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Choosing an Inhaled Steroid

This post compares the effectiveness, safety, and cost of medicines called inhaled corticosteroids, or just inhaled steroids. These medicines are primarily used to treat people with asthma. But they also are prescribed for people with a condition called chronic obstructive pulmonary (lung) disease, or COPD.

Inhaled steroids are favored over steroid pills because they act directly on the airways. This enhances their effectiveness and lowers the risk of side effects.

For the treatment of asthma, the effectiveness of the six inhaled steroids we evaluate is quite similar. Each reduces symptoms and prevents attacks by roughly the same amount, and none have been shown to be consistently better than the others in treating asthma in adults or children, based on the results of 24 studies and one large-scale review.

Notably, the inhaled steroids differ with respect to their use in children. Because of each drug’s unique properties and potency and the populations in which they were studied, not all of the inhaled steroids can or should be used in children of all ages. Table 1 and Table 3 present this information.

The effectiveness of the inhaled steroids in treating COPD (chronic obstructive pulmonary (lung) disease) is not as clear cut. Fewer studies have compared the drugs in treating COPD and those that have are not definitive. Nevertheless, several studies indicate that two inhaled steroids – budesonide (Pulmicort Turbuhaler) and fluticasone (Flovent HFA) have benefited people with moderate to severe COPD, but not people with mild chronic obstructive pulmonary disease. Table 1 presents information on the effectiveness of the inhaled steroids in people with COPD.

Table 1. The Effectiveness of Inhaled Steroids for Asthma and COPD

Generic Name (Brand Name) Effective for Asthma Prevention in Adults Effective for Asthma Prevention in Children Effective for Mild COPD Effective for Moderate to Severe COPD
Beclomethasone (QVAR) Yes Yes, in children 5 years and older No evidence available No evidence available
Budesonide (Pulmicort Turbuhaler) Yes Yes, in children 6 year and older Probably not Yes
Budesonide (Pulmicort Respules)1 No Yes, in children 1 year and older Probably not No evidence available
Flunisolide (AeroBid) Yes Yes, in children 6 years and older No evidence available No evidence available
Fluticasone (Flovent HFA) Yes Yes, in children 12 years and older Probably not Yes
Mometasone (Asmanex Twisthaler) Yes Yes, in children 12 years and older No evidence available No evidence available
Triamcinolone (Azmacort) Yes Yes, in children 6 years and older Probably not No evidence available

1 This drug is packaged in a nebulizer, an alternative type of inhaler.

Of course, as with all medicines, you may respond better to one inhaled steroid than another, or experience fewer side effects with one. Only trying the medicines can determine this, and you and your doctor will be able to assess whether you are responding well or not.

The inhaled steroid drugs differ in their convenience of use, the inhaler device in which they are packaged, and their cost. Indeed, inhaled steroids come in a variety of doses and preparations – which is both an advantage and a burden in terms of choice. Your doctor and pharmacist can help guide you, but the more you know about your preferences the better off you’ll be.

Choosing_an_Inhaled_Steroid

First, the strength and potency of each medicine is different. That means that the dose you may need and the number of puffs you may have to take each day could vary quite widely from drug to drug.

For instance, triamcinolone (Azmacort) has a relatively low potency and, depending on the severity of your condition, it could take 7 to 25 puffs per day to get the required dose. By comparison, mometasone (Asmanex), which is more potent, requires only 1 to 3 puffs per day for an adult.

Table 2. Inhaled Steroid Choices and Cost Comparison – Adults

Generic Name and Stength Brand Name Use1 Puffs Per Day2 Average Monthly Cost3
Beclomethasone 40 mcg QVAR Low 4 $87
Medium 9 $196
High4 16 $349
Beclomethasone 80 mcg QVAR Low 2 $51
Medium 4 to 5 $115
High4 8 $204
Budesonide 200 mcg Pulmicort Turbuhaler Low 2 $60
Medium 4 to 5 $136
High4 8 $241
Flunisolide 250 mcg AeroBid Low 3 $86
Medium 6 $172
High4 11 $316
Flunisolide 250 mcg AeroBid-M (menthol flavored) Low 3 $82
Medium 6 $164
High4 11 $302
Fluticasone 44 mcg Flovent HFA Low 4 $92
Medium 10 to 11 $241
High4 19 $436
Fluticasone 110 mcg Flovent HFA Low 1 to 2 $45
Medium 4 $119
High4 8 $239
Fluticasone 220 mcg Flovent HFA Low 1 $46
Medium 2 $92
High4 4 $184
Mometasone 220 mcg (30 puffs per inhaler)5 Asmanex Twisthaler Low 1 $122
Medium 2 $244
High4 3 $366
Mometasone 220mcg (60 puffs per inhaler)5 Asmanex Twisthaler Low 1 $61
Medium 2 $121
High4 3 $182
Mometasone 220 mcg (120 puffs per inhaler)5 Asmanex Twisthaler Low 1 $41
Medium 2 $82
High4 3 $124
Triamcinolone 100 mcg Azmacort Low 7 $100
Medium 15 $214
High4 25 $357

1. The range of low to high use is from the National Asthma Education and Prevention Program (NAEPP) Expert Panel. We use the mid-point of low and medium dosing ranges and an approximation of a reasonable dose in the high dosing range to further classify the number of puffs per day and average monthly cost.
2. The number of puffs per day reflects the mid-point or a reasonable estimate based on the NAEPP dosing categories.
3. Prices reflect nationwide retail average for December 2005, rounded to the nearest dollar. This information from data provided by Wolters Kluwer Health, Pharmaceutical Audit Suite.
4. This dosing exceeds the manufacturer’s highest recommend dose, but is consistent with the NAEPP Expert Panel’s classification of a high dose.
5. This drug comes in an inhaler programmed to deliver a specified number of puffs.

