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.
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|
|Beclomethasone 80 mcg||QVAR||Low||2||$51|
|Medium||4 to 5||$115|
|Budesonide 200 mcg||Pulmicort Turbuhaler||Low||2||$60|
|Medium||4 to 5||$136|
|Flunisolide 250 mcg||AeroBid||Low||3||$86|
|Flunisolide 250 mcg||AeroBid-M (menthol flavored)||Low||3||$82|
|Fluticasone 44 mcg||Flovent HFA||Low||4||$92|
|Medium||10 to 11||$241|
|Fluticasone 110 mcg||Flovent HFA||Low||1 to 2||$45|
|Fluticasone 220 mcg||Flovent HFA||Low||1||$46|
|Mometasone 220 mcg (30 puffs per inhaler)5||Asmanex Twisthaler||Low||1||$122|
|Mometasone 220mcg (60 puffs per inhaler)5||Asmanex Twisthaler||Low||1||$61|
|Mometasone 220 mcg (120 puffs per inhaler)5||Asmanex Twisthaler||Low||1||$41|
|Triamcinolone 100 mcg||Azmacort||Low||7||$100|
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|
|Beclomethasone 80 mcg (≥ 5 years)||QVAR||Low||1 to 2||$38|
|High6||5 to 6||$140|
|Budesonide 200 mcg (≥ 6 years)||Pulmicort Turbuhaler||Low||1 to 2||$45|
|High6||5 to 6||$166|
|Budesonide 0.25 mg/2 ml (1-8 years)||Pulmicort Respules5||Low||2||$376|
|Budesonide 0.5mg/2ml (1-8 years)||Pulmicort Respules5||Low||1||$197|
|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|
|Fluticasone 110 mcg (≥ 12 years)||Flovent HFA||Low||1||$30|
|Medium||2 to 3||$75|
|Fluticasone 220 mcg (≥ 12 years)||Flovent HFA||Low||–||–|
|Medium||1 to 2||$69|
|Triamcinolone 100 mcg (≥ 6 years)||Azmacort||Low||6||$86|
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.