New Developments: Once Daily Inhalers to Control Asthmaby James Thompson, M.D. Health Professional, Medical Reviewer
Less is more when it comes to the maintenance of asthma with controller medications. Believe it or not, in the late 1980s, patients were instructed to take controller inhalers (for example Vanceril) four puffs three times daily. Many of them were also on Intal (Cromolyn) two puffs four times daily and theophylline tablets (now rarely prescribed) twice daily. The percentage of adults and children who were actually taking their medication three or four times a day was likely small. Studies on compliance with asthma medications cast a dim view on how we currently manage asthma. Some research reports a range of 30-70 percent non-compliance (meaning patients miss doses of their medication up to 7 out of 10 times).
Just in case you didn’t know, “compliance” means following instructions. “Adherence” is an agreement between the health care provider and patient to follow a set of established guidelines in treatment. Doctors prefer the latter term, adherence, in managing chronic medical conditions but the terms are interchangeable.
Many reasons explain why some people are not adherent to medicine schedules despite good intentions. Kathi McNaughton, formerly one of our health experts, posted a detailed review on this topic earlier this year. Kathi gave six reasons people have poor compliance with asthma medications. Reason four was forgetting to take doses, and reason five was that it’s easier to use the rescue inhaler when symptoms arise (since the rescue inhaler is always kept close by).
It makes sense that a once daily schedule of medications is easier to remember than twice, three or more times daily schedule. Recently, Glaxo addressed this matter by formulating two new controller inhalers for treatment of asthma. Last August, Arnuity Ellipta became available for treatment of asthma for age 12 and older. A 100 or 200 micrograms puff inhaler is available by prescription. As a controller agent, Arnuity Ellipta is only used for establishment of control and maintenance of asthma, not for relief of symptoms. It is very similar to fluticasone propionate (fp) inhalers (Flovent), but the fp inhalers are only approved for twice daily use.
Weeks ago Breo Ellipta, a combination corticosteroid and long acting beta agonist (Laba) inhaler became available by prescription for control of asthma in those age 18 or older. Currently a 100 microgram strength (based on the inhaled steroid component) is available, but a higher 200 mcg is on the way. Breo Ellipta also contains a fluticasone derivative (same as Arnuity Ellipta) similar to Flovent and Advair. The Laba in Breo Ellipta is vilanterol and is completely different from salmeterol, which is the Laba in Advair. Breo Ellipta has a box warning, as does Advair and other similar combination inhalers because of the Laba component.
Over the years we’ve learned to live with the box warnings on combination inhalers for asthma because a multitude of people have benefited from them, and side effects are rare.
Let’s face it, most of us don’t want to have to think about taking multiple medications multiple times a day. Once daily, compared to more often, is an easy choice as long as:
The medication works
It’s not too costly (covered by insurance plan)
The medications is readily available (some pharmacies are slow to stock newer formulations)
The medication is safe and has no additional side effects compared to the others
According to clinical trials (before FDA approval) and experience since being approved, Arnuity Ellipta and Breo Ellipta meet most of the above criteria. Both inhalers may be prescribed with discount coupons that greatly reduce the cost for several months. Some discount coupons (occasionally get one free coupons) may be printed off the GSK website.
Final Words Advances in asthma care continue at a high rate of speed, as millions of dollars continue to poor into research and development of new medications. Simplifying the daily medication schedule by developing long-acting controller inhalers that require only one puff daily is a huge contribution to advancement. Adherence should be less difficult as time goes on.