What! My Advair Isn’t Covered? Advair vs Symbicort, Does It Matter?

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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Enough of you were using Advair Diskus (fluticasone propionate and salmeterol) to make it one of the top 10 selling drugs last year. Now, Express Scripts, the nation’s largest pharmacy benefit manager, will not cover it or Advair HFA (see more information here) and instead recommends Symbicort (budesonide and formoterol). So, what’s the deal?

Why do we need bronchodilators plus inhaled glucocorticoids in the first place?

Advair, Symbicort and Dulera are all inhaled glucocorticoids mixed with a long-acting bronchodilator. For patients with asthma and COPD (chronic obstructive pulmonary disease) who have significant symptoms or repeated exacerbations you will use one daily. Know that the evidence for these inhalers for asthma is much more compelling than for COPD but all three of them work better than placebo for your symptoms. The combination inhalers are used after your bronchodilator (Proventil or Proair) hasn’t helped you out enough.

Do the combo inhaled steroid/bronchodilators work?

Yes. When compared to using an inhaled steroid alone or an inhaled bronchodilator (albuterol) alone, combination therapy significantly improves some outcomes. Symbicort has collected more data on teens and adolescents with asthma but all three of these inhalers work better than placebo in folks with asthma and COPD. There aren’t many comparisons for us to know which of these three inhalers is best but in one head to head study Symbicort edged out Advair in reducing hospitalizations and ER visits in people older than 16 with asthma.

What about Advair?

Well, the largest two trials ever done using these combination inhalers for COPD were with Advair. Advair has been proven to work well and significantly improved lung function, health status, and the rate of exacerbations compared to placebo, salmeterol alone, or fluticasone alone. Advair also showed a reduction in mortality rate over three years compared to placebo (folks doing nothing).

What about the others?
Dulera is another combination (mometasone and formoterol) that works well for asthma and severe COPD. There are no comparisons of Dulera to Advair or Symbicort.

Is there anything new?

Yes, there is a once daily dry powder inhaler called Breo Ellipta (fluticasone furoate and vilanterol) which has been approved by the FDA for the treatment of COPD and asthma. Stay tuned on this because while once a day is appealing, it has just appeared on the market and it’s pricey.

Take home message:

It’s a hassle but you will be fine with a switch from Advair to Symbicort if the powers that be demand it. There is no strong evidence for one over the other.

Dr O.

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