Economic Impact of Asthma Therapy With Fluticasone Propionate, Montelukast, or Zafirlukast in a Managed Care Population

Dev S. Pathak, D.B.A., E. Anne Davis, Pharm.D., Richard H. Stanford, Pharm.D.


Pharmacotherapy. 2002;22(2) 

In This Article

Abstract and Introduction

Study Objective. To compare asthma-related health care expenditures among patients newly prescribed fluticasone propionate 44 or 110 µg, montelukast 5 or 10 mg, or zafirlukast 20 mg.
Design. Retrospective cohort analysis of medical and pharmacy claims.
Setting. University-affiliated health outcomes research center.
Patients. Seven hundred eighty-one patients (aged >= 4 yrs) with asthma treated with controller therapy for 9 months (postindex period), with no claim for an inhaled corticosteroid or leukotriene modifier in the previous 9 months (preindex period).
Intervention. Asthma-related medical and pharmacy data from insurance claims of four managed care plans (two Northeastern, one Midwestern, and one Western) were tabulated over the pre- and postindex periods.
Measurements and Main Results. Numbers of patients identified were 284 beginning fluticasone propionate; 302, montelukast; and 195, zafirlukast. Fluticasone propionate treatment was associated with significantly (p<0.001) lower risk-adjusted asthma-related charges compared with montelukast and zafirlukast treatment: $528, $967, and $1359, respectively. In this cohort, fluticasone propionate also was associated with fewer hospitalizations, less need for additional controller agents, and longer maintenance on the index drug compared with montelukast and zafirlukast.
Conclusions. Based on these real-world data, as well as established national and international asthma guidelines, consideration should be given to inhaled corticosteroid therapy, particularly fluticasone propionate, for first-line, long-term effective management of asthma.

Asthma is a chronic inflammatory disease with increasing prevalence and morbidity.[1] Costs for asthma care in the United States are estimated at $12.7 billion (1998 dollars), with direct medical expenditures accounting for 58%.[2] Physician services, hospitalization, and emergency department costs constitute the greatest percentage (56.7%) of these direct medical costs. Costs for asthma-related emergency department visits and asthma-related hospitalization are substantial and should be considered avoidable costs.[3] The Global Initiative for Asthma[4] and the National Heart, Lung, and Blood Institute[5] have both proposed that patients with mild persistent asthma should receive inhaled corticosteroids as first-line treatment. The guidelines of the National Heart, Lung, and Blood Institute propose leukotriene modifiers as an alternative controller therapy.

Inhaled corticosteroids reduce the morbidity and mortality of asthma.[6,7,8,9,10] Our search of the literature, however, revealed no such evidence to establish that leukotriene modifiers have a similar benefit in patients with asthma. In addition, the results of recent studies indicate that treatment of persistent asthma with inhaled corticosteroids provides significantly greater improvement in pulmonary function and asthma symptoms compared with treatment with leukotriene modifiers.[11,12,13,14] To determine whether the differences observed between inhaled corticosteroids and leukotriene modifiers in randomized clinical trials are supported in real-world clinical practice, and if so, whether these differences translate into significant cost savings for inhaled corticosteroids over leukotriene modifiers, we compared asthma-related health care expenditures related to inhaled fluticasone propionate (Flovent; GlaxoSmithKline, Research Triangle Park, NC) with that of oral zafirlukast (Accolate; AstraZeneca Pharmaceuticals, Wilmington, DE) and montelukast (Singulair; Merck &Co, West Point, PA) in patients beginning controller therapy for asthma.


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