Alternative Inhaled Corticosteroids to Qvar
For patients requiring an alternative to Qvar (beclomethasone dipropionate), fluticasone propionate is the preferred substitute, as it provides equivalent or superior asthma control at approximately half the dose of beclomethasone. 1
Primary Alternative: Fluticasone Propionate
Fluticasone is the most evidence-based alternative to Qvar based on multiple considerations:
- Efficacy advantage: Fluticasone at half the daily dose of beclomethasone produces significantly greater improvements in FEV1 (0.14 liters), morning PEF (11.10 L/min), and evening PEF (9.31 L/min) 2
- Dose equivalence: 100 mcg fluticasone ≈ 200 mcg beclomethasone 3
- Clinical outcomes: Low-dose fluticasone (88 mcg twice daily) improved FEV1 by 14% compared to 8% with higher-dose beclomethasone (168 mcg twice daily), with similar safety profiles 3
Practical Conversion
If a patient is on Qvar 80 mcg twice daily (160 mcg/day total), switch to fluticasone 88 mcg twice daily (176 mcg/day total). This provides equivalent or better control at a similar nominal dose.
Secondary Alternatives
Budesonide
- Equivalence to beclomethasone: Budesonide and beclomethasone show equal efficacy and safety at equivalent doses 4
- Special populations: Budesonide is the only Pregnancy Category B inhaled corticosteroid (all others are Category C) 5
- Pediatric use: Available as nebulizer suspension for children over 6 months of age 5
- Device options: Available as dry powder inhaler, useful for patients who cannot coordinate MDI technique
Mometasone
- Once-daily dosing: Preferred if adherence is an issue with twice-daily regimens 5
- Limited comparative data: Fewer head-to-head studies versus beclomethasone
Ciclesonide
- Efficacy: Highly effective in once-daily dosing 5
- Side effect profile: Minimal side effects even at high doses 5
- Evidence limitation: Newer agent with less long-term comparative data
Non-Inhaled Corticosteroid Alternatives
If the patient cannot or will not use any inhaled corticosteroid:
Leukotriene Receptor Antagonists
For mild persistent asthma only, leukotriene receptor antagonists are appropriate alternatives 1:
- Montelukast: Once daily dosing (patients >1 year old)
- Zafirlukast: Twice daily dosing (patients ≥7 years old)
- Advantages: Ease of use, high compliance rates, good symptom control in many patients
- Critical limitation: Less effective than inhaled corticosteroids for moderate-to-severe asthma 6
Other Non-Preferred Alternatives (Step 2 Therapy)
For mild persistent asthma when inhaled corticosteroids cannot be used 1:
- Cromolyn
- Nedocromil
- Theophylline (requires serum level monitoring)
Important Caveats
Device considerations: The effectiveness of any inhaled corticosteroid depends critically on proper inhaler technique. If switching from Qvar MDI:
- Assess patient's ability to use the new device
- Consider spacer/valved holding chamber if coordination is difficult
- Breath-actuated inhalers may help patients unable to coordinate actuation and inhalation
Hoarseness risk: When fluticasone is given at the same daily dose as beclomethasone (1:1 ratio rather than 1:2), there is an increased incidence of hoarseness 2. Use the 1:2 dose ratio to minimize this risk.
Never use long-acting beta-agonists as monotherapy: If considering combination therapy, long-acting beta-agonists should never be used alone without an inhaled corticosteroid due to increased risk of severe exacerbations and death 1