airways.
We know that in COPD, these patients are oftentimes going to have a lot of mucus. Now, not only are we opening up those airways, but we are getting an antimuscarinic in there that's going to help to dry up some of that mucus so that the patient either is able to clear it themselves, or the body will naturally take care of the rest.
Witt: Our patient left the hospital with just a LAMA. Would you switch him right away or would you wait and see how he does?
Martirosov: I would ask a couple of questions, but my short answer is yes. We need to switch him because that's what's actually going to benefit this patient. Given the fact that he's already had an exacerbation that led to a hospitalization, we are trying to do everything we can to prevent future exacerbations because that means future worsening of overall lung function.
The short answer is that we want to switch him. But before we do, I want to make sure that he is able to even afford the tiotropium he got on the first round. Then, I would like to assess his ability to use the inhalers before I decide which of the combination therapies I want to switch him to.
That's so important to think about when switching therapies and devices. If your patient couldn't use the first device, you're setting them up for failure because they're not going to be able to use the new device that you give them, even though you're giving them the correct drug therapy.
Witt: What are some of the device delivery options and how would you assess what to give him?
Martirosov: We always have to think about three different types of devices, and then we throw nebulizers in on the back end. Our historic albuterols have always been what we call a metered-dose inhaler (MDI). Then we have dry-powdered inhalers (DPIs). Many people are going to think of the Advair or (the fluticasone propionate–salmeterol Diskus).
Then we have the newer class, which is actually what this patient was prescribed; SMI. Now, I want to make a quick note. I said three, but within the MDI category, the QVAR RediHaler [beclomethasone dipropionate HFA], and it's the only one of its type, is actually what we call a breath-actuated inhaler.
It operates just like a MDI, but instead of the patient having to depress a canister, the canister will naturally depress as the patient inhales. It is a breath-actuating canister depression that it administers it. It is the only device like that. It technically falls under a metered-dose, but just want to make sure our audience is aware of those differences.
One of the things that's really important when we think about these different devices is the breath technique. This morning, I had a conversation with one of our respiratory therapists (RTs), who's been an RT for 40 years. She said, "Wait, we don't use MDIs quick and fast?" And I said, "Actually that's the worst way to use them." If you think about a MDI or a breath-actuated inhaler, there is a forceful spray behind that. If the patient matches that with a forceful and quick inhalation, the only place that medication can go is to the back of the throat. What we want our patients to do is create a very soft breath. When they start to inhale, we don't even want it to be audible. It should be just like a normal respiratory effort, slow and steady. They should press the canister for about 1-2 seconds after they've started to inhale and then continue that inhalation process for as long as possible. That's different from a DPI. With a DPI, we have this powder that we have to aerosolize. With that device, what we actually want our patients to do is take a very deep and steady breath. Their breath should be audible, but it needs to be steady enough that the patient can inhale for about 4-5 seconds to ensure that that medication will deposit within the lungs.
With those SMIs, the technique should be identical to that of what we would use for the MDI. That very slow, steady, not audible breath for as long as possible.
Witt: It's hard for patients to understand all the technique differences. It's not something that I learned in training. Learning yourself and training yourself is really the first step. I know that in pharmacy school, you get a lot more education about that. I'm sure you've had a lot of experience teaching other doctors about how to use inhalers. What have you seen? We're terrible, right?
Martirosov: I work in a pulmonary clinic, and every year, I test our fellows. In 10 years of practice, I can count on one, maybe one and a half, hands how many of our fellows have gotten it correct with their inhaler technique. That's important to talk about because these are pulmonologists, they're trained to be able to educate patients. There are a lot of different devices, and there's a lot of things that physicians have to master. Asking them to then get inhaler technique right and being able to classify these devices the correct way so that they can educate correctly, that's intimidating. It also may not be something physicians want to spend their time on, when they have other diagnostic things to consider to ensure that patients get the best care.
There are some great tools, though, that you could easily use. There are some great apps that you can download on your phone that make it easier for you as a physician to just pull out your phone and say, "Hey, let's look at this together to make sure that we're doing this correctly."
There are also good resources through the Asthma & Allergy Network, which give you a nice picture of all the different device types and explains whether it's a MDI, breath-actuated inhaler, DPI, and things like that. There is also a new one through the American Lung Association.
There are some tools that you can use to assess whether or not your patient can use their inhalers correctly. Currently, there are two that have been studied. The first one I'll talk about is the Vitalograph Aerosol Inhalation Monitor. What's nice about this is you can use it to train your patients on the correct breath technique. You can also use it to assess them.
If they're not able to correct that technique after multiple education attempts, then that tells you that they need to switch to a different device. The second device that we can use is only going to help you assess inspiratory effort, and whether or not your patient is going to be able to generate enough flow to aerosolize the product appropriately. That device is called the In-Check DIAL.
