Is Advair Safe to Use?

Advair has a black box warning and an editorial in a recent New England Journal of Medicine by Fernando D. Martinez, MD, that says other drugs should be used first (and second). This continues to cause concern in our patients with asthma who benefit from using Advair.

However, it is still the belief of the doctors of The Allergy Clinic that Advair is safe when used as recommended. The Journal of Allergy and Clinical Immunology has an editorial by Harold Nelson, MD, the most respected allergist in the country in its December, 2005 issue. In it, Dr. Nelson defends Advair, stating that "these outcomes (deaths) were not a direct toxic effect of the drugs and increases the possibility that they resulted from an interaction between relief of symptoms by ²2-agonists and delay in seeking medical care."

In other words, it was not the combination drug, Advair, increasing the risk of death. Rather, it was use of Advair's component half, Serevent, without also using an inhaled steroid. Plus, because stimulant drugs like Serevent and albuterol make your asthma feel better for a little while, you may postpone the necessary doctor visit to get appropriate treatment.

An advisory panel of the FDA met in 2006 to consider taking Advair off of the market. You can imagine the scare this put into our patients who are taking that medication, particularly those who are receiving such benefit from it. Bottom line: If you are on Advair, Do Not Worry! Do Not Stop the drug unless your doctor advises it. The FDA advisory panel unanimously decided not to remove Advair, Serevent or Foradil from the market.

A little background on this: Advair is actually a combination of two drugs: salmeterol and fluticasone. Each of these was sold alone as, respectively, Serevent and Flovent. Flovent is an inhaled steroid, and no one is worried about that drug. Serevent, on the other hand, is a mixed blessing, particularly if it is being used by itself. Serevent is a bronchodilator, similar to albuterol (Ventolin, Proventil). Serevent has a longer duration of action than albuterol, though. It works for 12 hours instead of 3 or 4 hours. The way that bronchodilators work is by relaxing the smooth muscle on the outside of the airway. That relaxation allows the airway to open wider and let more air come through. The relaxation actually takes place because albuterol and salmeterol are beta agonists and they stimulate beta receptors. The problem with salmeterol by itself is that when you over-stimulate a beta receptor, your body responds by down-regulating (decreasing) the production of the beta receptors. Thus, you end up with fewer receptors for those beta agonists to attach themselves to.

Luckily, that problem doesn't happen when you use an inhaled steroid at the same time you use salmeterol. Advair contains salmeterol and fluticasone, an inhaled steroid. One important benefit of inhaled steroids is that they up-regulate (increase) the production of beta receptors. That up-regulation more than offsets the detrimental down-regulation that salmeterol by itself can cause.

Whenever The Allergy Clinic prescribes a long-acting beta agonist such as salmeterol (Serevent) or formoterol (Foradil), we also prescribe an inhaled steroid to prevent any possible worsening of asthma symptoms. Advair has that beneficial inhaled steroid built in, so there is usually no need to worry about Advair worsening your asthma.

In summary, Advair has been a wonderful addition in the treatment of asthma. Patients on it should continue using it, but please contact your medical provider if you have questions. Patients on Serevent or Foradil who are not also using an inhaled steroid should contact their medical provider as soon as possible to have their condition re-assessed.

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs.