Combination Therapy for Asthma: Perspectives of the Patient, Provider, and Payer
Harold J. Farber
As treatment for moderate to severe persistent asthma, inhaled corticosteroid drugs combined with long-acting beta-adrenoceptor agonists are being marketed in a single inhaler device. These combination products have important benefits (e.g. convenience, improved adherence, and improved day-to-day asthma symptom control); however, there are also problems (e.g. risk of severe asthma flares associated with long-acting beta-adrenoceptor agonist therapy, high price of combination inhalers, and limited ability to titrate the dose of each component independently). Combination therapy is most likely to benefit patients with moderate to severe persistent asthma whose disease is not controlled on inhaled corticosteroids alone. Some patients may prefer this combination product to inhaled corticosteroids plus a leukotriene modifier or theophylline. For other patients with moderate to severe persistent asthma, inhaled corticosteroid adherence may be improved by use of the combination product. Combination long-acting beta-adrenoceptor agonist/inhaled corticosteroid therapy is not appropriate for patients with predominantly exercise-induced asthma, patients unable to use the inhaler device, patients with either mild intermittent or mild persistent asthma, and patients whose asthma can be controlled on a low to moderate dose of inhaled corticosteroid medication alone. As currently priced, combination long-acting beta-adrenoceptor agonist/inhaled corticosteroid therapy leads to increased costs compared with inhaled corticosteroids alone; however, in appropriately selected patients, this cost is offset by improvements in asthma symptoms and lung function. Some patients may value increases in symptom-free days, convenience, and a less offensive taste (especially with a dry-powder inhaler delivery system). Others may prefer drug minimization and/or may prefer metered-dose inhaler or nebulizer delivery systems. Providers need to be able to match the medication to the medical needs and preferences of the patient/family as best as possible. Providers need to be able to educate the patient and/or parents on the role of the medication, expected results, and inhalation techniques. Inappropriate use of combination therapy, such as for individuals with only mild asthma whose asthma can be controlled on simpler therapy, should be avoided. Health plans are accountable for both quality and costs of care. They are interested in restricting inappropriate use of combination therapy.
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