College weighs in on fluticasone fracas

3 minute read

It’s now been three weeks since new restrictions were imposed on PBS scripts for a children’s asthma medicine.

The PBAC decision to restrict PBS-funded prescriptions of fluticasone propionate 50 microgram to children under six was made without consulting GPs, the RACGP alleges.

On 1 April, the PBS listing for the fluticasone propionate 50 microgram/actuation inhalation, 120 actuations (Axotide Junior, Flixotide Junior) changed.

Under the new rules, the PBS will only fund prescriptions of the medicine for children under six years, and then only if there is no alternative and if the drug is initiated by a specialist paediatrician or respiratory physician.

It is now an Authority Required drug.

For patients over the age of six, the PBS recommends switching to an alternative medicine, such as budesonide, beclomethasone dipropionate or ciclesonide.

GPs and nurse practitioners will be able to prescribe continuing treatment and can still write a private prescription for the medicine.

Late last week, RACGP president Dr Nicole Higgins wrote to PBAC chair Professor Andrew Wilson pointing out that, despite GPs seeing the majority of children under five with wheeze or asthma, the college was not given an opportunity to consult on the change.

“The RACGP is unaware of any inappropriate prescribing of fluticasone propionate in young children, and in the absence of reasonable alternatives that are equally as effective, safe and accessible, the clinical need for this change is unclear,” she said.

Dr Higgins also asked for clarification on whether the PBS change was based on a new interpretation of evidence or whether it was a funding-based decision.

“[This decision] creates a false assumption that GPs are unable to diagnose and prescribe appropriately for children with asthma aged between one and five years,” the RACGP said.

“This could further result in many more referrals to paediatricians as GPs take a more cautious approach to childhood asthma, delaying appropriate medication whilst awaiting a potentially unnecessary paediatrician review.

“It may also erode the community trust in GPs due to obligatory referrals to paediatricians and respiratory physicians.”

Given that around 85% of paediatricians and 90% of respiratory doctors work in MMM1 locations – that is, major cities – children in rural and remote areas will be disproportionately disadvantaged in terms of access.

“In many parts of Australia there are very few bulk-billing paediatricians and respiratory physicians and lengthy waitlists which mean that patient access will be restricted, particularly for vulnerable groups,” the college said.

While acknowledging that Aboriginal and Torres Strait Islander children are not necessarily predisposed to asthma, the RACGP argued that there would be a precedent to leaving GP-initiated fluticasone propionate 50 microgram on the PBS for Indigenous children.

Being Aboriginal or Torres Strait Islander, the RACGP said, is associated with reduced income and reduced access to non-GP specialists, and there are already a number of PBS items that are restricted to First Nations Australians.

Other unintended consequences of the change, according to the college, include the overuse of oral corticosteroids, over-reliance on short-acting beta agonists and a blowout in paediatric or respiratory wait times.

There’s also the likelihood that children aged under five, who have been well controlled on the 50 mcg dose, will be swapped to the 125 mcg formulation, which remains on the PBS.

“Children will end up on higher inhaled corticosteroid doses for the sake of convenience and lower costs and some will be changed to other inhaled corticosteroid formulations such as ciclesonide 80 mcg once daily,” the RACGP said.

Restoring PBS access to the medicine for Aboriginal and Torres Strait Islander people specifically would be a partial solution, it said, but the college preference is to see the decision fully reversed.  

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