Publicly Insured Patients With Asthma Treated Less Often With Biologics

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Treatment of asthma with biologics was lower for those on public health insurance compared with those who had private insurance, with Blacks underrepresented relative to Whites in publicly insured visits where biologic treatment is used.

A new study found that treatment of asthma with biologics was not only lower for individuals who were publicly vs privately insured visits but that Whites were more likely to be treated with biologics than Blacks or Hispanics.

Sixty-four percent of asthma treatment visits were for Whites despite a higher prevalence of severe asthma among minority populations.

The study, published in The Journal of Allergy and Clinical Immunology: In Practice, has particular implications because the findings mean there might be a widening of the disparities in how asthma is treated, with the authors saying providers should be aware of these possible disparities.

Study results by researchers from Johns Hopkins University and Johns Hopkins Bloomberg School of Public Health showed that biologics, which can cost up to $48,000 a year, were used nearly twice as often for individuals with private insurance vs public insurance visits: 28.3 vs 16.3 per 1000. No instances of the uninsured receiving biologic treatment were seen.

“The basis for disproportionately lower use of biologics among the publicly insured, where the burden of uncontrolled asthma is greatest, merits further investigation,” the authors wrote.

Their results also showed that even though Whites accounted for only 60% of asthma treatment visits paid for by public insurance, 80% of the visits involving biologic treatment were for Whites.

“These findings underscore prior evidence suggesting the underutilization of outpatient services for asthma in minority populations,” they wrote.

Researchers used IQVIA’s National Disease and Therapeutic Index, a nationally representative sample of about 4000 office-based physicians across the United States to investigate patterns in the use of 5 monoclonal antibodies (mAbs): omalizumab (Xolair), mepolizumab (Nucala), reslizumab (Cinqair), benralizumab (Fasenra), and dupilumab (Dupixent).

The use of biologics was examined from January 2003 to December 2019 in patients aged 6 and above. Analysis of patient characteristics was restricted to 2019, the only year when all 5 were mAbs on the market, since patient populations on a specific biologic may have changed with the introduction of newer biologics.

Biologic use rose from 2003 to 2006 with the entry of omalizumab, plateaued from 2007 to 2015, and rose again between 2016 to 2019 due to use of mepolizumab, benralizumab, and dupilumab.


Overall, biologics were used during just 2% of asthma-related visits in 2019, the study said, up from 1% in 2015. Omalizumab was used most often (36.6%), followed by benralizumab (26.7%), mepolizumab (21.4%), dupilumab (14.7%), and reslizumab (0.6%).

Children aged 6 to 14 years were rarely prescribed biologic treatment (accounting for less than 3% of biologic treatment visits) although they comprised over 17% of all asthma treatment visits. Most (70.5%) biologic treatment visits were for adults aged 25 to 64 years, with an average of 26 to 33 biologic treatment visits per 1000 asthma-related visits.

The investigators also examined the characteristics of biologic treatment visits by payer and by individual biologic. The number of dupilumab treatment visits was approximately equal between publicly and privately insured individuals (23,386 and 26,304, respectively). For publicly insured treatment visits for those aged 6 to 14 and 15 to 24 years, dupilumab was the most prevalent biologic, making up a third of biologic treatment visits for adults up to age 64.

For those with private insurance, dupilumab was the least prevalent and mepolizumab and benralizumab were the most common. However, for teenagers and young adults aged 15 to 24 years, omalizumab was more common.

More frequent treatment with dupilumab among the publicly insured was likely related to coverage through Medicare Part D and its status as the only biologic treatment approved for self-administration at the time, the study said. A similar pattern has been seen in other conditions such as rheumatoid arthritis, where low-income subsidy beneficiaries with low out-of-pocket costs were likely to receive self-administered biologics covered under Part D than those administered in facilities and covered by Part B.

These results might indicate that racial/ethnic groups are less likely to receive newer treatments despite similar insurance, the study noted, and underscores what is already known about this issue; for instance, inhaled corticosteroids are underprescribed in communities of color, the authors noted.

Other factors include variation in insurance coverage and reimbursement policies, cultural beliefs, and adherence to medication regimens, the study said. Physicians may be less inclined to prescribe expensive medications to those considered less likely to stick to their regimen.

Other possible issues could be communication barriers between providers and patients, physician competency, and lack of provider awareness of the disease severity experienced by minorities.


Akenroye AT, Heyward J, Keet C, et al. Lower use of biologics for the treatment of asthma in publicly-insured individuals, J Allergy Clin Immunol Pract. Published online February 5, 2021. doi:10.1016/j.jaip.2021.01.039.