Dr J. Allen Meadows Discusses Adherence to Biologics for Asthma

Despite the price, adherence to biologics for asthma is usually good because of the effectiveness, said J. Allen Meadows, MD, president of the American College of Allergy, Asthma & Immunology, a solo community-based practitioner at the Alabama Allergy & Asthma Clinic, and a clinical faculty member at the Alabama College of Osteopathic Medicine.

Transcript

Do you run into any challenges with prescribing biologics for patients with asthma?

I see a lot of patients that are frustrated, because when you're talking about a biologic, you're talking about something that's a big investment for society. And I've had a patient who actually was a personal friend and colleague, who had declined biologics because of how expensive they were. And not because of how expensive they were to him, but because of how expensive they were to society. And this gentleman had a life-threatening asthma. I mean, we have episodes that frighten me, and bad chronic rhinosinusitis with Nasal Polyps. He didn't have eczema, but I just knew that a biologic was going to be life altering for him.

And I don't give out my cell phone number to patients. But this person had my cell phone number, called me at home on the weekend after being on dupilumab for, I don't know, a couple of months, and he says, “Alan, this has changed my life. I can't believe I didn't listen to you sooner about that.”

And you have many conversations with patients that start that way, whether they're in the office, or somebody that called you to make you a real believer. You know, prescribing biologics, for those of us who are allergist and asthma doctors is an expensive proposition. I've got an RN [registered nurse], that I hire the shepherds over all my patients in getting these drugs approved.

You know, one of the conversations I have in the shared decision making with patients is that “if you want this biologic, and you're going to get it, I'm glad to get approved for you. But where we're going to have a parting of the ways is if I have my staff spend 4 or 5 hours getting this drug approved, and then you change your mind. We're not doing that. All right, I don't want you to make a decision until you have made up your mind that this is the right drug for you.” And if we get it approved, because literally, we spent hours doing that—it's completely unreimbursed.

But I love people I went into medicine because I wanted to see people with asthma to stop suffering needlessly. And now that we have the biologics, I have an RN who is very good at getting things approved, she knows the angles. When she runs into a problem, she talks to me about it. And in fact, after I've done shared decision making, I can think of one patient who qualified for all of them. And what he said was “whatever I can get the quickest. You know, I'm tired of feeling this way.” And so, I went to the RNs and say, “Okay, here's the profile, you know, here can we get the approval the quickest and the easiest?” And so, it's different with different patients.

Is nonadherence a concern given the cost of biologics?

Well, you know, certainly adherence is an issue with any medicine. And a lot of times you know, you find your patients with severe asthma and you think would be most adherent are least adherent. Fortunately, we are beginning to have some medicines that sync with your phone, so that maybe we're going to have a better idea about that with the auto refill programs at pharmacies. You know, somebody could have a load of their prevention medicine in their house and you might not know it, but drugs for these patients are so life altering the adherence is great.

I'll tell you the reason there is nonadherence, it's almost solely economic. When the co-pay cards run out. I had one patient that really had a life-altering response with chronic sinusitis with polyposis and asthma, with dupilumab, and they made a mistake with their insurance. They gave us 2 insurance cards, and one of them wasn't active. And, you know, the substance remained that they had these 2 cards and ended up with a big bill. Now, wasn't my fault. And I'm really, really, really sorry about it. But you know, he elected to go off the medicine.

You know, I've had some patients with high-deductible plans where the co-pay cards run out. And they go out, you know. Certainly, now that we've got more than one biologic for asthma, pharmaceutical companies are happy to supply us with samples. And so sometimes in those patients, we can, you know, supplement them with that if it's only a month or two that they're going to be out of at the year.

But by and large with the biologics, I found that patients you know, want to be adherent. I had a I had a conversation with a young lady who was on Dupixent, dupilumab, and I cut her off. I said we're not going to do your recertification for it until you come into this office and we can see you. She’d been no shows for multiple virtual visits—no show for a virtual visit, which is in my practice, very rare.

One patient population, the Medicaid population, our show up rate in person is about 30%; on the virtual visits over 90%. But this one was a multi no show for virtual visits. Yet when I got her in, she wasn't taking any of our medicines, right, except for her biologic. And she was taking it completely right. And that's how I got her in because I wasn't going to recertify or for her for her biologic until she came in for the visit. And really, she had actually had eczema, not asthma. But I say, “Listen, I've got to look at your skin.” And you know, we were set up a virtual business on videos and she didn't come and so we finally say, you know, “you got to come.”

And you know, when we took the history and looked at things and looked at the refill persistence, and the only thing that she was doing was her biologic. And so, we've had a coaching session. In fact, immediately before I jumped on this this video, I got on the fax machine message it had been reapproved.

So, that's been my experience with adherence to biologics. It's usually good. And when it's not good, it's economic.