Can Advair (fluticasone-salmeterol) and Spiriva (tiotropium) be ordered as PRN (pro re nata) medications?

Advair and Spiriva Should Not Be Prescribed as PRN Medications

Advair (fluticasone-salmeterol) and Spiriva (tiotropium) should not be ordered as PRN (as needed) medications but rather should be prescribed as scheduled maintenance therapy for optimal management of respiratory conditions such as COPD and asthma. 1

Rationale for Scheduled Use of These Medications

Advair (Fluticasone-Salmeterol)

• Advair is a fixed-dose combination of an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA) designed for regular maintenance therapy, not for acute symptom relief 2
• The 2023 Canadian Thoracic Society guideline recommends ICS/LABA combination therapy as regular maintenance treatment for patients with COPD who have moderate to high symptom burden and high exacerbation risk 1
• The anti-inflammatory effects of the fluticasone component require consistent use to achieve and maintain therapeutic tissue levels and cannot provide immediate symptom relief when used intermittently 3

Spiriva (Tiotropium)

• Tiotropium is a long-acting muscarinic antagonist (LAMA) approved for once-daily dosing due to its 24-hour bronchodilator effect 4
• The medication is specifically designed for regular maintenance therapy to provide sustained bronchodilation throughout the day 1
• Spiriva was approved in the United States in 2015 for once-daily administration, not for as-needed use 1

Evidence Supporting Regular Scheduled Use

Pharmacological Considerations

• Long-acting bronchodilators like those in Advair and Spiriva are designed to maintain consistent blood levels for sustained bronchodilation over 12-24 hours 1
• The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends that long-acting bronchodilators be given on a regular basis to prevent or reduce symptoms 1
• Short-acting bronchodilators (SABAs or SAMAs) are the appropriate choice for PRN symptom relief, while LABAs and LAMAs are intended for maintenance therapy 5

Clinical Outcomes with Regular Use

• Regular use of tiotropium has been shown to produce long-lasting (24 hours) bronchodilation and meaningful clinical improvements in lung function, exercise tolerance, and quality of life 4
• Consistent use of Advair has demonstrated better outcomes in reducing exacerbation rates compared to intermittent use 6
• The combination of salmeterol and tiotropium with fluticasone has been shown to improve lung function more effectively than either bronchodilator alone, but this benefit requires regular administration 7

Appropriate PRN Options for Respiratory Conditions

• Short-acting bronchodilators (SABDs) are the appropriate choice for PRN use across the spectrum of COPD severity 1
• The 2023 Canadian Thoracic Society guideline explicitly states that "SABD prn (as needed) should accompany all recommended therapies across the spectrum of COPD" 1
• For immediate symptom relief, short-acting agents like albuterol or ipratropium are more appropriate than long-acting medications like those in Advair and Spiriva 5

Risks of PRN Use of Long-Acting Agents

• Inconsistent use of ICS/LABA combinations like Advair may increase the risk of adverse events without providing the intended therapeutic benefits 2
• Intermittent use of LABAs without regular ICS coverage has been associated with increased risk of asthma-related mortality 3
• PRN use of tiotropium would not maintain the consistent bronchodilation needed to prevent symptoms and exacerbations 4
• Irregular use of these medications may lead to suboptimal disease control and increased risk of exacerbations 5

Conclusion

Based on the most recent guidelines and evidence, Advair (fluticasone-salmeterol) and Spiriva (tiotropium) should be prescribed as regular maintenance therapy, not as PRN medications. Short-acting bronchodilators remain the appropriate choice for as-needed symptom relief in patients with respiratory conditions like COPD and asthma 1, 5.