“In St. Louis, asthma is the greatest health care inequity, with African-American children having an incidence rate greater than 10x that of white children. Children in St. Louis are afflicted by rates of asthma 3x higher than that of the national average, and asthma is currently the leading chief complaint at St. Louis Children’s Hospital. Underserved communities face a multitude of issues that exist beyond the medical aspects of health care. And unfortunately, asthma is not only an issue due to its accompanying signs and symptoms, but for its pertinence well beyond its pathology.”

Tejas Sekhar is a graduate student.

He shares his story and discusses his KevinMD article, “Inhaler nonadherence and social determinants of health.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Tejas Sekhar. He is a graduate student, and he wrote the KevinMD article “Inhaler nonadherence and social determinants of health.” Tejas, welcome to the show.

Tejas Sekhar: Thank you for having me.

Kevin Pho: We’ll get to the article in a little bit, but first off, can you share your story and journey to where you are today?

Tejas Sekhar: Sure. I graduated from Northwestern University in 2020, and I’m now a graduate student wrapping up at Washington University. I’m an aspiring physician, and I also do some research at the intersection of social health, health disparities, asthma, as well as COVID. So there are a couple of different topics under my belt.

Kevin Pho: Wonderful. And regarding that intersection with your research, tell me how you got interested in that avenue.

Tejas Sekhar: I’ve always had a long-standing interest in social equity and social determinants of health. Being a student at the time when everyone was being sent home during COVID, I found a lot of great opportunities back home here in St. Louis to get involved with research, and through Washington University School of Medicine, there were a couple of different avenues that opened up for me. So I jumped on board to do COVID testing, to interview patients during contact tracing, and to provide help with those efforts. I also got involved with the pulmonary and critical care department to learn a little bit more about asthma, as well as to do some mixed methods, interviewing patients during that as well.

Kevin Pho: All right, so let’s talk more about that intersection between asthma and social determinants of health. It’s in your KevinMD article, “Inhaler nonadherence and social determinants of health.” Now, for those of you who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Tejas Sekhar: Sure. As I started interviewing patients and providers for my research with asthma, we were essentially interested in learning more about provider and stakeholder perspectives of asthma, as well as the latest recommendations that have come out from different governing bodies on asthma. So GINA and EPR-4 released the latest guidelines about new recommendations that can be done to combine maintenance and rescue inhalers into one form. With those recommendations, we’re seeing that these better reflect what the patient population is currently using.

A lot of times, patients in these mild to moderate asthma patient populations are forgetting to use their maintenance inhaler, and they just end up using their rescue inhaler chronically. That is an issue for a couple of reasons. It bears on their costs. It affects their refills and their insurance. So what we’re kind of seeing here is that these governing bodies, GINA and EPR-4, have sort of adopted and understood patients to be utilizing only their rescue inhalers, essentially. To ensure that patients are also being exposed to an inhaled corticosteroid, as with their maintenance inhaler, they’ve essentially combined these to create budesonide-formoterol combinations. These combined ICS-LABA inhaler combinations again better reflect what patients are actually doing in practice and are able to deliver them an ICS as well.

Kevin Pho: So tell us about some of the reasons why patients sometimes just rely more on their rescue inhalers rather than that maintenance steroid inhaler. What are some of the obstacles that prevent them from going that route?

Tejas Sekhar: Right. What we’re seeing from a lot of these interviews with patients is that oftentimes they just forget to take their maintenance inhaler. If you think about asthma as being this chronic condition, you have all these varying demographics. Some of the demographics that are involved are patients who might have comorbidities of dementia, or younger patient populations who aren’t necessarily taking inhalers or any sort of medication on a daily basis. For both of these populations, inhaler maintenance is a difficult thing, especially with those maintenance inhalers, because again, they don’t necessarily feel the effects of it, or they forget about the effects of it, because they might be feeling fine for a day or two.

But when you’re in an acute situation, you always remember to take your rescue inhaler, because you experience that flare, you experience the symptoms. With forgetting to take a maintenance inhaler, you might not feel those effects from one day to another. So that’s what we’re kind of seeing as some of those issues, as well as some sort of integration with their lifestyle. Maybe they might be in a rush in the morning, or maybe they have something in the evening, so they might forget to set aside a time to actually take that maintenance inhaler. And again, there are the reasons of maybe not feeling those symptoms when they’re a mild or moderate asthmatic patient.

Kevin Pho: Now, can you comment on the effects of cost? I think whenever I talk to my patients regarding prescribing a long-acting maintenance inhaled corticosteroid, or even now these albuterol inhalers, the cost of these inhalers is sometimes prohibitive for a lot of patients. So what does your research say about the cost of these inhalers?

Tejas Sekhar: Yeah, what we’re seeing here is that it really depends, at the end of the day, on the patient’s insurance formulary. Whether or not that inhaler is covered by it is essentially the reason why or why not a patient will use an inhaler. This reflects a difficulty for providers as well, as they constantly have to adapt to what these patients’ insurance formularies are and their different insurances. So they can’t necessarily always have a standardized practice from patient to patient. Even within similar social determinants of health, such as SES or geographical location, those things kind of somewhat go out the window when you have to consider the formulary as being kind of the gold standard.

