What is the recommended dosing for Advair (fluticasone-salmeterol)?

Advair Dosing for Asthma and COPD

For adults with mild to moderate asthma, start with Advair 100/50 (fluticasone 100 mcg/salmeterol 50 mcg) twice daily; for moderate to severe asthma, use Advair 250/50 twice daily; and for severe asthma or COPD, use Advair 500/50 twice daily. 1

Standard Dosing by Disease Severity

Mild to Moderate Asthma

• Initiate therapy with fluticasone 100 mcg/salmeterol 50 mcg twice daily (Advair 100/50), which corresponds to low-dose inhaled corticosteroid therapy 1
• This dosing provides 200 mcg/day total fluticasone, falling within the low-dose ICS category of 88-264 mcg/day for adults 1
• Most patients achieve satisfactory asthma control at this starting dose 1

Moderate to Severe Asthma

• Use fluticasone 250 mcg/salmeterol 50 mcg twice daily (Advair 250/50) for patients with moderate persistent asthma or those inadequately controlled on low-dose ICS 1, 2
• This combination is more effective than fluticasone 500 mcg alone for moderate to severe asthma 1
• The 250/50 strength provides medium-dose ICS therapy (500 mcg/day total fluticasone) 3

Severe Asthma or COPD

• Prescribe fluticasone 500 mcg/salmeterol 50 mcg twice daily (Advair 500/50) for severe disease 1
• This provides high-dose ICS therapy (1000 mcg/day total fluticasone) 3

Dosing Algorithm Based on Current Treatment

For Patients Using Short-Acting Beta-Agonists Frequently

• If using SABAs ≥2-3 times daily, initiate inhaled corticosteroids (fluticasone 100-250 mcg twice daily) and consider adding salmeterol 50 mcg if symptoms persist 1
• Regular SABA use exceeding twice weekly for symptom control (not prevention of exercise-induced bronchospasm) indicates need for controller therapy 3

For Patients Already on Inhaled Corticosteroids

• If asthma remains poorly controlled on ICS alone, add salmeterol 50 mcg rather than doubling the corticosteroid dose 1
• Combination therapy (low-dose ICS + LABA) is more effective than doubling the ICS dose in reducing exacerbations 2
• When switching from higher-dose ICS monotherapy, transition to Advair 250/50 or 500/50 depending on previous corticosteroid dose 1

Administration Technique

Proper Inhaler Use

• Exhale fully, place the mouthpiece between the lips, inhale deeply while activating the device, and hold breath for 10 seconds 1
• Rinse mouth and spit after each use to prevent oral candidiasis 1, 2
• Using a spacer device can significantly increase medication delivery, especially important for patients with coordination difficulties 1

Timing

• Administer twice daily, approximately 12 hours apart 1, 2
• Consistency in timing helps maintain steady therapeutic levels 2

Dose Titration Strategy

Step-Down Approach

• Show 1-3 months of stability before reducing the inhaled steroid dose 1
• Decrease by 25-50% at each step when stepping down 1
• Consider stepping down to lower strength Advair or to ICS alone after achieving control, monitoring closely for loss of asthma control 1

Step-Up Approach

• If inadequate control on twice daily dosing, increase the frequency to four times daily at the same total daily dose before increasing the total dose 1
• Reassess asthma control every 2-6 weeks initially when adjusting therapy 2

Pediatric Dosing Considerations

Children 4-11 Years

• Advair Diskus 100/50 is approved for children 4-11 years 1
• Most children ≥4 years can generate sufficient inspiratory flow for the Diskus device 1
• For children under 4 years, budesonide nebulizer suspension is the only FDA-approved ICS 3

Administration in Young Children

• Use a face mask that fits snugly over nose and mouth for children unable to use mouthpiece properly 2
• Wash face after each treatment to prevent local side effects 3, 2

Critical Safety Considerations

Black Box Warning

• Long-acting beta-agonists should never be used alone for asthma and must always be combined with inhaled corticosteroids 1, 2
• Monotherapy with LABAs increases risk of severe exacerbations and asthma-related deaths 1, 2

Common Side Effects to Monitor

• Salmeterol-related: tremor, tachycardia, hypokalemia, headache, muscle cramps 3, 1
• Fluticasone-related: oral candidiasis, dysphonia, cough 3, 1
• Local side effects are reduced by using spacer devices and mouth rinsing 3, 2

Systemic Corticosteroid Effects

• At high doses, monitor for adrenal suppression, growth velocity reduction in children (typically transient and approximately 1 cm), and bone mineral density effects 3, 2
• These effects are rare at low-to-medium doses 2

Special Populations

Elderly Patients

• No dose adjustment required based on age alone 1
• Monitor closely for tremor from salmeterol and systemic corticosteroid effects 1
• Consider ECG monitoring with first dose in patients with ischemic heart disease 1

Drug Interactions

• Potent CYP3A4 inhibitors (ritonavir, ketoconazole) can increase systemic fluticasone concentrations, potentially causing Cushing syndrome and adrenal insufficiency 3
• Use caution when combining with these medications 3

Short-Term Dose Doubling

When Asthma Control Deteriorates

• Doubling the dose of Advair for a period of 2 weeks in adult asthmatics is safe and well tolerated 4
• This strategy showed minimal differences in heart rate (<2 beats/min) and no clinically significant ECG changes 4
• Only one subject experienced tremor (mild) when doubling the dose 4

Important Caveat

• While common practice to advise patients to double inhaled steroids at first sign of deterioration, corroboratory evidence from trials is lacking for this approach 3
• Consider this strategy only for short-term use (up to 2 weeks) based on available safety data 4