covid-19 and pediatric asthma · 5/5/2020 · 2 covid-19 response (as of april 7,2020) •...
TRANSCRIPT
PHN Grand Rounds:
COVID-19 and
Pediatric Asthma Presented by:
Deepa Rastogi MD
Dinesh Pillai MD
Shilpa Patel MD MPH
Eduardo Fox MD
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COVID-19 Response (as of April 7,2020)
• Children’s National Hospital is open for business.
• Telehealth is deployed system-wide. Patients can request telehealth during scheduling appointments with the call center.
• Full time specialists available for real time consults – to contact dial Physician Access Line 202-476-4880 (M-F 8a to 5p; hospital operators 202-476-5000 after hours).
• Explore and participate in shared learning opportunities Childrensnational.org/webinars.
• Drive up/walk up specimen collection site (limited to patients age 22 or under as referred by a primary care physician). Childrensnational.org/COVID19testforms.
• Most elective surgeries are postponed.
• Hospital is preparing for a surge in patients and is taking measures to preserve the health of clinical staff in the event of influx.
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Children’s National Resources
Stay informed with the latest resources for providers, staff and patients on the Children’s National Coronavirus (COVID-19) Resources for Primary Care
Practices
https://childrensnational.org/healthcare-providers/refer-a-patient/covid
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Future of Pediatrics 2020: June 16-17 In-Person
Meeting Cancelled, Virtual Series Coming Soon
There is a “Future of Pediatrics” after COVID-19! It is with great sadness we announce that we will not be hosting an in-person event this June. We realize that, even if current COVID-19 restrictions are lifted, our pediatricians are busy focusing on recovery and most would not be able to take two full days away from their practice to participate in CME.
But you can still get your learning, networking and CME! We are busy reimagining our 21st annual Future of Pediatrics program as a virtual learning experience. This ongoing, online series will include CME credit and the same “practical pediatrics for practicing pediatricians” clinical topics that you have come to value.
We will have more information to share soon and we look forward to gathering in-person at the Business of Pediatrics program in December. Thank you, as always, for your commitment to our children, families, and community.
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PCP Town Halls Tuesday, May 12, 2020 @ 12-1PM
Speakers include: Denise Cora-Bramble, M.D., MBA, Bud Wiedermann, M.D., Meghan Delaney,
D.O., Mike Bell, M.D., Hemant Sharma, M.D., Ellie Hamburger, M.D.
Agenda includes:
• Introduction and Acknowledgements
• Infectious Disease
• COVID-19 Testing/ Lab Updates
• Critical Care Overview/ Case Study
• Allergies and COVID-19
• Q&A
Visit www.pediatrichealthnetwork.org for Zoom information.
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COVID-19 Youth and Family Town Halls
Children’s National Hospital will be hosting a series of family and youth town halls to address community needs in response to coronavirus (COVID-19). The youth town halls, “COVID Convos”, are a three-part series for high school students that will focus on adolescent health and the effects of the pandemic. The COVID Convos will be held from 2-3pm on May 6, 7, and 8. . The family town halls are a four part series for families living in the DC region that will focus on how the COVID-19 pandemic is affecting families and identify resources available to them. The Family Town Halls will be held over 4 consecutive Tuesdays from 3-4pm on May 5, 12, 19, and 26. Registration information: Family Town Halls – https://bit.ly/2zJ186L Youth Town Halls “COVID Convos” - https://bit.ly/2yYUSao
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A few notes about today’s Grand Rounds
• All lines are muted throughout the webinar.
• Please use the Chat function to ask questions or make comments.
• To avoid feedback noise, please do not have computer audio and phone audio active at the same time.
• Today’s Webinar recording and slides will be posted to the PHN website following the presentation. www.pediatrichealthnetwork.org
PHN Grand Rounds:
COVID-19 and
Pediatric Asthma Presented by:
Deepa Rastogi MD
Dinesh Pillai MD
Shilpa Patel MD MPH
Eduardo Fox MD
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Meet Our Speakers
Deepa Rastogi, MD Dinesh Pillai, MD Shilpa Patel, MD MPH Eduardo Fox, MD
Today’s presenters have no conflicts to disclose:
• No financial or business interest, arrangement or affiliation that could be perceived as a real or
apparent conflict of interest in the subject (content) of their presentation.
