Why would fluticasone/vilanterol (Breo) and Advair HFA (fluticasone/salmeterol) be taken together?

Fluticasone/Vilanterol and Advair HFA Should Not Be Used Together Due to Therapeutic Duplication

Taking fluticasone/vilanterol (Breo) and Advair HFA (fluticasone/salmeterol) together is not recommended as it represents a therapeutic duplication that increases risk without additional benefit.

Understanding the Medications

Both medications contain similar components:

• Fluticasone/vilanterol (Breo):

  • Contains fluticasone furoate (inhaled corticosteroid)
  • Contains vilanterol (long-acting beta-agonist/LABA)
  • Dosed once daily

• Advair HFA (fluticasone/salmeterol):

  • Contains fluticasone propionate (inhaled corticosteroid)
  • Contains salmeterol (long-acting beta-agonist/LABA)
  • Dosed twice daily

Reasons Why These Medications Should Not Be Combined

1. Therapeutic Duplication

   • Both medications contain an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA)
   • Using both would result in excessive doses of both medication classes 1

2. Safety Concerns

   • Increased risk of corticosteroid-related adverse effects:
     • Adrenal suppression
     • Increased risk of pneumonia
     • Potential for osteoporosis with long-term use
   • Increased risk of LABA-related adverse effects:
     • Tachycardia
     • Tremor
     • Hypokalemia
     • Potential cardiovascular effects 1

3. No Additional Clinical Benefit

   • Clinical trials have not demonstrated additional benefits of using multiple ICS/LABA combinations
   • The 2015 American College of Chest Physicians guidelines do not support using combinations of these therapies 1

Appropriate Use of These Medications

For COPD Management:

• Either fluticasone/vilanterol OR fluticasone/salmeterol may be used (not both)
• Selection should be based on:
  • Dosing preference (once daily vs. twice daily)
  • Individual response
  • Insurance coverage
  • Device preference 1

For Asthma Management:

• ICS/LABA combinations are recommended for moderate to severe asthma not controlled with ICS alone
• Either medication may be appropriate, but they should never be used simultaneously 2

Clinical Evidence

Research comparing these medications shows:

• Fluticasone furoate/vilanterol (FF/VI) once daily has similar efficacy to fluticasone propionate/salmeterol (FP/SAL) twice daily in asthma patients 3
• In COPD patients, FF/VI showed improvements in lung function similar to FP/SAL 4
• Neither medication has shown superior efficacy that would warrant combination use 1

Common Prescribing Errors

• Medication reconciliation errors: Patients may receive both medications when transitioning between healthcare providers
• Brand/generic confusion: Providers may not recognize that different brand names contain similar active ingredients
• Failure to discontinue previous therapy: When switching from one ICS/LABA to another, the previous medication may not be discontinued

What To Do If Both Are Prescribed

If a patient has been prescribed both medications:

• Contact the prescriber immediately
• Clarify which medication should be continued
• Discontinue one of the medications
• Consider whether the patient might benefit from a different class of medication (such as a long-acting muscarinic antagonist) if additional therapy is needed

Remember that LABAs should never be used as monotherapy for asthma control and should always be combined with ICS, but using two different ICS/LABA combinations simultaneously is inappropriate and potentially harmful.