Wednesday, May 6, 2009

Thoughts about Advair and alternatives

As I blogged about yesterday, many people have been asking about alternatives to Advair and Symbicort due to the high cost of these meds. I have listed some options here on this blog as they've come to me.

Today I have another option that has popped into my always thinking head. I'm a very curious person, and therefore sometimes I find myself thinking of things other people may never have considered. I'm not saying they'll work, I'm just thinking here.

It's something that's far out there, but actually it isn't. Since Advair** is an expensive mixure of a corticosteroid (Flovent) and long acting bronchodilator (Serevent) meant to treat both the chronic inflammation and prevent acute bronchospasm, why can't a mixture of less expensive meds be used as a replacement for Advair.

Of course Advair is the asthma wonder drug of choice not just because of what it prevents, but because it's easy to carry around, easy to use, and only needs to be taken twice a day. It's highly convenient, and makes asthmatics much more compliant than in years past. If cost were no obstacle, Advair is the medicine of choice.

The only problem with Advair (aside for some minor side effects), is that it costs an arm and a leg. And, since it costs so much, people who do not work, are poor, or have no health insurance have no way of gaining access to it. And it's these people we see in hospital emergency rooms.

So, as a replacement for an Advair discuss that costs $120 a month, why can't Asthmatics (and COPDers too), take Vanceril at $38 a month and Ventolin, which costs $42. That's still a chunk, but it's $40 less than Advair.
I can see a doctor switching a patient from Advair to Vanceril or some other generic corticosteroid (like Azmacort, Beclovent, Aerobid, etc). But instructing every asthmatic to take Ventolin every four hours is frowned upon. Why?

The asthma guidelines themselves say that any asthmatic who needs Ventolin more than 2-3 times in a two week period does not have control of his asthma. If that is true, then why are people who need Serevent in their systems all the time considered under control? Aren't they the same type of medicine, except one lasts for 12 hours and the other 4-6?

And yet, while the asthma guidelines recommends Advair and frown upon overuse of Ventolin (overuse would consist of using it more than the asthma guidelines recommend), it seems every single patient admitted to the hospital with Asthma or COPD is given Ventolin*** every 4-6 hours regardless of whether their disease is exacerbated. Ventolin lasts in the system about that long.

So a wise man asks: Why is it okay to order Ventolin every four hours as a preventative medicine in the hospital, but not okay to order it the same way for outpatient therapy?

A doctor recently gave me an answer when I questioned why she keeps ordering Ventolin Q4 on all her patients. She said, "Because they need it in their system to prevent shortness of breath."

Okay? So, if a patient needs it in his system while in the hospital to PREVENT shortness of breath, then why does this philosophy not apply outside the hospital? Either Ventolin is a preventative medicine or it is not?

It would seem to me if a patient does not respond well to Serevent, then Ventolin is a viable option. Of course you must consider what works for one patient does not work for all.

Personally, I don't think Ventolin prevents anything for most patients. The pre-use of Ventolin has never prevented me from having a bronchospasm. However, the pre-use of a corticosteroid has. However, I'm not saying Ventolin won't prevent for some patients.

I know Ventolin doesn't prevent for me because I had a pre and post PFT done to prove this. But doctors rarely order PFTs to determine if the Ventolin they are ordering on all their patients is working.

That would make too much sense. Better sense would be to use common sense and not order ventolin at all unless it is needed, or at least proven to be effected, which could be a subjective or objective measure.

But actually assessing to determine effectiveness would mean an actual assessment, which would be way to much work for some doctors to bother with. So they just order what feels right, not what is right (Kind of like Washington Politics, hey!).

I suppose you can create a third angle with this argument. If Ventolin should never be used unless a patient is having an exacerbation, then Serevent should never be used period. If the corticosteroid is doing its job, the patient should never get short of breath in the first place.

Yet that may not be a reasonable claim for many patients. Still, Serevent and Ventolin are the same medicine. And, while a patient is taking Serevent on a daily basis, it is still considered safe to use Ventolin with Serevent ( but never safe to use Serevent more than twice a days).

So, if you still need to use Ventolin every day regardless of being on Serevent, is the Serevent even doing it's job? Is it really preventing bronchospasm?

Or, is the reason Advair improves the lives of asthmatics so much more do do with the fact it's easy to use, convenient to carry around, and only needs to be taken twice a day, and not because it has both a corticosteroid and long acting bronchodilator. In other words, would a discus of Flovent alone work as well as Advair?

If the answer is yes, then any patient on Advair that costs $120 could easily be switched to a medicine like Vanceril which costs $38, and not lose any of the benefits. However, there would be one big if here: the patient would have to be as compliant with the Vanceril inhaler as he is with the Flovent discus.

Vanceril may be needed 4 times a day instead of the convenient two. Plus those patients who are now taking Vanceril will also have to lug around a bulky spacer. Obviously we're supposed to carry one around with our Ventolin too, but you and I both know most asthmatics (especially guys) don't carry spacers with them.

Ideally, Advair is better all the way around, except for cost. But, if you are strapped for money, perhaps an alternative generic corticosteroid may work just as well as the Advair, if proper technique is used. That means you have to use a spacer.

And perhaps, if you or your doctor thinks Serevent works so well for you, then why not take Ventolin every 4-6 hours round the clock too, regardless of what the guidelines say.

