What is a good alternative to fluticasone (Fluticasone) salmeterol (Salmeterol) for asthma/COPD treatment if insurance won't cover it?

Alternative to Fluticasone/Salmeterol for Asthma and COPD

For asthma, switch to budesonide/formoterol or mometasone/formoterol as your first-line alternative; for COPD, consider fluticasone furoate/vilanterol or a LABA/LAMA combination like umeclidinium/vilanterol depending on exacerbation history. 1, 2

For Asthma Patients

Preferred ICS/LABA Alternatives

Budesonide/formoterol is the optimal alternative because it offers the unique advantage of SMART (Single Maintenance and Reliever Therapy) protocol, where the same inhaler serves as both maintenance and rescue therapy for patients 12 years and older at steps 3-4 of asthma management. 3, 1 This approach has been extensively studied and reduces exacerbations while simplifying the treatment regimen. 3

• Mometasone/formoterol can potentially be used in SMART protocol, though it is less extensively studied than budesonide/formoterol, and provides similar ICS/LABA combination benefits with a different corticosteroid component. 3, 2
• Critical caveat: Formoterol is the preferred LABA due to its rapid onset of action; salmeterol has a slower onset and should not be used for SMART. 3

Other ICS Options

If combination therapy is not needed or affordable, consider these alternatives:

• Budesonide (Pulmicort) administered twice daily as an alternative inhaled corticosteroid. 1
• Beclomethasone dipropionate (QVAR) administered twice daily. 1

Non-Corticosteroid Alternatives for Mild Asthma

For mild persistent asthma in patients unable or unwilling to use inhaled corticosteroids:

• Montelukast (Singulair) administered once daily, approved for patients older than one year, with advantages of ease of use and high compliance rates. 1
• Cromolyn sodium or nedocromil work by stabilizing mast cells and can be used as preventive treatment before exercise or unavoidable allergen exposure. 1

Important safety note: LABAs should never be used as monotherapy for asthma control; they must always be used in combination with an ICS due to safety concerns. 1

For COPD Patients

ICS/LABA Alternatives

Fluticasone furoate/vilanterol is an excellent once-daily alternative that improves lung function and reduces exacerbations more effectively than either of its monocomponents. 3, 4 This combination showed substantial improvements in morning lung function sustained over 24 weeks with no additional safety concerns compared to individual components. 5

• Once-daily fluticasone furoate/vilanterol 100/25 μg was more effective than twice-daily fluticasone propionate/salmeterol 250/50 µg for pulmonary function. 4
• Pneumonia risk caveat: As with long-term use of all ICS agents, 12-month data indicate an increased risk of pneumonia with fluticasone furoate/vilanterol. 4 Salmeterol/fluticasone showed 8% pneumonia rate versus 4% with tiotropium alone. 2

LABA/LAMA Dual Bronchodilator Alternatives (Avoiding Corticosteroids)

For patients at lower exacerbation risk or those concerned about pneumonia, LABA/LAMA combinations are recommended as an alternative choice, particularly in GOLD B patients, and avoid corticosteroid-related adverse effects including pneumonia risk. 2

• Umeclidinium/vilanterol was recently approved as once-daily combination bronchodilator therapy. 3
• Tiotropium/olodaterol, aclidinium/formoterol, or glycopyrronium/indacaterol are other LABA/LAMA options under development or available. 3

LAMA Monotherapy

Tiotropium showed longer time to first exacerbation and exacerbation requiring hospitalization compared to control, and reduced dyspnea incidence by 39% compared to placebo. 2 Long-acting tiotropium also showed reduced myocardial infarction risk versus placebo. 2

Decision Algorithm Based on Clinical Characteristics

For COPD with Frequent Exacerbations:

• ICS/LABA combinations are recommended for patients with FEV1 <50-60% predicted and ≥2 exacerbations per year. 2
• Consider triple therapy (ICS/LABA/LAMA) for patients with FEV1 <50% predicted and ≥1 exacerbation treated with systemic steroids/antibiotics in past year. 2
• The 2023 Canadian Thoracic Society guideline suggests single inhaler triple therapy (SITT) in all patients at high risk of AECOPD, as SITT reduces mortality in individuals with moderate-severe disease. 3

For Asthma-COPD Overlap Syndrome (ACOS):

• ICS/LABA combinations show particular benefit in ACOS patients. 2
• Evidence of eosinophilia (marker of inflammation) should prompt treatment with ICS/LABA; several studies have shown improvement in airflow limitation and reduction in exacerbations with salmeterol-fluticasone combination. 6

For Patients with Cardiovascular Disease:

• Salmeterol is a highly selective partial β-2 agonist with no increased risk of new cardiovascular adverse events; the combination may provide certain degree of cardio-protection. 6
• Consider caution with ICS in patients at risk of pneumonia. 2

Common Pitfalls to Avoid

• Never prescribe a LABA without an ICS for asthma patients - this is a critical safety issue. 1
• Do not use salmeterol-containing products for SMART protocol - only formoterol has the rapid onset needed for rescue use. 3
• Be aware of insurance formulary restrictions - if insurance won't cover two canisters of the same ICS/LABA for SMART, you could theoretically use one ICS/LABA as maintenance and another formoterol-based product as reliever, though this has never been formally tested. 3