But in addition to that, what we’re seeing is that, as you know, inhalers are expensive, but the combined approach might be more effective in the long run. If you think about these patients who are not taking their maintenance inhaler, and they might be using their albuterol, or the rescue, on a more chronic basis, that significantly drives up the price point. If they’re not actively managing the condition over the long term, they might be seen at the emergency department, for example, when they experience a flare-up that albuterol can’t necessarily handle. And if you do a cost-benefit analysis in the long run, which is something that we’re doing, we see that these patients are actively spending more, even with the coverage of their insurance.

So this combined approach, getting a maintenance inhaler kind of in the mix here, getting it actually into the patient’s system and ensuring that they’re using some sort of steroid or ICS, effectively brings down the cost in the long run, even though in the acute moment it might seem that this might be a more expensive option. But again, once you average that out over the longevity of how often patients are actually having asthma and using their inhalers, it ends up being a lower price point for them.

Kevin Pho: So just to be clear, tell me what the new recommendations are. Are we contrasting an inhaled corticosteroid maintenance inhaler with a combined long-acting beta agonist/corticosteroid inhaler? What are the data points between those two routes?

Tejas Sekhar: Right. What we saw in the data here, with GINA coming out with recommendations in 2019, is that you have the traditional approach. There’s the general step-up therapy, which is completely fine and advocated for. That is something that a lot of providers are still using, where you have your separate rescue inhaler and your separate maintenance inhaler. But what GINA is advocating for, because a lot of the patients, again, are forgetting to actually use that maintenance inhaler for a number of reasons, is that if you get something like Symbicort, which has a combined budesonide-formoterol basis, that’s a way of getting that inhaled corticosteroid into the mix, because otherwise patients effectively aren’t using it. So that’s kind of the new recommendation that we’re seeing with GINA.

Kevin Pho: And then that medicine, like Symbicort combined, that’s going to be used on an as-needed basis?

Tejas Sekhar: Exactly. Yes, it’s on an as-needed basis, even though what we’re seeing as well is there are some discrepancies with it being an off-label use. Even though GINA and other regulatory bodies are advocating for this, it’s still not an FDA-prescribed use, even though it’s been used for similar indications. So it’s technically off-label, but that’s, again, one of the challenges that we’re kind of seeing with interviewing these providers, and how they might be able to write the script in order to get the patient to use Symbicort on an as-needed basis.

Kevin Pho: Just from your experiences with interviewing various clinicians, approximately how many are using those combined inhalers, as you mentioned just now?

Tejas Sekhar: Yeah, that’s a great question. It really varies in what we see. We see some interesting trends across academic medicine versus community medicine. A lot of times, we see that maybe within academic medicine, providers are reading up on these guidelines a little bit more actively, and they might have a more relaxed patient population, or a more mild to moderate patient population that isn’t kind of seeing tons of specialists within an outpatient setting. We’re seeing that these providers might be a little bit more inclined to get into the mix here, to use that new GINA updated guideline and to use that combined inhaler.

But that’s not to say that community providers aren’t using this at all. It’s just that because they’ve been more set in their ways, because they’re a little bit more disconnected from the guidelines that are coming out, for various taxes being some of these issues, we see that they are a little slower to adopt this, or a little bit more reluctant or hesitant to adopt this, with good reason and good understanding for that. Because again, what they see in their patient population is ultimately what matters. If they have a patient that already works with their current strategy, there’s no reason necessarily to shift their strategy. This is, again, better for patients with mild to moderate asthma who are maybe a little bit more non-compliant or have a couple of other comorbidities that tend to make them forget to use this maintenance inhaler.

Kevin Pho: So you mentioned GINA a few times. For those who aren’t familiar with that organization, can you tell us a little about that?

Tejas Sekhar: Yeah. GINA is one of the largest governing bodies of asthma regulations. They push out guidelines every now and then, but they usually have an annual conference every year where they provide updates to the field of asthma.

Kevin Pho: And GINA being short for the Global Initiative for Asthma, correct?

Tejas Sekhar: That is correct, yes.

Kevin Pho: All right, we’re talking to Tejas Sekhar. He is a graduate student. He wrote the KevinMD article “Inhaler nonadherence and social determinants of health.” Tejas, what are some of your take-home messages that you want the KevinMD audience to come away with?

Tejas Sekhar: Yeah, so relating this back to my interest in health equity, and again, with the article being titled about social determinants of health, I think it’s really important for everyone involved here to step back at the end of the day and really think critically about that. As we’re thinking about these social determinants of health, we might leave certain patient populations as being nonadherent, or even non-compliant, for reasons that aren’t necessarily related to disposition. For example, you might think of a stereotypical patient who’s difficult to deal with, but the reality might be a little bit more complex than that and a little bit more multifaceted.

It might be for reasons due to insurance coverage, as we talked about, or due to the inability to pay, or a number of other reasons. Maybe the pharmacy is too far away from their house, or maybe they have a ton of other factors going on in their daily life, so that adding another thing like a daily asthma inhaler to use might not be the right fit for them. Maybe they might require some sort of other intervention. So I think as we think about nonadherence, we need to think about, and continue to research, the reasons why this might be the case, without stopping the ball at just the level of the patient’s involvement here. We have to think about the reasons that go and extend beyond that.

Kevin Pho: Tejas, thank you so much for sharing your time and insight, and thanks again for being on the show.

Tejas Sekhar: Thank you.