A new inhaled drug for chronic asthma may improve lung function as much as two older inhaled asthma drugs but at half the dose, a review of recent studies concludes.
At the smaller dose, the new drug fluticasone was just as effective as beclomethasone and budesonide at opening up constricted breathing passages, according to review author Dr. Nick Adams, a private practitioner in Tonbridge, England, and colleagues.
Patients taking the three drugs had similar rates of “rescue” inhaler use, the researchers found. Rescue inhaler medications such as albuterol are used to immediately open the lung’s airways during an asthma attack. Fluticasone, beclomethasone and budesonide prevent and reduce the severity of asthma attacks over a longer period of time.
The studies did not contain enough information to determine how any of the drugs affected asthma symptoms like wheezing and shortness of breath or whether any of the treatments led to more severe asthma attacks.
“A clear recommendation for fluticasone over the older agents cannot be made on the basis of every outcome from this review, but in the most severe patients fluticasone may confer an advantage over beclomethasone or budesonide,” Adams and colleagues write.
The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
Fluticasone, beclomethasone and budesonide are inhaled corticosteroid drugs that decrease airway swelling and irritation in asthma patients. Fluticasone is sold under the brand name Flovent and is an ingredient in the combination asthma medication Advair. Beclomethasone is sold under the brand names Beconase, QVAR and Vanceril. Budesonide is sold under the brands Pulmicort and Rhinocort.
Adams and colleagues examined 56 studies of 12,119 chronic asthma patients to compare the effectiveness and safety of the three drugs. In 26 of the studies, patients received either fluticasone or beclomethasone. In 30 studies, patients received fluticasone or budesonide.
The studies measured the drugs’ effects with the help of standard measurements of lung capacity that have been used to diagnose asthma, such as the amount of air that can be forcibly expelled from the lungs in one second after a deep breath.
For instance, a dose of fluticasone that was half the size of the beclomethasone or budesonide dose increased the amount of air exhaled in one second by an average of .14 liters, the researchers found.
In the studies that compared equal doses of fluticasone and beclomethasone or budesonide, the researchers found that fluticasone patients had slightly better lung function, but the improvements were not as impressive as previous studies of fluticasone’s potency would predict, according to Adams.
“A logical explanation would be for even greater benefits favoring fluticasone to be seen when given at equal … daily dose to beclomethasone or budesonide,” Adams says. He suggests the “apparent paradox” may be a result of fewer studies and less data comparing equal doses.
Compared to patients receiving the same size dose of beclomethasone or budesonide, patients taking fluticasone were more likely to report hoarseness. Fluticasone patients did not have an increased likelihood of other steroidal side effects like oral thrush or sore throat, however.
Although the Cochrane reviewers did not do a cost comparison of the drugs, University of Iowa asthma expert Dr. Miles Weinberger says price may be a factor in why doctors prescribe one medication over another.
For instance, the Pulmicort Turbohaler, which contains budesonide, “is the most cost-effective preparation because the cost per usual daily dose, one inhalation twice daily, is lower than any of the other inhaled steroids,” Weinberger says.
In a second review conducted by Adams and colleagues, the researchers compared fluticasone treatments with a placebo and concluded that the drug “is highly effective even in low doses” and can be used alongside more powerful oral steroids.
“In people with severe asthma who need oral steroid tablets to control their asthma, it can reduce the dose of oral steroids they need and improve their asthma at the same time,” Adams explains.
Patients taking fluticasone were less likely than those taking a placebo to abandon the treatment because their asthma was getting worse instead of better, an advantage that is “clearly worthwhile from a clinical perspective,” the reviewers write.