• No unapproved or investigational use of any drugs, commercial products or devices
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Learning Objectives
• Discuss the evolving epidemiology of COVID, particularly as it relates to patients with asthma
• Provide ongoing asthma management, adhering to latest guidelines during the pandemic
• Conduct a thorough video visit for patients with asthma
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Disease Epidemiology
COVID19 Case Growth Rate: Global, US, NY, Region (thru 5.1.20)
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Daily New Cases 4.29.2020 https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
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Weekly COVID19 Admission Rates (4.25.20) https://gis.cdc.gov/grasp/covidnet/COVID19_3.html
>85 yrs
Overall
<18yrs
United States
Maryland
>85 yrs
<18yrs
Overall 19-49 yrs
19-49 yrs
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Children’s National COVID19 Cases (5.1.2020) Excludes Popup Testing Sites
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Questions?
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Disease Pathophysiology
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What is SARS-CoV2 and COVID-19?
• SARS-CoV2 is a single-stranded RNA virus in the Coronaviridae family
• SARS-CoV2 is responsible for Coronavirus disease 2019
(COVID-19) pandemic
• Virus binds to cells through the ACE2 receptor
• Transmembrane receptor • Quite ubiquitous
• Alveolar cells • Airway epithelial cells • Enterocytes • Endothelial cells
• Following endocytosis, the virus multiplies in the cell, cell undergoes apoptosis, virus is released to infect more cells
Photo credit: NIAID
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Mechanism of viral sepsis due to SARS-CoV2
Li et al. Lancet
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ACE2 receptor, atopy and pediatric asthma
Jackson 2020 JACI
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Questions?
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Disease Presentation
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Pediatric impact of SARS-CoV2 and COVID-19
Ludvigsson 2020 Acta Pediatr Dong et al. 2020 Pediatrics
• Disease burden in children
• 0.02% of all cases in China
• 1.2% in Italy
• 1.7% in US
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COVID-19 presentation in children- symptoms and labs
Zheng et al. 2020 Current Med Sci
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COVID-19 presentation in children- symptoms and labs
Qiu et al. 2020 Lancet
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COVID-19 Presentation in Children
• Fever (41.5%)(most commonly seen in children in close proximity of an infected adult)
• Pharyngeal erythema (46.2%)
• Cough (48.5%)
• Diarrhea (8.8%)
• Fatigue (7.6%)
• Tachypnea (28.7%), tachycardia (42.1%), desats below 92% (2.3%)
Ludvigsson 2020 Acta Pediatr
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COVID-19 Presentation in Children-Imaging
Sun et al. 2020 World J Pediatr
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Pediatric Impact of SARS-CoV2 and COVID-19 on Children
N=6
N=8
N=9 N=2
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Pediatric Impact of SARS-CoV2 and COVID-19 on Children
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COVID-19 and Asthma
Halpin et al. 2020 Lancet Goyal et al. NEJM
• 345 Pediatric cases with info on underlying conditions
• 80 (23%) had 1 underlying condition
• Most common: 40% Chronic lung disease (asthma)
• 25% Cardiovascular disease
• 10% Immunosuppression
• 77% of admitted children had underlying condition (28 of
37)
• 12% of non-admitted children had underlying condition (30 of 258)
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Children’s National COVID19 Patient Characteristics (4.22.2020)
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Questions?
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Management
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Asthma treatment recommendations during COVID-19
Pandemic (NAEPP, GINA, CDC)
• Unclear if any increased risk of COVID-19 morbidity in children with asthma
• Unknown if asthma controller meds (ICS, combo therapy, montelukast, biologics) pose risk when treating COVID-19
• Unknown if COVID-19 increases risk of asthma exacerbations
• Best course of action: Maintain asthma control!
Abrams EM, Szefler SJ. J Peds 2020.
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Asthma treatment recommendations during COVID-19
Pandemic (NAEPP, GINA, CDC)
Well controlled patients
1. Keep on current dosing
Do not step down, unless clear need/concern
Consider spring season
2. Avoid triggers
Allergens – outdoor allergens may be decreased, indoor increased (ETS)
Handwashing
Physical distancing
Review technique frequently
Abrams EM, Szefler SJ. J Peds 2020.
