Male: You mentioned in asthma a combination, you see ads all over the place, there is this drug called Advair, which I particularly don’t use but it is not recommended on kids that are under 11 as well and there is a new combination product that came out called Symbicort, what is that all about?
Dr. Marcus: Combination medications are a convenience when the patient has already been diagnosed as asthma and the asthma is severe enough where a single medication has been proven not to be effective and we now need to go to combination therapy. Symbicort is the newest combination product that has come on the market and it is a combination of two drugs. budesonide which is Pulmicort plus Foradil, which if formoterol. This combination of Pulmicort and Foradil combines the inhaled corticosteroid with a long-acting beta-agonist and gives us two advantages. One, being a combination product, it allows the patient to carry only one canister but being able to get two medicines at the same time. And it forces the patient to take both medications not to eliminate one or the other on their own. This is especially important since the long acting beta agonist formoterol should never be given alone to an asthmatic but should always be given as a combination product. The benefit of using this combination product therefore is that it decreases the inflammation in the lungs with the Pulmicort portion while helping the lungs to open up in relieving the spasm in the lungs the formoterol product.
Male: It is a relatively new product but what do we know about the safety of that combination?
Dr. Marcus: Even though the combination is new, the products that make up the combination are two of the oldest available asthma product that are presently on the market. Pulmicort has been around for at least ten years now and in Europe even more than that. And it is a product where a study was published in 1997, which began in 1987, which showed 10 years of children taking this medication on an everyday basis led to no significant side effects of concern. There were no problems with growth, no ocular problems, and no problems with liver. And so, this was a very important study that alleviate concerns about the use of this medication and that begun in 1987. Formoterol similarly has been in the European market for more than 10 years and has been in the United States market now for about seven. And it is a product that also has a very good safety profile for a very long period of time. So these medications as independently given medications are safe and the combination being given as a separate dose has also been shown to be safe in many studies.
Male: How is it given?
Dr. Marcus: The medication is given in an inhaler form or pump and the pump should always be given two puffs, twice a day. The first time you use the pump, you should shake it for approximately 30 seconds to make sure it mixes well and then you should prime the prime the pump. You should pump one dose just into the air and make sure that the device is working properly. Thereafter, anytime you use the medication, shake it for just five seconds and then take one inhalation, deep breath, and then second inhalation, and a second deep breath. You would always use this on a twice a day schedule.
Male: You see my concern is about Advair, with some reported deaths from Advair. It is because they were using it when they are in a middle of an attack the first time and obviously you don’t do that with that kind of medicine. Now could that also true with this particular product?
Dr. Marcus: Well both Advair and Symbicort carry the same black box warning, which states that there is a risk of asthma related deaths in the family of long-acting beta-agonist based on the studies that were done with Serevent, which is the long-acting beta-agonist that is present in Advair. They have never seen that same problem with formoterol, which is the long-acting beta-agonist in Symbicort. However, to be on the safe side, the FDA has put the same warning of both products. I think what is most important is to realize that it is a controller medication. Therefore it should be used to prevent the symptoms of asthma and should not be used to rescue the patient if they are having an acute attack. That being said, however, there are studies in Europe which show that this combination if used with a patient having an attack can be helpful and the reason for that is that the formoterol, the long-acting beta-agent in Symbicort actually works within five minutes. Whereas the Serevent, which is the long-acting beta-agent in Advair, took anywhere from 45 minutes to upto two hours before it started to work. That therefore is the difference between the two medications and why there maybe a better safety profile with the Symbicort than the Advair.
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