From the Guidelines
The most cost-effective inhaled corticosteroid (ICS) inhaler option is typically a generic dry powder inhaler (DPI) or a metered-dose inhaler (MDI) with a spacer, such as generic fluticasone propionate (e.g., Flovent HFA generic) or beclomethasone dipropionate (QVAR), as they provide good anti-inflammatory control for asthma and COPD at a lower price point than newer alternatives 1. When choosing an ICS inhaler, it's essential to consider the patient's ability to use the device correctly, as well as their preferences and inspiratory flow rate.
- DPIs are a good option for patients who can generate sufficient inspiratory flow and have good coordination and technique.
- MDIs with spacers are suitable for patients who have difficulty using DPIs or need assistance with coordination.
- The standard starting dose for adults is 88-220 mcg twice daily, adjusted based on symptom control.
- It's crucial to rinse the mouth after each use to prevent oral thrush and use a spacer device if necessary.
- Newer ICS inhalers like fluticasone furoate (Arnuity Ellipta) or mometasone (Asmanex) may offer once-daily dosing but typically cost more without providing substantially better symptom control for most patients.
- Insurance coverage varies significantly, so it's essential to check with the pharmacy about specific pricing with the patient's insurance plan.
- A study published in 2022 found that local variation in prescribing guidelines for adult asthma in England was associated with differences in MDI use, highlighting the importance of considering clinical efficacy, financial costs, environmental factors, and patient preferences when creating local prescribing guidance 1.
From the Research
Cost-Effectiveness of ICS Inhalers
- The cost-effectiveness of as-needed budesonide/formoterol versus low-dose inhaled corticosteroid (ICS) maintenance therapy in patients with mild asthma has been assessed in several studies 2, 3.
- A study conducted in the UK found that as-needed budesonide/formoterol was associated with a £292.99 cost saving and quality-adjusted life year (QALY) gains of 0.001 versus ICS + SABA 2.
- Another study conducted in Canada found that as-needed budesonide-formoterol was the dominant treatment option, providing incremental cost savings of $9882 per patient and QALY gains of 0.002 versus low-dose maintenance ICS plus as-needed SABA over a 50-year time horizon 3.
Comparison of ICS Inhalers
- A comparison of budesonide/formoterol maintenance and reliever therapy vs. conventional best practice in asthma management found that the simplified regimen using budesonide/formoterol was at least as effective at improving clinical control compared with conventional best practice, with a significantly lower ICS dose and lower drug costs 4.
- A review of the extrafine formulation of beclomethasone dipropionate/formoterol fumarate/glycopyrronium bromide delivered via pressurized metered-dose inhaler found that it was a viable add-on therapeutic strategy for difficult-to-treat and severe asthma, with a significant improvement in respiratory function and a reduction in the frequency of exacerbations 5.
Efficacy of Budesonide
- Budesonide has been extensively evaluated in clinical trials and has been found to be effective in the management of adult and pediatric patients with moderate to severe asthma 6.
- The efficacy of budesonide is associated with a dose-response effect, and it has been found to be effective at a significantly lower dose than beclomethasone dipropionate administered by pressurized metered-dose inhaler 6.