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Encourage early telemedicine visit vs. ED
1. Important history
Duration of symptoms
Albuterol use: frequency, number of puffs
Activity/fatigue level
Night time symptoms
2. Telemedicine clinical exam (in context of when last albuterol dose given)
COVID-19 pandemic asthma exacerbation recommendations
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Treatment
1. High dose Albuterol MDI: Increase number of puffs (4-6 puffs minimum) every 4 hours
High albuterol dose for 4 hours around the clock for 24-48 hrs
Unable to make every 4 hours:
Give red zone (3 high doses back to back 15 minutes apart)
Send to ED
2. Consider oral steroids at home : Weigh clinician and parent comfort vs. sending to ED
Able to maintain higher dose albuterol q4hr but still needing >24 hours
Predniso(lo)ne 2 mg/kg/day for 5 days (max dose 60 mg daily)
Dexamethasone: 0.5 mg/kg/day x2 days
Follow up in 24-48 hours
At any time, if not able to make 4 hour mark for Albuterol, must do Red Zone and go to ED
COVID-19 pandemic asthma exacerbation recommendations
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MDI vs. nebulizer concerns during COVID-19 pandemic
Try to minimize nebulizer when possible
Aerosol generating procedure, may increase time suspended in air up to 3 hours
May induce cough
Increased risk of viral lower lung deposition
30-40% asymptomatic carrier rates reported
Consider home environment (elderly family members, ability to isolate neb location)
What to do
Switch to MDI, prescribe aerochambers
ICS in older patients: consider MDI and DPI options
Abrams EM, Szefler SJ. J Peds 2020. Shaker et al., JACI 2020
Amirov I. CAMJ 2020
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Albuterol doses in acute asthma (RED Zone)
Weight
Nebulizer dose
MDI/spacer dose*
5-10kg
2.5 mg INH Q 20 minutes x 3 doses
4 puffs INH Q 20 min x 3 doses
>=10kg to 30 kg
2.5 mg INH Q 20 minutes x 3 doses
6 puffs INH Q20 min x 3 doses
>= 30 kg
5 mg INH Q20 minutes x 3 doses
8 puffs INH Q20 min x 3 doses
* No guidelines available for true equivalency. These are doses used in our Emergency Department.
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MDI shortage
Attempt to cohort MDI for COVID+ patients, early purchases due to COVID concerns
Appears to be pharmacy specific
Call pharmacy directly to understand level of shortage
MDI availability local DC pharmacies:
https://docs.google.com/spreadsheets/d/1mog8Qkqzj8CIWJRdCHpc7JouvzEAkGaoFdo-y9yzDKM/edit#gid=0
What to do:
Prescribe neb treatments and neb machine, mask, tubing
Remind family efficacy of MDI vs. neb
GOAL: Treat the patient
MDI shortage during COVID-19 pandemic
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Other asthma medication considerations
Continue all allergy/eczema medications
Give refills, fill 90 day supplies – minimize community based exposures, family anxiety
Oral steroid concerns: not treating COVID-19, treating asthma
Oral steroids not recommended for COVID-19 infection
Asthma control strongly recommended even if +COVID-19 – TREAT w/ steroids if needed
Other rescue medications
Can consider anticholinergics for exacerbations – weigh comfort level, delivery mechanism
Biologics: convert to home use when safe/possible
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Rescue Meds: In 0ffice concerns during COVID-19 pandemic
Do not use nebulizer without proper precautions in health care setting
N95 mask (surgical mask over N95), gown, eye protection, gloves
Negative pressure room – can re-use room in 30 minutes
No negative pressure room – re-use room in 3 hours
Wipe down entire room with appropriate cleaner
NEED TO REDUCE RISK OF POTENTIAL SPREAD TO HEALTHCARE WORKERS, COMMUNITY
Recommendations:
Have child use albuterol at home prior to coming to clinic
Have families bring home albuterol, aerochamber to clinic
Send to ED for neb treatments
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Other concerns during COVID-19 pandemic
Pulse oximetry home use
NOT RECOMMENDED
May increase stress, anxiety
Sends wrong message, do not want to delay
Asthma Action Plans work when used properly
Excellent ED based care is available - Patient not improving, have them seen in the ED
Other co-morbidities
Obesity: less school = less activity, weight gain. Encourage regular exercise/play at home
Sickle cell disease: keep treating, maintain control, use MDI in lieu of nebs
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Questions?
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Tips for Telehealth Asthma Visits
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Challenges/ Opportunities
Limited Time
• Pick and choose which components to do at the visit
• Can break up the visit as needed
• No shows (choose good time for parents while at home during pandemic)
Lack of Exam
“On the ground” assessment
Environmental Assessment
Telemedicine may be easier for some parents who have previously been difficult to reach
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Intake Symptoms (cough, wheeze, chest pain, exercise intolerance, fatigue)
Triggers (colds, exercise, changes in weather, stress, pets, dust, smoke, strong smells, pollen)
Risk
• # of ED asthma visits in last 12 months
• # of admission in last 12 months
• # of urgent care visits in the last 12 months
• # of systemic steroid courses in last 12 months
Impairment
• daytime symptoms- days/week
• Nighttime awakenings- nights/month
• Albuterol use for symptom control (not counting pre-exercise)- times/week
• Interference with normal activity (none, minor, some, severe)
• School absences due to asthma
Asthma Control Test (ACT)- Can be difficult to do during telehealth visit.