If I haven't lost you with my rambling here, tell me where you think I'm wrong (or right).

* costs listed are estimates.
**Advair and Symbicort are basically the same med, so when I refer to one, I'm also referring to the other.
***Xopenex may be ordered as well, and if it is the frequency is usually every 4-8 hours because that's how long the medicine lasts.

14 comments:

Anonymous said...

Woww Advair costs roughly a mere $129 bucks, I know this was written back in 2009, It's now 3 yrs later, the Advair cost is now about $240 (without prescription plan) at a Shoprite pharmacy!

Rick Frea said...

I think the cost to the hospital I buy from was about $129 bucks, although I could be wrong. Thanks for the update on the actual cost.

Anonymous said...

I am currently experimenting with my doctor's permission. I have a major problem with throat-clearing. Sometimes I cannot even clear the mucus that "attacks" when I'm in the middle of teaching. I will be off Advair for a week to see if the condition improves. I've never been hospitalized for asthma even though I grew up with it. I do live in the Central Valley of CA, so there are plenty of allergens. It will be interesting to see if I can do just as well on the Proventil. I can take it before exercise, and it prevents wheezing and tightening.

Anonymous said...

I too have an inquiring mind, always trying to make sense of medical madness. Just stumbled across your website and enjoy your writings. Last year, I ordered Advair 500/50 through mail-order; 3 disks at a time cost me $70 (yes, a true blessing) but Medco stated it "saved" me $789 (for 3). This would make 3 disks cost $859, or $286 each. This is an impossible price for anyone without decent Rx insurance.

Jen said...

I've always had good insurance so Advair used to cost me a mere $15. Hoorah!... Now I have a different insurance because of various annoying things.. and the insurance only took off $50.. $200 a month so I can breathe the same stuff that is free to others.. great. Safe to say I'll be talking to my doctor about a different and far less expensive solution.

Rick Frea said...

I actually have a list of places that can help people afford advair, although these are mainly for people without health insurance. It's safe to say Asthma is an exorbitantly expensive disease. I feel your pain

Anonymous said...

I picked up my Advair earlier this week. My co-pay was $256. That's over $3,000 a year ... with insurance coverage. The pharmacists said I could get a $20 off coupon on line. Ha

bonesneeze said...

By the definition of the poster in my Allergists office, your asthma is not well controlled if you use your rescue inhaler more than twice a week or more than two canisters a year. According to Advair, it is to be used if you asthma isn't well controlled by corticosteroids. Sometimes when I get a cold, maybe 3-4 times a year, I'll take the rescue inhaler more often than twice a week. I've never used two canisters a year.

My doctor's have never suggested or offered up anything other than Advair and insist I need to be on it all the time. When I asked why they don't try a corticosteroid to see if it works before trying the Advair they said of course they do, that is what they try first. There is some reason they push it so hard but I'm sure you won't get that out of them.

bonesneeze said...

By the definition of the poster in my Allergists office, your asthma is not well controlled if you use your rescue inhaler more than twice a week or more than two canisters a year. According to Advair, it is to be used if you asthma isn't well controlled by corticosteroids. Sometimes when I get a cold, maybe 3-4 times a year, I'll take the rescue inhaler more often than twice a week. I've never used two canisters a year.

My doctor's have never suggested or offered up anything other than Advair and insist I need to be on it all the time. When I asked why they don't try a corticosteroid to see if it works before trying the Advair they said of course they do, that is what they try first. There is some reason they push it so hard but I'm sure you won't get that out of them.

Rick Frea said...

I've discussed this before, but that poster is referring to pure asthma. Other asthmatics, like myself, also have allergies, COPD, etc., other things that complicate asthma. That poster might be fine for 90% of asthmatics, but there are still some of us who are on all the right medicines, are compliant, and still require Ventolin more often than 2-3 times in a two week period.

According to the asthma guidelines, asthma control can also be based on the quality of your life. A person, such as myself, can take 20 puffs of Ventolin a week, and still have good asthma control.

It's also important to note that Advair IS a corticosteroid.

Anonymous said...

Of course it is the best option and the most expensive.....that's how pharmacutical companies make their money!!! By overcharging for medicine they know people HAVE to have!!!

Anonymous said...

In March I went on Medicare, including drug coverage.

I had been getting a generic version of Advair from Canada. A three month supply of Advair is $149.00. Generic is $122.00.

At a major US pharmacy down the street from me no generic is available and a three month supply of Advair is $720.00.

Anonymous said...

I'm a pharmacist and this guy's an idiot. He obviously didn't do his research before he ranted and raved. I couldn't even read the whole thing. What a turn off. Serevent is a long acting beta agonist and Ventolin is a short acting one. Ventolin only does the job for a few hours. If you keep dosing yourself, you'll get too much and it'll affect your heart, etc. You want to be controlled by the controller inhalers like long acting ones, such as Serevent and the steroids. If you're not controlled on the controller inhalers and you just keep temporarily opening up your airways for a few hours with Ventolin, all you're doing is overdosing your body with Ventolin.

john bottrell said...

For the record, I think Mr. Frea was merely postulating an idea for those who cannot afford the exorbitant price of Advair. His idea would be far better than foregoing any preventative therapy. Ventolin is a safe and effective medicine with negligible side effects. It is for this reason many lung patients are prescribed the medicine Q4 or QID, and often without merit.