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.