If budesonide-formoterol were to become available over the counter (OTC) and used as-needed for mild asthma, it would save lives and cut healthcare costs, according to a computer modeling study presented at the American Academy of Allergy, Asthma, &Immunology (AAAAI) 2023 Annual Meeting in San Antonio.
Asthma affects 25 million people, about 1 in 13, in the United States. About 28% are uninsured or underinsured, and 70% have mild asthma. Many are using a $30 inhaled epinephrine product (Primatene Mist) — the only FDA-approved asthma inhaler available without a prescription, said Marcus Shaker, MD, MS, professor of pediatrics and medicine at Geisel School of Medicine at Dartmouth and clinician at Dartmouth Health Children’s, New Hampshire.
A new version of Primatene Mist was reintroduced on the market in 2018 after the product was pulled for containing chlorofluorocarbons in 2011, but it is not recommended by professional medical societies because of safety concerns over with epinephrine’s adverse effects, such as increased heart rate and blood pressure.
Drugs in its class (bronchodilators) have long been associated with a higher risk for death or near-death.
Meanwhile, research more than two decades ago linked regular use of low-dose inhaled corticosteroids with reduced risk for asthma death.
More recently, two large studies (SYGMA 1 and SYGMA 2) compared maintenance therapy with a low-dose inhaled corticosteroid (budesonide) vs on-demand treatment with an inhaler containing both a corticosteroid (budesonide) and a long-acting bronchodilator (formoterol).
“Using as-needed budesonide-formoterol led to outcomes that are almost as good as taking a maintenance budesonide dose every day,” said Shaker.
The Global Initiative for Asthma (GINA) guidelines now recommend this approach — as-needed inhaled corticosteroids (ICS) plus long-acting bronchodilators — for adults with mild asthma. In the United States, however, the National Heart, Lung, and Blood Institute still suggests daily ICS plus quick-relief therapy as needed.
Shaker and colleagues used computer modeling to compare the cost-effectiveness of as-needed budesonide-formoterol vs over-the-counter inhaled epinephrine in underinsured U.S. adults who were self-managing their mild asthma. The study randomly assigned these individuals into three groups: OTC inhaled epinephrine (current reality), OTC budesonide-formoterol (not yet available), or no OTC option. The model assumed that patients treated for an exacerbation were referred to a healthcare provider and started a regimen of ICS plus as-needed rescue therapy.
In this analysis, which has been submitted for publication, the OTC budesonide-formoterol strategy was associated with 12,495 fewer deaths, prevented nearly 14 million severe asthma exacerbations, and saved over $68 billion. And “when we looked at OTC budesonide-formoterol vs having no OTC option at all, budesonide-formoterol was similarly cost-effective,” said Shaker, who presented the results at an AAAAI oral abstract session.
The cost savings emerged even though in the United States asthma controller therapies (e.g., fluticasone) cost about 10 times more than rescue therapies (e.g., salbutamol, OTC epinephrine).
Nevertheless, the results make sense. “If you’re using Primatene Mist, your health costs are predicted to be much greater because you’re going to be in the hospital more. Your asthma is not going to be well-controlled,” Thanai Pongdee, MD, an allergist-immunologist with the Mayo Clinic in Rochester, Minnesota, told Medscape Medical News. “It’s not only the cost of your ER visit but also the cost of loss of work or school, and loss of daily productivity. There are all these associated costs.”
The analysis “is certainly something policymakers could take a look at,” he said.
He noted that current use of budesonide-formoterol is stymied by difficulties with insurance coverage. The difficulties stem from a mismatch between the updated recommendation for as-needed use and the description printed on the brand-name product (Symbicort).
“On the product label, it says Symbicort should be used on a daily basis,” Pongdee said. “But if a prescription comes through and says you’re going to use this ‘as needed,’ the health plan may say that’s not appropriate because that’s not on the product label.”
Given these access challenges with the all-in-one inhaler, other researchers have developed a workaround — asking patients to continue their usual care (i.e., using a rescue inhaler as needed) but to also administer a controller medication after each rescue. When tested in Black and Latino patients with moderate-to-severe asthma, this easy strategy (patient activated reliever-triggered inhaled corticosteroid, or PARTICS) reduced severe asthma exacerbations about as well as the all-in-one inhaler.
If the all-in-one budesonide-formoterol does become available OTC, Shaker stressed that it “would not be a substitute for seeing an allergist and getting appropriate medical care and an evaluation and all the rest. But it’s better than the status quo. It’s the sort of thing where the perfect is not the enemy of the good,” he said.
Shaker is the AAAAI co-chair of the Joint Task Force on Practice Parameters and serves as an editorial board member of the Journal of Allergy and Clinical Immunology In Practice. He is also an associate editor of the Annals of Allergy, Asthma, and Immunology. Pongdee serves as an at-large director on the AAAAI board of directors. He receives grant funding from GlaxoSmithKline, and Mayo Clinic is a trial site for GlaxoSmithKline and AstraZeneca.
American Academy of Allergy, Asthma, & Immunology (AAAAI) 2023 Annual Meeting. Oral Abstract Session 4606. Presented February 27, 2023.
Esther Landhuis is a freelance science & health journalist in the San Francisco Bay Area. She can be found on Twitter @elandhuis .