What is a substitute for fluticasone propionate (Flonase) and salmeterol (Serevent) 113 micrograms (mcg)?

Substitutes for Fluticasone Propionate and Salmeterol 113 mcg

Budesonide/formoterol is the most appropriate substitute for fluticasone propionate/salmeterol 113 mcg, providing similar efficacy with potentially lower daily inhaled corticosteroid dosage. 1, 2

Equivalent Combination Options

First-line alternatives:

• Budesonide/formoterol combination
  • Available as Symbicort (DPI)
  • Dosing: Typically 160/4.5 mcg, 2 inhalations twice daily 2
  • Advantages: Can be used in both maintenance and reliever therapy (MART) approach, which may allow lower total ICS exposure 2

Other alternatives:

• Mometasone/formoterol combination
  • Available as Dulera (MDI)
  • Dosing: 100/5 mcg or 200/5 mcg, 2 inhalations twice daily 1

Efficacy Comparison

Head-to-head studies have shown:

• Budesonide/formoterol produces similar improvements in lung function compared to fluticasone/salmeterol when given twice daily for 12 weeks 3
• The most recent evidence (2023) indicates budesonide/formoterol MART might be similarly effective to fluticasone/salmeterol fixed-dose therapy in COPD patients, while using a lower daily ICS dosage 2
• Both combinations significantly improve lung function, reduce exacerbations, and improve quality of life compared to monotherapy with either component alone 4, 5

Clinical Considerations for Substitution

For asthma patients:

• Ensure the substitute provides equivalent ICS dosing:
  • Low-dose fluticasone propionate can be substituted with low-dose budesonide (180-600 mcg daily) 1
  • Medium-dose fluticasone propionate can be substituted with medium-dose budesonide (>600-1200 mcg daily) 1

For COPD patients:

• Both fluticasone/salmeterol and budesonide/formoterol combinations reduce exacerbation rates compared to monotherapy 3
• The INSPIRE trial suggests fluticasone/salmeterol may be associated with lower mortality than tiotropium monotherapy in COPD patients 6

Important Precautions

1. Never substitute with LABA monotherapy

   • LABAs should never be used as monotherapy for asthma and should always be combined with an appropriate ICS dose 1
   • Salmeterol monotherapy has been associated with increased risk of exacerbations 3

2. Monitor for side effects with any ICS/LABA combination:

   • Common side effects: Headache, throat irritation, hoarseness, oral candidiasis 4, 7
   • Cardiovascular effects: Tachycardia, palpitations, premature ventricular contractions 1
   • Metabolic effects: Mild decrease in serum potassium (typically 0.5-0.54 mmol/L) 1
   • Neurological effects: Tremor and dizziness 1

3. Pneumonia risk:

   • Inhaled corticosteroids may increase pneumonia risk in COPD patients
   • In one study, pneumonia rates were 5% with budesonide/formoterol MART vs 1% with fixed-dose fluticasone/salmeterol, though this difference was not statistically significant (p=0.216) 2

Practical Implementation Tips

• Ensure proper inhaler technique with the new device, as different combinations use different delivery systems
• Consider spacer devices to increase effectiveness of inhaled medications 1
• Recommend rinsing the mouth after ICS use to reduce the risk of oral thrush 1
• Schedule follow-up within 1-3 months after switching to assess control and adjust therapy if needed 1

When substituting fluticasone propionate/salmeterol 113 mcg, budesonide/formoterol represents the most evidence-based alternative, with similar efficacy and potentially lower daily ICS exposure.