For someone who needs a relatively high dose, a drug that requires you to take many puffs per day is inconvenient and may lower the benefit they can get from the drug.

Second, inhaler devices differ. You may prefer one over another. Your doctor may also. Two of the drugs, budesonide (Pulmicort Turbuhaler) and mometasone (Asmanex Twisthaler), are available in so-called dry powder inhalers rather than in metered dose inhalers.

Cost is the third criteria to consider in your choice of an inhaled steroid, especially if you are paying out of your own pocket but even if your drug costs are covered by insurance. Your insurer may have chosen one of the inhaled steroids as a preferred drug, which lowers the cost to them but to you as well. Unless your doctor advises a particular inhaled steroid for clinical or convenience reasons, you or your child may be best off using the one your health plan prefers if it will cost you less.

Table 3. Inhaled Steroid Choices and Cost Comparison – Children

Generic Name and Strength (Approved Ages)1 Brand Name Dose2 Puffs Per Day3 Average Monthly Cost4
Beclomethasone 40 mcg (≥ 5 years) QVAR Low 3 $65
Medium 6 $131
High6 11 $240
Beclomethasone 80 mcg (≥ 5 years) QVAR Low 1 to 2 $38
Medium 3 $76
High6 5 to 6 $140
Budesonide 200 mcg (≥ 6 years) Pulmicort Turbuhaler Low 1 to 2 $45
Medium 3 $90
High6 5 to 6 $166
Budesonide 0.25 mg/2 ml (1-8 years) Pulmicort Respules5 Low 2 $376
Medium 4 $752
High6 8 $1504
Budesonide 0.5mg/2ml (1-8 years) Pulmicort Respules5 Low 1 $197
Medium 2 $394
High6 4 $789
Flunisolide 250 mcg(≥ 6 years) AeroBid Low 2 to 3 $72
Medium 4 to 5 $129
High6 7 to 8 $215
Flunisolide 250 mcg (≥ 6 years) AeroBid-M (menthol flavored) Low 2 to 3 $69
Medium 4 to 5 $123
High6 7 to 8 $206
Fluticasone 44 mcg (≥ 12 years) Flovent HFA Low 3 $69
Medium 7 $161
High6 13 $298
Fluticasone 110 mcg (≥ 12 years) Flovent HFA Low 1 $30
Medium 2 to 3 $75
High6 7 $209
Fluticasone 220 mcg (≥ 12 years) Flovent HFA Low
Medium 1 to 2 $69
High6 3 $138
Triamcinolone 100 mcg (≥ 6 years) Azmacort Low 6 $86
Medium 10 $126
High6 18 $228

1. Ages approved by the Food and Drug Administration.
2. The range of low to high use is from the National Asthma Education and Prevention Program (NAEPP) Expert Panel. We use the mid-point of low and medium dosing ranges and an approximation of a reasonable dose in the high dosing range to further classify the number of puffs per day and average monthly cost.
3. The number of puffs per day reflects the mid-point or a reasonable estimate for the NAEPP dosing categories.
4. Prices reflect nationwide retail average for December 2005, rounded to the nearest dollar. This information from data provided by Wolters Kluwer Health, Pharmaceutical Audit Suite.
5. This drug is packaged in a nebulizer, an alternative type of inhaler.
6. This dosing exceeds the manufacturer’s highest recommend dose, but is consistent with the NAEPP Expert Panel’s classification of a high dose.

Tables 2 and 3 present the list of inhaled steroids, the dose strength options for each, the number of puffs you have to take depending on need and severity of your illness, and the average monthly cost of each drug at various typical uses. The dose calculations are based on information from the National Asthma Education and Prevention Program Expert Panel.

These tables should help you and your doctor make an appropriate choice. Taking effectiveness, safety, dosing convenience, and cost into account, we have chosen the following steroid inhalers for treating adult and childhood asthma and adult chronic obstructive pulmonary (lung) disease:

Beclomethasone (QVAR) 80 mcg – for adults and children aged 5 and over with asthma

Budesonide (Pulmicort Turbuhaler) 200 mcg – for adults with asthma who may prefer a dry powder inhaler and for children with asthma aged 6 and over

Fluticasone (Flovent HFA) 110 mcg -for children with asthma aged 12 and over

Fluticasone (Flovent HFA) 220 mcg -for children aged 12 and over and adults with asthma, and for adults with moderate to severe COPD

Mometasone (Asmanex Twisthaler) 220 mcg -for adults with asthma

As you can see in Tables 2 and 3, all four medicines at the specified doses are well priced at the low and medium number of puffs needed per day, which are the most common ones. In addition, at these doses, low- and medium-level use requires fewer puffs per day. That assures better compliance and control of your symptoms over time.

As you can also see in the tables, if you need a low or medium amount of inhaled steroid, the cost is not too excessive – though it is not trivial. However, if you need a high dose – usually because your asthma or COPD is severe – the cost can be quite steep, over $200 or $300 a month. For some of the inhaled steroids for children, the cost is even higher. If you need this amount of any of a steroid inhaler, talking with your doctor about the most afforable one becomes even more important.

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