For patients with chronic obstructive pulmonary disease (COPD), the Global Initiative on Obstructive Lung Disease recommends long-term term pharmacologic and nonpharmacologic therapies based on each patient's symptoms and disease severity.
Yet even the most effective drugs work only when patients take them as directed, and according to the World Health Organization, fewer than half of all patients worldwide are fully compliant with long-term COPD drug regimens.
And as a recent cross-sectional study showed, nearly one in six patients in the United States reported missing a COPD drug dose, lowering the dose, or delaying filling a prescription for financial reasons.
"I care for patients with COPD as their pulmonologist, and this is a very common problem that we see in clinical practice," said Meredith McCormack, MD, a pulmonary and critical care medicine physician and Associate Director of the Pulmonary & Critical Care Medicine Division at Johns Hopkins University in Baltimore.
Dr McCormack, who is also a national spokesperson for The American Lung Association, said that she shows new patients the photos of all available inhalers and asks which ones they have and how they take them.
"I would say that a majority of the time people are taking their medicines slightly differently than prescribed, and often, this is due to cost," she said.
Serious Consequences
Cost-related medication nonadherence (CRN), as investigators term it, can have major health effects and can be significantly more costly in the long run due to increased hospitalization rates, higher morbidity, and greater risk for COPD-related death associated with suboptimal care.
"For some patients even a month or two of being off medications increases the risk of having exacerbations, having more symptoms, [and] having a decline in their lung function," said Douglas M. Beach, MD, a pulmonologist at Beth Israel Deaconess Medical Center in Boston.
In the aforementioned cross-sectional study, published in the open access journal BMC Public Health,Xin Wen, MD, from the Jiamusi (China) University School of Public Health, and colleagues looked at data on a representative sample of US adults who participated in the US National Health Interview Survey from 2013 through 2020.
The sample included 15,928 persons aged 18 years or older with a self-reported history of COPD who completed a CRN survey including the following questions:
"During the past 12 months, have you
…skipped medication doses to save money?"
…taken less medicine than prescribed to save money?" or
…delayed filling a prescription to save money?"
The investigators found that a weighted 18.56% of participants representing 2.39 million persons with COPD answered "yes" to one of the questions.
Translated into representative population numbers, that works out to an estimated 1.61 million persons with COPD missing doses, 1.72 million taking lower doses than those prescribed, and 2.03 million delaying filling prescriptions to save money.
A multivariable logistic regression analysis showed that those who were most likely to be nonadherent for financial reasons were patients younger than 65 years, women, persons with low family income, those who lacked health insurance, and patients with multiple comorbidities, the authors found.
Financial Barriers
One of the biggest barriers to COPD medication adherence is, somewhat paradoxically, insurance status, particularly Medicare, said Corinne Young, MSN, FNP-C, FCCP, from Colorado Springs Pulmonary Consultants.
"What's so unfair about Medicare is that patients have to buy a drug plan, so they have to already pay for an extra plan to have access to drugs, and the plans vary because there are so many choices," she said in an interview.
Elderly patients may be confused about the available options and may choose the Medicare Advantage plan with the lowest monthly premiums, which have the highest annual deductibles, usually in the $5000-and-up range, she said.
In addition, the Medicare Part D prescription coverage gap, commonly known as the "donut hole," requires patients to pay a percentage of drug costs above a certain limit ($5030 in 2024) until a yearly out-of-pocket limit (currently $8000) is reached, after which the plan will again pick up most of the costs.
Although makers of inhalers have voluntarily agreed to limit monthly co-pays to $35 for uninsured patients, Medicare plans require insured patients to shell out considerably more, with 30 days of Trelegy Ellipta (fluticasone furoate, umeclidinium, and vilanterol) setting patients back nearly $350 per month, according to a recent search of costs for a United Healthcare Medicare Advantage plan.
Chasing Lower-Cost Options
"I have a lot of patients who use Canadian pharmacies to try to get around it, and I have a lot of patients who make a trip to Mexico every year and load up. I have patients who don't take their inhalers as they are supposed to in order to make them last longer, and I have patients who take the inhalers of other family members," Ms Young said.
Humanyun Anjum, MD, FCCP, from Dallas Pulmonary and Critical Care in Dallas, Texas, said in an interviewthat when patients claim that a prescribed drug isn't working as expected for them, financial pressures may be partly to blame.
"When you investigate a little bit more, that's where things become a bit more clear, and the patient may say 'yeah, I stopped using this inhaler because it was costing me 200 bucks a month and I'm already on other medications,'" he said.
He noted that, when possible, he will steer patients toward discount prescription services such as GoodRx, which offers discounts at local pharmacies, or Mark Cuban Cost Plus Drugs, an online pharmacy which offers generic versions of Advair Diskus (fluticasone propionate/salmeterol) at a 100-50 mcg dose for $94.70, a savings of $307.30 over retail pharmacies, according to the company's website.
Dr Beach noted that Beth Israel Deaconess has a pharmacist embedded in the pulmonary clinic who can help eligible patients get financial assistance to pay for their medications.
"The influencing factors of CRN are multifaceted and necessitating more rigorous research. Health policy interventions focusing on reducing drug costs, delaying disease progression, preventing exacerbations, and reducing the risk of comorbidities may improve the economic burden of COPD and its outcomes," Dr Wen and colleagues wrote.
The study by Wen and colleagues was funded by grants from Chinese national and academic sources. Dr McCormack has served as a consultant to Aridis, Boehringer Ingelheim, GlaxoSmithKline, MCG Diagnostics, ndd Medical Technologies, and UpToDate. Ms Young, Dr Anjum, and Dr Beach reported no conflicts of interest.
