April 17, 2024 – Across the U.S., warmer days have beckoned an earlier spring, and with that, an earlier pollen season and worse seasonal allergies. Pair that with an ongoing respiratory virus season – particularly influenza A and B – and insurance and regulatory issues that have created barriers for patients to get inhalers in 2024, making this a tough time of year for those who struggle with allergies and asthma control.
In Chicago, for instance, adults and kids appear to be having an uptick in allergy and breathing concerns related to the warmer weather, said Juanita Mora, MD, a doctor and CEO at Chicago Allergy Center and a national volunteer medical spokesperson for the American Lung Association.
“Climate change is making allergy seasons longer, with a median of about 20 days longer around the country, which leads to increased carbon dioxide levels, more pollen and environment triggers,” she said. “With pollen levels rising, you really want to get started on nasal steroids and antihistamines, as well as preventive and maintenance inhalers for those who use them.”
Some people with asthma have faced challenges, in particular, because GlaxoSmithKline discontinued Flovent inhalers at the start of this year. Although authorized generic versions have replaced the popular corticosteroid, patients have expressed concerns about what to do, especially if their insurance doesn’t cover the generic version sold by GSK.
In March, three companies – GSK, Boehringer Ingelheim, and AstraZeneca – announced a $35 monthly cap on out-of-pocket costs for their inhaler products, which begins June 1. Mora calls the move “a game-changer,” especially for patients with large deductibles. But until then, patients are keeping a watchful eye on changes with their medications as seasonal flares happen and potential formulary updates are announced.
“The generic isn’t always available, and paying out-of-pocket costs can be difficult for families as well,” she said. “Patients need access to their medications to keep their asthma under good control, which is extremely important at this time of year.”
In Chicago, flu cases remain elevated, Mora said, noting that patients can still receive a vaccine, even though it’s not the typical season for influenza. People who recently traveled for spring break or to see the eclipse, for instance, may have gotten the virus and brought it home, and it could continue to spread at schools and gatherings. As graduation season, Mother’s Day, Memorial Day, and other spring and summer celebrations approach, people should continue to take precautions, she advised.
“You can do environmental control with allergens as much as you can, such as driving with the windows closed or taking a shower after being outdoors,” she said. “You can also speak with your local allergist about identifying triggers and considering allergy shots or immunotherapy to remain under good control.”
Addressing Regulatory and Insurance Challenges
The U.S. faces unique challenges in meeting global standards for asthma management, which recommends the use of an inhaled corticosteroid plus formoterol (called ICS-formoterol) for SMART therapy (or single maintenance and reliever therapy). The idea is for a single inhaler to contain medication for both fast relief from a steroid and a long-acting bronchodilator for the lungs to help with maintenance.
Although recommended by the National Heart, Lung, and Blood Institute and the Global Initiative for Asthma, the FDA hasn’t approved ICS-formoterol for acute asthma relief or SMART therapy, and in turn, insurance companies won’t pay for enough ICS-formoterol inhalers for SMART therapy use. These barriers make it difficult for U.S. doctors to prescribe this treatment to patients, according to a recent editorial published in The Journal of Allergy and Clinical Immunology: In Practice.
“The research and guidelines are clear that being able to use specific inhalers – which combine a lung opener and a steroid – have better outcomes when you’re experiencing symptoms,” said Nonie Arora, MD, an allergy and immunology fellow at the University of North Carolina at Chapel Hill. Arora co-authored the editorial with colleagues in Maryland and Michigan, who were inspired by their firsthand experiences with patients.
“Right now, it’s hard for us to prescribe these inhalers in a way that’s affordable for patients,” she said. “There are challenges with FDA approval and insurance companies being willing to pay for the inhalers, which makes it more expensive.”
Plus, the struggles related to the Flovent stoppage have hit patients hard. Although people with asthma tend to do well once they switch to an option that works for them, Arora said, it may take weeks or months for them to get used to it, which isn’t ideal at this time of year. The burden has also increased for medical practices, which are fielding dozens of requests.
