What are the alternative therapy options for a patient with poorly controlled asthma on Breo (fluticasone-vilanterol) inhaler 200-25 who cannot afford a budesonide-formoterol inhaler for maintenance and rescue?

Alternative Therapy Options for Poorly Controlled Asthma on Breo Inhaler

For a patient with poorly controlled asthma on Breo (fluticasone-vilanterol) 200-25 who cannot afford budesonide-formoterol, the best alternative is to increase to high-dose inhaled corticosteroid (ICS) plus long-acting beta-agonist (LABA) and add a leukotriene modifier or theophylline as a third controller medication. 1

Assessment of Current Therapy

Before changing therapy, it's important to:

• Verify proper inhaler technique with Breo
• Confirm adherence to current regimen
• Identify and address potential triggers or comorbidities (GERD, rhinosinusitis)
• Rule out other causes of persistent symptoms

Step-Up Therapy Options

Option 1: Increase ICS Dose (Preferred)

• Increase to high-dose fluticasone within Breo or switch to another high-dose ICS/LABA combination
• High-dose ICS options include:
  • Fluticasone propionate >480 mcg daily
  • Beclomethasone HFA >480 mcg daily
  • Mometasone DPI >400 mcg daily 1

Option 2: Add a Third Controller Medication

• Add a leukotriene modifier (montelukast, zafirlukast) 2, 1

  • More affordable than many inhalers
  • Once-daily oral dosing improves adherence
  • Particularly effective if patient has allergic rhinitis

• OR add theophylline 2

  • Low-cost option
  • Requires monitoring of serum levels
  • More side effects than leukotriene modifiers

Option 3: Consider Oral Corticosteroids

• For severe persistent asthma not responding to high-dose ICS/LABA plus additional controller
• Prednisone 1-2 mg/kg/day (generally not exceeding 60 mg/day) 2
• Make repeated attempts to reduce systemic corticosteroids while maintaining control with high-dose inhaled corticosteroids 2

Medication Selection Algorithm

1. First verify: Is the patient using Breo correctly? Are there modifiable triggers?
2. If technique and adherence are good:
   • Increase to high-dose ICS/LABA combination
   • Add leukotriene modifier (preferred for affordability and once-daily dosing)
   • If no improvement, add theophylline (with appropriate monitoring)
3. If still uncontrolled: Consider short course of oral corticosteroids and referral to specialist

Important Considerations

• LABAs should never be used alone for asthma management due to increased risk of asthma-related death 1, 3
• Combination therapy with ICS/LABA is more effective than doubling the dose of ICS alone 4, 5
• Patients should always have a rescue inhaler (SABA) available for breakthrough symptoms
• Monitor for potential steroid side effects with high-dose ICS including oral candidiasis, which can be prevented by rinsing mouth after use 1

When to Refer

Consider referral to an asthma specialist if:

• Symptoms remain uncontrolled despite step-up therapy
• Patient has had ≥2 exacerbations requiring oral corticosteroids in past year
• Additional testing is needed to identify triggers or comorbidities 1

Patient Education

• Emphasize the importance of controller medication adherence
• Demonstrate proper inhaler technique
• Create a written asthma action plan
• Schedule follow-up within 2-6 weeks to assess response to therapy changes 1