WHAT IS ADVAIR DISKUS?
Advair Diskus is a combination product that includes two active ingredients: fluticasone propionate and salmeterol. It is indicated for those with asthma who are not completely controlled on a long-term asthma medication (like inhaled corticosteroids) or for those who require an inhaled corticosteroid with a long-acting beta1-adrenergic agonist (LABA). Advair Diskus can also be used to treat airflow obstruction in those with chronic obstructive pulmonary disease (COPD), such as with emphysema or chronic bronchitis. It is also used to decrease COPD exacerbations.
Advair Diskus comes in the form of an inhaler. The inhaler has a foil blister strip containing the inhalation powder. The strip will either have 100, 250, or 500 mcg of fluticasone propionate. Advair Diskus will also contain 50 mcg of salmeterol in each blister.
Common side effects of Advair Diskus include:
- Upper respiratory tract infection
- Thrust in the mouth or throat
- Throat irritation
- Hoarseness or voice changes
- Nausea and vomiting
- Respiratory infections
- Muscle and bone pain
- Thrush in the mouth or throat
- Throat irritation
- Hoarseness of voice changes
WARNINGS AND PRECAUTIONS
Serious Asthma-Related Events – Hospitalizations, Intubations, Death
Using a LABA alone without an ICS for the treatment of asthma has been shown to raise one’s risk of asthma-related death. Additional data suggests that using a LABA alone can also raise a pediatric or adolescent patient’s risk of having an asthma-related hospitalization. All LABA therapies are thought to demonstrate this effect. These findings contrast those that look at severe asthma events such as hospitalizations, intubations, and death in those on a combination LABA and ICS therapy. Patients on this combination are not at increased risk of serious asthma-related events.
Deterioration of Disease and Acute Episodes
Advair Diskus has not been evaluated in those with rapidly progressing disease. In fact, patients who have significant worsening in their asthma have had an increased rate of serious and sometimes fatal respiratory events with salmeterol. These types of patients include those that have elevation in symptoms, increased SABA requirements, decreased response to normal medications, increased requirement for systemic corticosteroids, frequent emergency room visits, or poor lung function. These events also happened in patients with less severe asthma, and therefore it is unclear if salmeterol was the cause of such adverse events. Advair Diskus therefore should be avoided in patients that have quickly deteriorating disease or those with life-threatening asthma or COPD attacks.
Excessive Administration of Advair Diskus and Administration with Other Long-acting Beta2-agonists
Advair Diskus is not supposed to be used more than twice daily, at increased doses than recommended, or in combination with other LABA medications. In fact, serious cardiovascular events and fatalities have been reported when sympathomimetic drugs are administered excessively. Therefore, patients should not be on concomitant medicines containing a LABA, such as formoterol fumarate, salmeterol, arformoterol tartrate, or indacatero.
Local Effects of Inhaled Corticosteroids
Mouth and pharynx infections of Candida albicans origins can occur in those who take Advair Diskus. These infections should be treated with antifungal therapy while continuing to treat with Advair Diskus. To avoid this effect, patients should rinse their mouths with water and avoid swallowing to decrease the risk of oropharyngeal candidiasis.
COPD patients on inhaled corticosteroids, such as fluticasone propionate and Advair Diskus, have been shown to be at increased risk of pneumonia and other lower respiratory tract infections. Pneumonia symptoms and COPD exacerbations can be very similar in presentation, and therefore doctors should be vigilant in detecting signs of pneumonia.
Those who are on immunosuppressive drugs are more likely to develop infections. Corticosteroids are immunosuppressant drugs that can cause more serious infectious disease if acquired. Therefore, ICS should be used with caution in patients who have active infections such as tuberculosis in the respiratory tract, systemic infections (bacterial, viral, fungal, or parasitic), or ocular herpes simplex.
Switching Individuals from Systemic Corticosteroid Therapy
Patients who are on systemic corticosteroids but are switching to an ICS need to be monitored. These patients are at increased risk for death due to adrenal insufficiency while recovering hypothalamic-pituitary-adrenal (HPA) function. Some patients may experience withdrawal symptoms upon discontinuation of oral corticosteroids, including symptoms of muscle and joint pain, depression, or lassitude.
Hypercorticism and Adrenal Suppression
Some patients may exhibit side effects associated with systemic corticosteroids such as hypercorticism and adrenal suppression. In this event, patients should slowly discontinue Advair Diskus, and other options should be explored.
Drug Interactions with Strong CYP3A4 Inhibitors
Concomitant use of strong CYP3A4 inhibitors is not recommended. Strong CYP3A4 inhibitors include drugs such as ritonavir, clarithromycin, ketoconazole, and itraconazole. Drugs such as these can increase concentrations of systemic corticosteroid and elevate the risk of cardiovascular events.
Paradoxical Bronchospasm and Upper Airway Symptoms
Paradoxical bronchospasm is a risk of inhaled medications such as Advair Diskus. If this phenomenon occurs, patients should be administered a short-acting bronchodilator and Advair Diskus should be discontinued. Upper airway symptoms include stridor and choking.
Effects on the Cardiovascular and Central Nervous System
Use Advair Diskus with caution in those that have pre-existing cardiovascular disease, specifically hypertension, coronary insufficiency, and cardiac arrhythmias. Too much beta-adrenergic activation can cause seizures, angina, hypotension or hypertension, arrhythmias, tachycardia, and more.
Decreased Bone Mineral Density (BMD)
Those who are on ICS products long-term can experience reduced BMD. Patients who are at risk for decreased BMD, such as those with advanced age or family history of osteoporosis, should be closely monitored for reduced BMD.
When used in children, inhaled corticosteroids can cause decreased growth velocity. Pediatric patients should be monitored consistently for these effects. Additionally, patients should be on the lowest possible dosage to properly manage symptoms to reduce the likelihood of these effects.
Cataracts and Glaucoma
Long-term use of ICS can cause cataracts, glaucoma, and raised intraocular pressure. If patients develop these symptoms, refer them to an ophthalmologist to manage their condition.
Advair Diskus should be used with caution in patients that have thyrotoxicosis, convulsive disorders, or who are abnormally responsive to sympathomimetic amines. Advair Diskus may also aggravate other conditions such as diabetes or ketoacidosis.
Both fluticasone propionate and salmeterol are substrates of CYP3A4. Therefore, strong inhibitors of CYP3A4 should not be used concomitantly with Advair Diskus. If used together, systemic corticosteroid concentrations can become increased and poor cardiovascular effects can occur.
Monoamine Oxidase Inhibitors (MAOIs) and Tricyclic Antidepressants (TCAs)
Salmeterol’s effects on the vascular system can be potentiated by MAOIs and TCAs. Therefore, Advair Diskus should not be used concomitantly or within 2 weeks of discontinuing these agents.
Beta-adrenergic Receptor Blocking Agents
Patients that have asthma or COPD should not be on beta-blockers. Beta-blockers inhibit the pulmonary effects of beta-agonists like salmeterol. They can also induce serious bronchospasm in those with asthma or COPD.
Salmeterol, a beta-agonist, can cause ECG changes and hypokalemia when used with non-potassium-sparing diuretics. Providers should take caution when prescribing Advair Diskus concomitantly with potassium-sparing diuretics.
FREQUENTLY ASKED QUESTIONS