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Tuesday, September 25, 2007

Managing Mild Asthma

Singulair versus Flovent versus Advair for Mild Persistent Asthma?

There is no question that in general Advair is more effective than Flovent and that Flovent is more effective than Singulair for controlling asthma. Most patients with mild asthma only go to see a doctor during an asthma exacerbation – that’s certainly not optimal, but that’s human nature. There are so many other responsibilities in life that you tend to ignore problems unless they become severe. The doctor then prescribes what she knows are the most likely drugs to “get you back on your feet” as soon as possible. That usually means a combination asthma controller inhaler (Advair or newcomer Symbicort) and, if your asthma severity is really worrisome, or if you’ve previously needed hospitalization for an asthma attack, she will prescribe a burst of prednisone.

[Strangely enough, the 10-14 days of prednisone (the strongest medication) will cost less than ten dollars, while each inhaler will cost somebody up to $200. ]

Anyway, within a few weeks, you will be feeling better and back into the yellow zone, and several weeks after that, you will probably be back into the green zone, demonstrating that your asthma is back in good control. What then? What asthma controller medications should you then be “stepped down” to? There are several options.

A new, large study addressed just that question. The investigators randomly assigned 500 children and adults with well-controlled mild asthma to step down to one of three options:

  1. Advair (100mcg fluticasone plus 50mcg salmeterol once each night);
  2. Flovent (100mcg fluticasone twice a day); or
  3. Singulair (a 5 or 10mg monteleukast pill every night; 5mg for kids, 10mg for adults).

About one-third of the patients had experienced an asthma exacerbation during the previous 12 months. About two-thirds of the patients also had allergic rhinitis. This study started in the summer of 2003 at 19 sites in the United States, and was funded by Glaxo (the company that makes Advair and Flovent inhalers) and the American Lung Association (published in NEJM May 2007). A colleague and friend of mine, Dr. Robert Wise at Johns Hopkins, was the principal investigator at the coordinating center. The measures of successful treatment were:

  • the number of days before another asthma exacerbation
  • the percentage of days free from asthma symptoms.

So what happened during the 4 months of follow-up for each study participant?

The percentage of asthma-free days was about 80% for all 3 groups, which means that on the average, they didn’t need to take albuterol for asthma symptoms for 4 of every 5 days.

About 20% of those who took the low dose Advair once-a-day and 20% of those who took the low dose Flovent every night had an asthma exacerbation, compared to 30% of those who only took a Singulair pill every night. There were 8 different events which were considered an asthma exacerbation (aka an event), including urgent care visits for asthma, the need for a burst of prednisone, the need for an excessive amount of albuterol for two or more days in a row, or a worrisome fall in lung function (FEV1 or peak flow). Half of the exacerbations were because the FEV1 had decreased more than 20% from the beginning of the study (even though the patient may have felt fine).

Side-effect rates (aka adverse events) were similar in the 3 groups, except that those taking Singulair reported fewer upper respiratory infections (27% versus 38%), fewer lower respiratory infections (7% versus 14%), and fewer episodes of fever (15% versus 25%). Hmmm, it sounds like even a low daily dose of fluticasone substantially increased the risk of viral respiratory infections, but reduced the risk of an asthma exacerbation. Since respiratory viruses are the most common cause of asthma exacerbations, this is a paradox.

I agree with the authors’ conclusion that “individual patients and their physicians must choose a treatment regimen for asthma that balances efficacy with actual or perceived risks and maximizes adherence. No single approach will provide the best combination of these factors for all patients with asthma.”

Don’t let your doctor practice “cookbook medicine” (one size fits all) for your asthma therapy. Once your asthma is well-controlled, ask her about stepping down your therapy. Learn all that you can about your asthma and asthma medicines. WebMD provides many resources for those with asthma.

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Posted by: Paul Enright MD at 9:17 am


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