Witt: The app that I love is the COPD Foundation app. They have a list of inhalers that you could choose by category, and then in the app, but also on YouTube, they have videos that you can share. This highlights how important the interprofessional team is because we all educate ourselves as much as we can. For example, we rely on you as a pharmacist in the clinic, or our advanced practice providers who are skilled at teaching patients about device use. It's so important. Do you have any idea of what you would recommend for our patient, Mr. Rivera? In the second part of the case, I chose one. If he had arthritis, for example, or cognitive impairment, how would you think about that?
Martirosov: I'm a big fan of the SMIs because it is such a nice delivery device for patients that might have advanced COPD. They may lack inspiratory effort. That soft mist replicates a nebulizer machine so we can ensure that the patients are getting more deposition into the lungs.
It comes back to whether the patient can put it together. If this patient has arthritic hands and isn't able to open the device to put the actual canister in and then twist it to be able to administer the dose, that's a problem. In that case, we would probably want to switch them to an alternative agent.
I find that some of my big, barreled-chest patients are great at that deep, steady breath. But then, when I ask them to slow it down, they say, "I don't know what you're talking about. I don't know how to do that." In that patient, where I can't get them to do that very slow, not audible, steady breath, I'm probably going to want to switch to a DPI. I know that DPIs, in this patient, is likely going to get better absorption down into the lungs vs the back of the throat. We would get the back of the throat deposition if this patient was using an SMI or that MDI, because they're using that very deep, breathy, inhalation technique.
Witt: Let's continue the case. Perhaps this hospitalization happened at the end of the year. Mr Rivera sends you a MyChart message in January. This is the beginning of the year on his next refill, you switched him to a LABA-LAMA, a low tiotropium-olodaterol SMI. He says his out-of-pocket cost is $450. He chose a Medicare Part D plan during open enrollment years ago before he had any medical problems, and he hasn't changed it since. He chose it based on the lowest monthly premium, but it has a high deductible. He asks whether you have any advice for him. I'm the medical director of our clinic. I see this every January, and I get a lot of questions like I don't understand why are the costs so high? Where are we getting so many medication rejections messages from pharmacists? Can you explain what's happening?
Martirosov: This is Medicare in a nutshell. We have three parts of Medicare that really cause problems for us as providers. The first is January, when the Medicare cycle restarts. If a patient has a deductible, that deductible will be due in January, which means when they go to pick up their high-cost drugs, typically brand-name drugs, they will be responsible for paying that deductible before they are able to get whatever their insurance pricing is.
I would bet money that this patient is in that initial coverage phase. Because of that, he is now responsible for this high deductible before his insurance will cover the cost of that drug for him. Then, he's going to get into a stage where he's going to be great, maybe he'll be able to afford it, maybe he won't.
I suspect that he's probably going to struggle if he picked an insurance plan based on the lowest premium, because oftentimes the lowest premium means the highest out of pocket costs for our patients. He'll be in what we consider like the coverage phase where maybe he only has to pay $45 for that brand name inhaler, or maybe he has what we would call a co-insurance where he's responsible for 20% or 30% of the average wholesale price.
What happens, though, in a lot of these patients, especially patients who pick their insurance plans based on the lowest premium, is that toward the later part of the year, usually August, September, if they are on a lot of high-cost drugs, they're going to enter what we call the coverage gap or that donut hole. That's a term many of you are probably familiar with. Now, the costs go up again, and that's because the patient has reached their maximums that the insurance have set, in terms of drug costs or other costs. The patient is now responsible for a larger share until they can get themselves out of that donut hole and into what we would then call catastrophic coverage. Leah, we have talked about Medicare. You and I are both very passionate about how we all need to understand this better. We need to be able to better educate our patients on this so that they can make better informed decisions, but it's such a hard thing, especially in the pulmonary world, because we have so few generics that we can rely on. More so than a lot of other, disease states and organ systems, we see a lot of issues with the Medicare plan coverages because we don't have generics to fall back on, so that we can provide our patients with different options.
Witt: So much changes year to year. This year, in 2024, there are good changes. The Inflation Reduction Act that was passed in 2022 is starting to lower some costs. It's eliminating the cost sharing for drugs in the catastrophic phase of coverage. Functionally, the cap is going to be around $3300 dollars, and then 2025, the cap will be $2000 dollars. That will help. But just like you said, planning for January is so important. Then, there are formulary changes, where the inhaler that a patient was on the previous year may not be the preferred inhaler. That's so hard and so disruptive.
Martirosov: To add to your point this year, that disruption was even worse. In late December, we found out that Flovent is no longer going to be available, but then all these formularies for January 2024 said that Flovent is their preferred inhaled corticosteroid. But wait, it's not available.
What do we do? At least in my clinic, it required a lot of prior authorizations because we had to figure out what was going to be covered or wait for them to come out with new formularies. I agree, the formularies are difficult. Understanding Medicare Part D as a collective whole is difficult.
