Pharmacare: Please note mountain of evidence supporting LABAs

It is now more than 12 years since the long-acting beta agonists (LABAs) became available in Canada for the management of asthma. When these medications, which include salmeterol (Serevent) and formoterol (Oxese), were first assessed by Pharmacare, they were made available for physicians (other than respirologists and allergists) only with Special Authority approval. At that time, the reason given for this restriction by Pharmacare was that there were not sufficient data to approve full coverage.

Since that time evidence of the efficacy of LABAs in the management of all but the mildest asthma has been demonstrated in dozens of studies, including a Cochrane analysis. The data and experience is so persuasive that their use is recommended in almost every set of asthma guidelines available, including the Canadian ones and the GINA international ones. Research has shown that the “number needed to treat” to prevent a hospital visit is as low as four!

Over the last 10 years or so there has been an increasing body of research demonstrating efficacy of these medications for COPD as well. Recently the results of the TORCH trial were published in the New England Journal of Medicine. This was a large 3-year trial of fluticasone/salmeterol (Advair) in patients with moderate to severe COPD. This trial showed a clear benefit for patients in quality of life, preservation of lung function, and decreased exacerbations, plus a trend to decreased mortality. Since exacerbations are the major cause of decreased quality-of-life for individuals with COPD, anything that can decrease there frequency is welcome. Recovery from an exacerbation takes 2 to 4 months, and 10% to 20% of individuals hospitalized for an exacerbation never leave hospital. Exacerbations of COPD are a major cause of hospitalization, with the average length of stay being 10 days—at a cost of $8000 to $10 000 per day. In recent years, there have been approximately 7000 admissions for this in BC alone. Therefore, decreasing their frequency also has a large economic benefit for the medical system.

Why then, are the LABAs still not a full Pharmacare benefit? When I asked a Pharmacare official recently, I was told that it was because the companies likely had not reapplied for coverage since the drugs were first marketed in BC. Having difficulty believing this, I asked one of the companies involved and was told that they had reapplied many times over the years, most recently in October 2006. Since the company has an inherent advantage to having the medications covered and Pharmacare has a financial incentive to keep their coverage limited, I tend to believe the company’s side of the story. Unfortunately, the money saved by Pharmacare not covering the LABAs is spent many times over elsewhere in the medical system. 

I call on Pharmacare to respond to the large body of scientific evidence and provide coverage for LABAs to patients with asthma and COPD. If the benefits in improved quality-of-life for patients and decreased use of scarce hospital resources are not sufficient, surely the financial benefit for the medical system as a whole should be sufficient reason to make this change.

—LML

Lindsay M. Lawson, MD. Pharmacare: Please note mountain of evidence supporting LABAs. BCMJ, Vol. 49, No. 6, July, August, 2007, Page(s) 294 - Editorials.



Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.


For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org

BCMJ Guidelines for Authors

Leave a Reply