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Modified Exam for Telemedicine Visit
Observe eyes, face, neck, chest, skin, and respiratory effort
Consider having patient/ parent adjust clothing observe chest and suprasternal area (depending on age of patient).
Can count respiratory rate
Sample Exam
• General: patient activity, ? Well or sick appearing
• HEENT: can comment on conjunctivae, nasal drainage, allergic shiners
• Lungs: No increased work of breathing, ? audible wheezing, ? able to sing or converse without dyspnea
• Cardiovascular: Pink, no cyanosis
• Abdomen: deferred or observation about “belly breathing”
• Neurological: normal gait, alert and oriented
• Skin: There were no obvious rashes or lesions noted. ? eczema, ? acanthosis
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Medication and Spacer
Technique
Confirm medications- ask family to get medications
Spacer – where is it stored, patient familiarity, sizing, ask families to demonstrate technique
Teaching Technique is billable
• HFA/spacer (Link to IMPACT DC videos): https://vimeo.com/channels/impactdc
• Breath-activated devices (https://www.qvar.com/redihaler/redihaler-and-childhood-asthma)
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Quick Video Home Visit (Trigger Assessment)
Environmental assessment- can use triggers identified during intake to tailor assessment but may consider:
• Bedroom/ sleeping space
• Smoke Exposure
• Pests
• Dust
• Moisture, Mold, Smells
• Pets
• Carpet and flooring
Evidence for interventions?
• No strong evidence for single trigger elimination
• Mild to moderate evidence for multi-component interventions but need more research
COVID-19 and resources for increased family needs List of compiled resources (food, unemployment help):
https://wamu.org/story/20/03/19/your-guide-to-getting-unemployment-and-other-relief-in-d-c-virginia-and-maryland/
DC COVID-19 CONNECT (comprehensive guide put together by GW Medical Students – available in multiple languages) and updated daily: https://bit.ly/2UUv87S
Free internet: Comcast is giving free internet connection for low-income families for 60 days. Families just need to visit www.internetessentials.com or call 1-855-846-8376 (Eng) or 1855-765-6995 (Sp).
https://corporate.comcast.com/press/releases/comcast-extends-comprehensive-covid-19-response-policies-to-june-30
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Additional Resources
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Additional Resources
Formulary for Medicaid
Steroid equivalency
Landlord Letter Template
Changes you can make at home
Asthma Action Plan
IMPACT DC Provider Resources:
https://childrensnational.org/departments/impact-dc-asthma-clinic/resources-for-providers
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IMPACT DC – How to refer
1. By email: [email protected]
2. By phone: 202-476-3970
3. Through eCW referral [Impact DC under Provider & Send fax].
• Just need patient info and contact info – IMPACT DC team will do the rest.
• All patients in the ED or admitted should be referred to IMPACT DC.
• Patients with asthma impairment, missing school days, or poor asthma education should also be referred.
• Locations include: CNMC main campus, CHC-Anacostia, and THEARC.
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Severe Asthma Clinic – How to Refer
• Sees patients with uncontrolled Moderate Persistent Asthma or worse
• Incorporate PFTs
• ID/Treat co-morbidities (tonsillar hypertrophy, GERD, allergic rhinitis, etc.)
• Step up therapy/consider biologics
• To refer, email [email protected] (Provide patient information, contact number)
• Patients can be referred to IMPACT DC and Severe Asthma Clinic
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Consider referral for any of the following:
>1 hospitalization
Admitted to ICU for at least 24 hours
Child >5 years requiring step 4 care or higher
Child <5 years requiring step 3 care or higher
Uncontrolled asthma after 3-6 months of active therapy and appropriate monitoring
Other complicating co-morbidities
Aerodigestive Clinic – How to Refer
Who to refer: Refractory ‘asthma’ symptoms (not responding to asthma therapies)
Patients requiring evaluation by >2 of the following specialties:
• ENT, GI, Pulmonary, Speech
Able to coordinate flexible bronchoscopy, rigid bronchoscopy and EGD at same time
• Concern for EOE, anatomical problems, etc.