Some of the Inflation Reduction Act is going to make a big difference, and overall, when we think about the Affordable Care Act, one of the goals was that it was going to shrink down that donut hole, that coverage gap, and it slowly but surely has. We've seen legislation about insulin and things like that, but we still have a long way to go before we make a difference in our pulmonary patients.
Witt: Do you have tips? This medication could easily be on his formulary, and his out-of-pocket cost is just high because he hasn't reached his deductible yet. Is there any way to know for sure, when you send it to a pharmacy, if it's going to be on the formulary? Are you counseling people in advance that it might be expensive? How do you navigate that?
Martirosov: It's a hard thing to navigate. One of the things you can do is trying to be aware of the resources are available to you. There are a couple of different websites like CoverMyMeds. These prescription websites will give you an idea of what the formularies are. The problem is that they are never 100% accurate because formularies change.
One Blue Cross Blue Shield insurance card, depending on which patient it's going to, may have five different formularies. The first thing is educating your patients. You brought up a good point, talking to the patients and saying, "Hey, these medications can be expensive. Don't hesitate to call me or call the clinic if it is expensive so that we can then intervene on your behalf." That's number one. Number two is being willing to try to see if there are drug assistance programs through the manufacturer. Something like tiotropium-olodaterol is still brand-name only. As such, there is federal legislation that even for your Medicare patients, while they're in the coverage gap for Medicare Part D, you could potentially get that patient free drug from the manufacturer for the rest of the year, which is a big win.
It's something that we have done in my clinic successfully for a very long time. I'm not always the biggest fan of things like GoodRX or shopping around, but if your hands are tied, you have to do the best that you can with potentially using GoodRX or, you know, some equivalent to that website. You might be able to say, Hey, your insurance is going to be, $400.
But if you pay cash price at this store with this coupon, it's only $120. Sometimes that is enough to make a difference. The last thing that I will mention, which I don't blanket say that we should do for our patients, is there's always nebulized solutions.
Here's the tricky thing with nebulized solutions. You have to determine whether or not the patient is covered by Medicare Part D vs Medicare Part B. With Medicare Part B, the patient often has a 20% coinsurance, which is oftentimes much cheaper than that deductible or whatever they're required to pay in the donut hole.
However, that doesn't always apply for our LAMAs or LABAs because they're brand-name only. So sometimes, if there is a patient with Medicare Part B vs D, and at your very worst, you have to get your patient something, there is always the alternative of putting them on short-acting beta-agonist and short-acting antimuscarinic, like ipratropium, but then scheduling it so that it's used around the clock like it's a long-acting agent. It's not perfect, but when you're desperate, you have your work around. It's an option. It's not the best option, and I would reserve it only in your patients where you're desperate to do something,
Witt: Thank you so much for reviewing this. There's always so much to learn. The last thing I always encourage people to do is review their Part D plan every fall during open enrollment. There's a really good website called Medicare Plan Compare. You can put in your medications and see what the best plan is for you. There are programs, in my area, and I think it might be federal, but I'm not 100% sure. There's a health insurance counseling and advocacy program where you can meet with somebody like a counselor to help you pick a good plan. Do you have that in your state?
Martirosov: Yes. I think it's a statewide requirement. They're great resources for patients.
Witt: I could talk to you all day about this, but we have to wrap up. Any key points that you want to leave our listeners with or resources they should check out?
Martirosov: I would just belabor the point that I always belabor, which is if you don't feel comfortable using inhalers, how can you expect your patients to do it? Please educate yourself so that you can then educate your patients and make a world of difference.
Witt: I feel the same way about understanding Medicare. COPD is a mostly a chronic disease in people who are likely on Medicare. There are some exceptions, but I think it's so important to understand the basics of Medicare Part D so you can talk to patients about why their costs are what they are and help brainstorm with them about reducing costs. Thank you so much again, Amber. Today we've talked to Dr Martirosov about inhaler choice and barriers to use, including high cost of care, my secret favorite topic in medicine. There is nothing more I love then nerding-out to Medicare Part D. Thank you so much for joining us. Take a moment to download the Medscape app to listen and subscribe to this podcast series on COPD. This is Dr. Leah Witt for the Medscape InDiscussion Chronic Obstructive Pulmonary Disease podcast.
Resources
Global Strategy for Prevention, Diagnosis and Management of COPD: 2023 Report
Nebulized Therapies in COPD: Past, Present, and the Future
Advair
QVAR RediHaler
Asthma & Allergy Network
American Lung Association
Optimization of Patient-Specific Inhaler Regimens With the Use of the Aerosol Inhalation Monitor
Guiding Inspiratory Flow: Development of the In-Check DIAL G16, a Tool for Improving Inhaler Technique
The COPD Pocket Consultant Guide Mobile App
CoverMyMeds
GoodRX
Medicare Plan Compare
This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