“While the cost caps are an important first step, more can and should be done. Because of our complex health care system, the changes will only apply to some patients,” said Melanie Carver, chief mission officer of the Asthma and Allergy Foundation of America.
“AAFA urges other manufacturers to address the high cost of their asthma medications,” she said. “We also call on all stakeholders in the drug pricing ecosystem (drug manufacturers, pharmacy benefit managers, insurance companies, employers, and federal policymakers) to take action. Cost is the primary barrier to treatment for many people with asthma.”
Some medical offices may have support staff to help with these changes, but many don’t. At the University of Alabama at Birmingham’s Asthma Clinic, staff make a point to discuss insurance changes and patient assistance programs with those who need financial help.
“We are making note of any changes and trying to get patients switched over to what they need, which takes a lot of intention and attention,” said Miranda Curtiss, MD, an assistant professor of medicine who specializes in pulmonary and allergy care medicine and immunology and co-runs the clinic.
“We’ve made major progress in getting patients into assistance programs, but we still see patients in the hospital with flares who have trouble with affording their inhalers,” she said. “In spite of everything you try to do to help, people are still having problems where they have to choose between filling heart failure medications or asthma inhalers, and those are horrible choices to have to make.”
Having Allergy and Asthma Control Plans
As the weather, air quality, and pollen sources continue to change this year, people can check pollen and air quality forecasts to understand what may affect them in their location, Curtiss said. Grass pollens begin to spread before the grass turns green, for instance, so she recommends that people use their inhalers or allergy medications year-round and create a plan for their use.
Current events may also shift that plan, so it’s important to remain aware and talk to your doctor about how to respond, she said. During the summer of 2023, for instance, wildfires across the country led to more particulate matter and spikes in air quality levels, and asthma patients used their rescue inhalers more often.
“Certain seasons lead to more triggers, whether allergies, viral infections, or irritants such as smoke,” Curtiss said. “Patients are likely aware of their own susceptibilities and can prepare.”
Later this year, ragweed pollen is forecasted to be higher than usual and last longer, according to the Asthma and Allergy Foundation of America, and that has become a problem for patients in some Northern states who aren’t used to it. In Minneapolis, for example, ragweed season has expanded by 2.5 weeks – the greatest jump nationwide.
And in Charleston, tree pollen counts have been pronounced so far this year, and mold allergens have been higher than usual due to low humidity, said Kelli Williams, MD, an associate professor of pediatrics and section chief of pediatric allergy at the Medical University of South Carolina.
“This season has really affected people, who are used to allergies being bad for 1 or 2 weeks and then being able to come off their emergency medications, but we’ve been going for over a month, which is problematic for those who have allergic asthma,” she said. “That makes it pretty uncomfortable – and sometimes dangerous – for people to enjoy things outside if they don’t know the fluctuating pollen counts.”
Patients should have both a regular asthma/allergy action plan and an emergency asthma/allergy plan, Williams said. For kids, she uses a stoplight analogy, with green, yellow, and red, to help patients remember what they should do daily, when symptoms, such as a dry cough, begin and how to react with an immediate plan.
Williams also recommends stocking up on over-the-counter medications for allergies, viruses, and other triggers, noting that drugmakers often offer coupons that can help reduce costs. Online platforms such as GoodRx and Cost Plus Drugs may help as well.
“Most asthma can be managed by adhering to a good asthma plan, and if you have one you understand and feel comfortable with and can adhere to, it’s the best way of preventing attacks,” said Jonathan Gaffin, MD, an assistant professor of pediatrics and director of the Severe Asthma Program at Boston Children’s Hospital.
“It’s important to make sure you have your medications on hand,” he said. “If you have concerns about whether your medications will be available or covered, connect with your doctor or pharmacist sooner than your last puff.”
