Update on Pulmicort : From Turbuhaler to Flexhaler

James Thompson, MD Health Pro July 14, 2008
  • According to the recently revised National Institute of Health asthma guidelines, inhaled corticosteroids are the preferred class of controller medications for treating persistent asthma in all ages. Pulmicort Turbuhaler, a brand of budesonide, was approved by the FDA (Food and Drug Administration) for marketing in the US in 1997.

     

    For almost 10 years it was available in a dry powder device that contained 200 doses. Each puff (dose) of Pulmicort provided 200 micrograms (mcg) of budesonide inhalant.  A small indicator window on the device displayed a red marker when there were 20 doses left. The marker would first appear in the upper part of the window, gradually moving with each dose taken, to the bottom of the window. Once at the bottom, the marker stayed there despite further attempts to advance doses. This meant the Turbuhaler was empty.

     

    Did you know Pulmicort Turbuhaler was discontinued in 2007?

    Astra Zeneca, the pharmaceutical company that makes Pulmicort made a few changes to their product and changed the name to Pulmicort Flexhaler, which became available last year. The Turbuhaler was replaced by Pulmicort Flexhaler 180 and Pulmicort Flexhaler 90.

     

    What are the changes?

    • The Flexhaler has two strengths : the 90mcg/puff and 180mcg/puff. The smaller dosed inhaler may be more useful for young children who require smaller amounts of inhaled steroid.
    • There is no longer a 200mcg/puff formulation of budesonide but the Pulmicort Flexhaler 180mcg/puff is equivalent to the Pulmicort Turbuhaler 200 based on the amount of medication that actually leaves the mouthpiece.
    • The mouthpiece has been modified. Grooves have been placed almost an inch from the tip of the mouthpiece to keep the you from placing the inhaler too far into the mouth.
    • Instead of having a red marker as the dose indicator, there is an open window with numbers that tell you how many doses are left. The doses are counted down by 10, alternating the numbers with a hatch (e.g. 12 - 100 - 80 - ...)
    • The number of doses in the Pulmicort Flexhaler was changed to 120 for the 180mcg/puff unit and 60 for the 90mcg/unit.
    • Instructions for priming and inhaling are very similar to the Turbuhaler. The new Flexhalers also require two cycles of complete turns of the brown grip but it doesn't matter which direction you turn (right or left). The click should be heard on one of the turns (remember: the mouthpiece should be pointing straight up when priming and loading).

    Are there any downsides to the new Flexhaler?

    I'm glad you asked. I have a few opinions based on my experience in prescribing both old and new formulations:

    • The number of doses in the Flexhaler 180mcg/puff was decreased to 120 from 200. The Turbuhaler allowed longer periods of time between pharmacy visits (especially when on low doses). The 90mcg/puff Flexhaler only has 60 doses, yet the recommended starting dose for children (age 6-17yrs) is 180mcg (2 puffs) twice daily. This means the inhaler will need to be refilled in 2 weeks. For this reason I rarely prescribe the 90mcg/puff Flexhaler.
    • The Flexhalers only have bid (twice daily) indications for dosing whereas the Turbuhaler allowed for optional dosing of once daily (when children or adults were on low dose maintenance). I have many of my patients step down to the once daily dosing when they are doing well despite this change.
    • The Flexhaler, like its predecessor (Turbuhaler) requires a forceful suction through the mouthpiece in order to fully draw out the medication. For some younger children this may be difficult. Practice with the placebo trainer is important.

    Final Comments

  • The Pulmicort Flexhalers have replaced Pulmicort Turbuhaler and offer the same inhaled steroid in a device with an improved design and two dosing options (180 or 90 mcg/puff).  Pulmicort, a brand of budesonide, is the only category B (a favorable pregnancy rating) inhaled corticosteroid. It is also the only inhaled steroid that has a formulation for the nebulizer, approved for children 12 months to 8 years of age (Pulmicort Respules).

     

    Pulmicort Flexhaler is firmly entrenched in my collection of inhaled steroids for control of mild to moderate persistent asthma. I also use other brands of inhaled steroids which offer different advantages in asthma care.

     

    All brands of inhaled corticosteroids including Pulmicort Flexhalers are prescription only, and should be used under the guidance of a physician.

     

    What do you think about Pulmicort Flexhaler?