What is the best inhaler for lung disease in patients with an allergy to fluticasone propionate (Flonase)-salmeterol (Serevent)?

From the Guidelines

For patients with lung disease who are allergic to fluticasone propionate-salmeterol, the best alternative inhaler would be a combination of budesonide and formoterol (Symbicort), as it provides both an inhaled corticosteroid and a long-acting beta-agonist without the allergenic components of Advair. This recommendation is based on the principle of maintaining effective control of lung disease symptoms while avoiding the allergen. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report 1, a combination of an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA) is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with moderate to very severe COPD.

Key Considerations:

• The choice of inhaler should be guided by the severity of the disease, the presence of any exacerbations, and the patient's history of response to previous treatments.
• It's crucial to monitor patients for potential side effects of inhaled corticosteroids, such as oral thrush, and to instruct them on proper inhaler use, including the use of a spacer device if prescribed.
• Alternative combinations like mometasone-formoterol (Dulera) or beclomethasone-formoterol (Foster) could be considered if budesonide and formoterol are not suitable.
• If a patient's allergy precludes the use of combination inhalers, separate inhalers for an inhaled corticosteroid and a long-acting bronchodilator could be an option, tailored to the patient's specific needs and allergic profile.

Treatment Approach:

• Start with a combination inhaler that does not contain fluticasone propionate-salmeterol, such as budesonide and formoterol, at an appropriate dose (e.g., 160/4.5 mcg, two inhalations twice daily).
• Monitor the patient's response and adjust the treatment as necessary to control symptoms and prevent exacerbations.
• Consider adding other therapies as recommended by GOLD guidelines 1, such as phosphodiesterase-4 inhibitors or mucolytic agents, based on the patient's disease severity and history of exacerbations.

From the Research

Alternatives to Fluticasone Propionate-Salmeterol for Lung Disease

Given the allergy to fluticasone propionate-salmeterol, alternative treatments must be considered for managing lung disease, including asthma and chronic obstructive pulmonary disease (COPD).

• Budesonide and Formoterol: This combination is a potential alternative, as it also combines an inhaled corticosteroid (budesonide) with a long-acting beta-agonist (formoterol) 2. Studies have compared this combination with fluticasone propionate-salmeterol, showing similar efficacy in managing asthma symptoms and lung function, although the choice between them may depend on individual patient responses and specific disease severity.
• Other Inhaled Corticosteroids and Long-Acting Beta-Agonists: Other combinations and individual medications within these classes could be considered, depending on the patient's specific condition, severity of disease, and history of response to treatments.
• Leukotriene Modifiers or Theophylline: For patients with asthma, adding a leukotriene modifier or theophylline to an inhaled corticosteroid could be an option, although these are generally considered less effective than adding a long-acting beta-agonist 3.
• Salmeterol Alternatives: For patients allergic to salmeterol but able to tolerate fluticasone propionate, an alternative long-acting beta-agonist could be considered in combination with fluticasone propionate, if available and appropriate.

Considerations for Selection

The choice of an alternative inhaler should be based on:

• The specific diagnosis (asthma or COPD) and severity of the disease.
• The patient's history of response to previous treatments.
• The presence of any allergies or intolerances to components of the inhalers.
• The ease of use of the inhaler device, as this can affect adherence to treatment.
• The availability of the medication and its cost, as these can vary significantly.

Evidence Base

The decision should be informed by the latest clinical guidelines and evidence from studies comparing different treatments for lung disease, such as those discussed in 4, 5, 6, 2. However, it's crucial to note that individual patient factors and the specific context of the disease must be considered in making treatment decisions.