Email: [email protected]
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Severe Asthma Clinic
Inpatient
Sleep Clinic
IMPACT DC Community Pediatricians
Allergy/ Immunology
Aerodigestive Clinic
Ciliary Dysfunction Clinic EoE Clinic Laryngoscopy EGD DLB
Bronchoscopy Ciliary Biopsy
FESS/FEES
nNO Video
Microscopy Genetics
PSG/Treatment
Food Allergies EoE Treatment
SPT RAST
AIT Immune W/U
Functional Studies PFTs, FeNO +/- CXR, PSG
Screening Labs (no OCS x 4 weeks)
CBC w/ Differential IgE, Vit D+/- IgA
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Medication USE WITH
SPACER?** Total Daily Dose
0-4 years 5-11 years ≥12 years Beclamethasone
(QVar Redihaler)
40 or 80 mcg/puff
NO
(has built in
spacer, but can
be manually
converted to
use with a
spacer) – Qvar
HACK
NA (L): 80-160 mcg
(M):>160-320 mcg
(H):>320 mcg
(L): 80-240 mcg
(M):>240-480 mcg
(H): > 480 mcg
Budesonide Nebules
(Pulmicort)
0.25, 0.5 or 1 mg
NO
(nebulized) (L): 0.25-0.5 mg
(M):>0.5-1 mg
(H): > 1 mg
(L): 0.5mg
(M):1 mg
(H): 2 mg NA
Fluticasone HFA/MDI
(Flovent HFA)
44, 110, 220mcg/puff
YES (L): 176 mcg
(M): > 176-352mcg
(H): > 352 mcg
(L): 88-176 mcg
(M): > 176-352 mcg
(H): > 352 mcg
*REQUIRES PRE-AUTH
(L): 88-264 mcg
(M): > 264-440 mcg
(H): > 440 mcg
Fluticasone DPI:
(Flovent Diskus)
50, 100 or 250 mcg/puff
NO NA
(L): 100-200 mcg
(M): > 200-400 mcg
(H): > 400 mcg
(L): 100-300 mcg
(M): > 300-500 mcg
(H): > 500 mcg Fluticasone*
(Arnuity Ellipta)
50, 100, 200 mcg
* once daily dosing
NO
NA 50mcg available but not
FDA approved
(L): 100mcg
(M): NA
(H): 200mcg
Mometasone
(Asmanex Twisthaler)
DPI: 110mcg,
220mcg/inhalation
NO
NA (L): 100-110 mcg
(M): >200-440 mcg
(H): > 440 mcg
(L): 100-220mcg
(M): >200-440 mcg
(H): > 440 mcg (Asmanex HFA)
HFA: 100 mcg,
200mcg/inhalation
YES
DPI – Dry Powder Inhaler HFA – Hydrofluoroalkane MDI – Metered-dose inhaler
(L): Low daily dose (M): Medium daily dose (H): High daily dose
BID: twice a day mcg – microgram mg - milligram
NA – Not available (not approved, no data available, or safe and efficacy not established in this age group)
Note: Doses are per NAEPP update in September 2012 except for (*)
Inhaled Corticosteroids Equivalency Chart for AmeriHealth DC (beginning February 2020) Notes: Based on consensus opinion of IMPACT DC. Preferred (due to age considerations and inhaler design) and covered medications are highlighted in BOLD.
Also it is preferred to administer 2 puffs of HFA per dose (not 1 puff with each dose). For reference, the guidelines above are from the NAEPP 2012 Update. More recent ICS dosing guidelines from GINA 2018 are below (http://ginasthma.org):
From AmeriHealth • AmeriHealth Caritas DC enrollees age 11 and younger can continue to fill Flovent HFA prescription without prior –authorization. • AmeriHealth Caritas DC enrollees age 12 and older can continue to fill Flovent HFA prescriptions through February 1, 2020 without prior-authorization. After this date, Flovent HfA prescriptions for this group of enrollees will only be filled when there is an approved prior -authorization request based on medical necessity by the treating provider. Note: For any AmeriHealth Caritas DC enrollee impacted by this change (those age 12 and over) who has an active prescription for Flovent, the pharmacies can use the 72-hour hold over supply code to process these prescriptions. We will send a communication out to the pharmacy network regarding the change.
Spring Medicaid Formulary 2020 - DC
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Spring Medicaid Formulary 2020 - MD
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Questions?
For more information, visit our website:
http://pediatrichealthnetwork.org
Email us at:
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