PURPOSE OF THE STUDY.
The investigators sought to compare asthma outcomes and costs of extra-fine hydrofluoroalkane (HFA)-beclomethasone (QVAR) and fluticasone (Flovent HFA).
Patients aged 12 to 80 years with asthma were followed up for at least 1 year before (baseline year) and 1 year after (outcome year) the index date. Some patients received a first prescription of inhaled corticosteroids (ICS) as QVAR or Flovent on the index date. Other patients were receiving 1 of these 2 options as step-up therapy on the index date.
This retrospective matched cohort study examined database markers of asthma control from a large US longitudinal health care claims database, matched on baseline demographic characteristics and asthma severity. The 3 coprimary outcome measures were composites of key elements of asthma control derived from the database. “Risk domain asthma control” included absence of hospital/emergency department attendance, prescription for acute course of oral corticosteroid, and lower respiratory tract infection requiring antibiotics or hospital admission for lower respiratory reason. “Overall control (risk and impairment)” incorporated use of a short-acting β-agonist of no more than 2 puffs daily. “Severe exacerbation” was defined as hospital admission or emergency department attendance for asthma or an acute course of oral steroids. Secondary outcome measures included 3 additional composite end points. “Treatment success” was defined as risk-domain asthma control plus no change in asthma therapy, such as increase in ICS dose, change in ICS or delivery device, or use of additional controller therapy. “Sensitivity analysis of treatment success” sought to exclude changes in therapy that could have been motivated by cost savings. The number of “respiratory-related hospitalizations and referrals,” defined as unscheduled hospital admissions or emergency department attendance for lower respiratory tract reasons or planned hospital outpatient attendance for asthma, was determined.
After matching, there were 10 312 patients initiating ICS and 572 stepping up the ICS dose included in the analysis. Patients started on QVAR had significantly higher odds of achieving overall control. They also had a lower rate of respiratory-related hospitalizations or referrals than patients on Flovent. Other database outcome measures were similar in the 2 cohorts. Prescribed QVAR doses were lower (P < .001) than Flovent doses (320 vs 440 μg/d). Adjusted respiratory-related health costs were significantly lower for the QVAR group and represented annual savings of $390.
Asthma treatment outcomes were similar or better with QVAR prescribed at significantly lower doses and with lower costs than Flovent.
The authors acknowledge that this study was not designed to evaluate the mechanisms behind the differences observed but speculate that the formulation characteristics for the HFA-beclomethasone pressurized metered dose inhaler are integral. We occasionally see fluticasone prescribed at inordinately high doses in children; these doses not only ignore the relatively flat dose–response curve for ICS but also likely have the systemic equivalence of several milligrams of prednisone per day. This study suggests that efficacy, cost, value, and, arguably, safety fall in favor of the beclomethasone product. Furthermore, given the smaller airway of the young child not included in this study population, the extra-fine particle size might magnify these benefits.
- Copyright © 2014 by the American Academy of Pediatrics