One thing I've learned, both as a patient and as a respiratory therapist, is that not all inhalers work the same for everybody.
That's why I get frustrated when insurance companies, and sometimes hospitals, limit patients to one preferred combination inhaler. The assumption seems to be that if two medications belong to the same class, one can easily replace the other.
But it's not always that simple.
My Experience With Combination Inhalers
For years, I used Advair, a combination of fluticasone and salmeterol. It worked well for me, and I tolerated it without significant side effects.
Then, because of insurance coverage, I was required to switch to Symbicort, which contains budesonide and formoterol.
Both medications combine an inhaled corticosteroid (ICS) with a long-acting beta-agonist (LABA). Both are effective asthma medications. But they contain different drugs, and I noticed a difference.
I experienced more side effects with Symbicort than I had with Advair.
More recently, I tried Breztri, which combines budesonide, glycopyrrolate, and formoterol. Once again, I experienced bothersome symptoms, including jitteriness and palpitations.
I eventually switched back to Trelegy, which contains fluticasone furoate, umeclidinium, and vilanterol. Since making that change, those symptoms have improved.
Trelegy is currently my preferred maintenance inhaler, and thankfully, my insurance covers it.
My experience doesn't prove that formoterol was responsible for every symptom. Other medications, caffeine, and individual health factors can contribute to palpitations and tremors. But the pattern has been consistent enough that I take it seriously.
And I believe patients deserve to have those experiences taken seriously, too.
Not All LABAs Are the Same
Advair contains salmeterol. Symbicort and Breztri contain formoterol. Trelegy contains vilanterol.
All three are long-acting beta-agonists, medications that relax airway smooth muscle and help keep the airways open.
But they aren't identical molecules.
They differ in their pharmacological properties, including onset of action, receptor interactions, duration of activity, and pharmacokinetics.
Formoterol, for example, has a relatively rapid onset of action, whereas salmeterol has a slower onset. That's one reason formoterol-containing ICS combinations can be used in certain maintenance-and-reliever treatment strategies, while salmeterol-containing combinations are not used that way.
Like other beta-agonists, LABAs can cause systemic effects such as tremors, palpitations, and increased heart rate.
A patient might tolerate one LABA very well while experiencing troublesome side effects with another.
That doesn't mean formoterol is a bad medication. It works very well for many patients. In fact, it worked just as well as the other LABAs at keeping my airways open. The problem wasn't its effectiveness. It was the side effects, which I found much harder to tolerate.
It simply means that a medication can work well for one patient and still not be the best choice for another.
The Delivery Device Matters, Too
Another issue that sometimes gets overlooked is the inhaler itself.
There are important differences between dry-powder inhalers (DPIs) and pressurized metered-dose inhalers (pMDIs).
Dry-powder inhalers depend on the patient's inspiratory effort to disperse and deliver the medication. Metered-dose inhalers use a propellant to generate an aerosol.
Both types can deliver medication effectively into the lungs, but their performance depends on factors such as particle size, formulation, inhalation technique, and inspiratory flow.
I remember the transition from the old CFC inhalers to hydrofluoroalkane (HFA) inhalers.
The change was primarily driven by environmental concerns, but it also created opportunities for improved aerosol formulations.
One example was HFA beclomethasone, marketed as QVAR. Its extrafine aerosol formulation demonstrated greater deposition in the peripheral airways compared with older CFC-beclomethasone formulations.
That was an important advancement.
However, greater lung deposition can also influence systemic drug exposure.
When inhaled medication deposits in the lungs, some of it may be absorbed into the pulmonary circulation. With beta-agonists, increased systemic exposure can potentially contribute to side effects such as tremors and palpitations.
That doesn't mean every HFA inhaler produces greater systemic effects than every DPI. Nor does it mean that deeper deposition always results in more side effects.
The specific medication, formulation, dose, and delivery characteristics can all influence how a patient responds.
And that's precisely my point.
You cannot assume two inhalers will behave identically simply because they contain medications from the same therapeutic classes.
The Problem With One-Size-Fits-All Formularies
I understand why insurance companies establish preferred drug formularies.
Healthcare resources are limited, and negotiating lower drug prices can help make medications more affordable.
Hospitals also have legitimate reasons for limiting the number of inhalers they stock, including purchasing costs, inventory management, and staff familiarity with devices.
But those considerations shouldn't automatically outweigh individual patient needs.
Suppose a patient has been well controlled on Advair for years, with minimal side effects. Then an insurance company changes its formulary and requires that patient to switch to Symbicort.
On paper, the substitution may appear reasonable. Both are ICS/LABA combinations approved for asthma maintenance treatment.
But what happens when the patient develops bothersome tremors or palpitations with the replacement?
Should that patient simply be expected to tolerate the symptoms because the preferred medication is cheaper?
I don't think so.
The same issue can arise when hospitals substitute one inhaler for another during an admission.
A formulary alternative may be clinically appropriate for many patients, but individual tolerance, inhaler technique, and previous treatment experience deserve consideration.
A patient who has successfully used one inhaler for years shouldn't have that experience dismissed.
Patients Are Individuals, Not Formularies
As respiratory therapists, we're taught to evaluate the patient, not just the numbers.
The same principle should apply to inhaler selection.
We need to consider whether the medication controls symptoms, whether the patient can use the device correctly, whether the dosing schedule is practical, and whether side effects interfere with treatment.
A medication that works beautifully in a clinical trial may not be the best choice for every individual patient.
And a medication that is theoretically equivalent to another may not feel equivalent to the person taking it.
That doesn't make the patient difficult or noncompliant.
It may simply mean the patient responds differently.
Give Patients and Clinicians Some Flexibility
I'm not arguing that every patient should receive the most expensive inhaler on the market.
I'm not arguing that Advair or Trelegy is superior to Symbicort or Breztri for everyone.
And I'm certainly not suggesting that patients should change their maintenance medications without appropriate medical guidance.
What I'm advocating is flexibility.
If a patient is doing well on a particular inhaler, there should be a good reason to change it.
If a formulary-required substitution causes significant side effects or poorer asthma control, there should be a reasonable way for the patient and prescribing clinician to obtain an alternative without unnecessary obstacles.
And if a patient has been doing well on a particular medication for years, a change in the insurance company's formulary shouldn't make it significantly more expensive to continue that treatment. In my case, I had been doing well on Advair when my insurance company decided to favor Symbicort. I could still get Advair, but my copay increased to $100, compared with just $20 for Symbicort. Eventually, I gave in and switched. As much as I preferred Advair, I simply couldn't justify spending $100 every month for a single inhaler. Unfortunately, that meant switching to a medication that caused side effects I hadn't experienced with Advair.
My own experience has taught me that I tolerate salmeterol- and vilanterol-containing inhalers better than the formoterol-containing combinations I've tried. Another patient might have exactly the opposite experience. And that's okay.
The best inhaler isn't necessarily the one an insurance company prefers. It's the one that provides effective asthma control, with acceptable side effects, that the patient can use correctly and consistently.
After nearly a lifetime with asthma and almost three decades working as a respiratory therapist, that seems like a pretty reasonable expectation.
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