Is Arnuity Ellipta (fluticasone furoate) an appropriate alternative to fluticasone propionate inhaler for a 15‑year‑old patient with asthma previously on fluticasone propionate HFA 44 µg twice daily?

Is Arnuity Ellipta an Appropriate Alternative to Fluticasone Propionate HFA for a 15-Year-Old with Asthma?

Yes, Arnuity Ellipta (fluticasone furoate) is an appropriate and effective alternative to fluticasone propionate HFA for this 15-year-old patient with asthma, offering the advantage of once-daily dosing with comparable efficacy to twice-daily fluticasone propionate. 1, 2

Dose Equivalency and Selection

For a patient previously on fluticasone propionate HFA 44 µg twice daily (88 µg total daily), the appropriate starting dose of Arnuity Ellipta is 100 µg once daily. 3, 1

• Fluticasone furoate 100 µg once daily falls within the low-dose ICS range for adolescents aged 12 years and older (100-250 µg/day total). 3
• This represents a comparable or slightly higher total daily dose than the previous regimen, which is appropriate for maintaining asthma control. 3, 1
• The 200 µg strength would be reserved for patients requiring medium-dose ICS therapy or those inadequately controlled on the 100 µg dose. 3, 1

Evidence Supporting Once-Daily Fluticasone Furoate

Fluticasone furoate 100 µg once daily demonstrates significant improvements in lung function and asthma control compared to placebo, with efficacy comparable to fluticasone propionate 250 µg twice daily. 2

• In a 24-week randomized controlled trial, fluticasone furoate 100 µg once daily improved pre-dose evening FEV1 by 146 mL compared to placebo (p = 0.009), with similar improvements to fluticasone propionate 250 µg twice daily (+145 mL, p = 0.011). 2
• Fluticasone furoate 100 µg once daily increased rescue-free 24-hour periods by 14.8% compared to placebo (p < 0.001). 2
• Once-daily evening dosing of fluticasone furoate 200 µg is non-inferior to the same total dose given twice daily (100 µg BD), with a mean treatment difference of only 11 mL (95% CI: -35 to +56 mL). 4
• Morning versus evening administration of fluticasone furoate produces comparable improvements in 24-hour weighted mean FEV1, so timing can be based on patient preference and adherence. 5

Advantages of the Ellipta Device

The Ellipta dry powder inhaler offers superior ease-of-use and patient satisfaction compared to traditional DPI devices, which may improve adherence in adolescent patients. 6

• In elderly asthma patients (a population with potential dexterity challenges similar to some adolescents), fluticasone furoate/vilanterol via Ellipta was significantly preferred over fluticasone propionate/salmeterol via Diskus (p < 0.01). 6
• The once-daily dosing regimen addresses the well-documented problem of poor adherence to twice-daily ICS therapy in asthma patients. 7, 4
• The device requires minimal coordination and provides dose confirmation, reducing technique-related errors. 6

Safety Profile

Fluticasone furoate 100 µg once daily has a safety profile comparable to fluticasone propionate, with minimal systemic effects at this low dose. 2

• On-treatment adverse events occurred in 53% of patients receiving fluticasone furoate 100 µg once daily versus 42% with fluticasone propionate 250 µg twice daily and 40% with placebo. 2
• Severe asthma exacerbations were lower with fluticasone furoate 100 µg once daily (3%) compared to placebo (7%). 2
• While statistically significant suppression of urinary cortisol was observed at week 24 with fluticasone furoate 100 µg once daily (p = 0.030), this was comparable to fluticasone propionate 250 µg twice daily (p = 0.036) and is not clinically significant at low doses. 2
• At low doses, ICS therapy is generally considered safe, with benefits outweighing risks for most patients with persistent asthma. 7

Critical Implementation Guidance

Ensure proper inhaler technique with the Ellipta device and establish clear expectations for daily use as controller medication, not rescue therapy. 3

• The patient must understand that Arnuity Ellipta is a maintenance medication requiring daily use even when asymptomatic, as asthma is a chronic inflammatory disease. 3
• Instruct the patient to rinse mouth and spit after each use to prevent oral candidiasis and dysphonia. 3
• Continue short-acting beta-agonist (SABA) as needed for acute symptom relief; SABA use >2 days/week indicates inadequate control and need to step up therapy. 7
• Reassess asthma control every 2-6 weeks initially after switching medications. 3

When to Consider Alternative Approaches

If asthma remains uncontrolled after 4-6 weeks on Arnuity Ellipta 100 µg once daily despite proper technique and adherence, step up to either Arnuity Ellipta 200 µg once daily or add a long-acting beta-agonist (LABA) to the low-dose ICS. 7, 3

• For adolescents aged 12 years and older with mild persistent asthma, either daily low-dose ICS with as-needed SABA or as-needed ICS with SABA used concomitantly are both acceptable Step 2 therapy options. 7
• Combination ICS/LABA therapy (such as fluticasone furoate/vilanterol) is preferred over high-dose ICS alone for moderate to severe persistent asthma. 8, 1
• Never allow LABA monotherapy due to increased risk of severe exacerbations and asthma-related deaths. 8

Common Pitfalls to Avoid

• Do not assume the patient will automatically use the device correctly—demonstrate proper Ellipta technique and verify understanding at the initial visit and follow-up appointments. 7
• Do not continue therapy indefinitely without reassessment—the goal is to find the minimum effective dose that maintains control, with consideration for stepping down after 2-4 months of sustained control. 3
• Do not increase to high-dose ICS monotherapy if control is inadequate—adding a LABA provides greater benefit than doubling the ICS dose for moderate to severe persistent asthma. 7, 8
• Do not prescribe Arnuity Ellipta for acute symptom relief—this is a controller medication, not a rescue inhaler. 3