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Asthma review missed key options

We would like to raise concerns regarding significant deficiencies in the article ‘Evidence-based asthma care', a reproduction of a review by Map of Medicine, which appeared in your sister title Practical Commissioning (


The article highlights NICE guidance1 and states ‘ensure the least costly single combination device is prescribed when introducing a long-acting ß-agonist for patients already taking an inhaled steroid', but it does not reflect the complete evidence and treatment options available.

It mentions fluticasone/

salmeterol (Seretide) and budesonide/formoterol (Symbicort), but fails to mention the third and least costly combination on the market, beclometasone dipropionate/formoterol (Fostair), produced by Chiesi. 

Fostair has been shown in robust clinical trials to be comparable in efficacy to both Seretide and Symbicort.2,3  Fostair 100/6 is dose equivalent to Seretide 125/25 and Symbicort 200/6, as Fostair is characterised by an extra-fine particle size – resulting in greater distribution to small airways.

As such, 100µg of beclometasone dipropionate extrafine in Fostair is equivalent to 250µg of beclometasone dipropionate non-extrafine, achieving comparable efficacy at a lower steroid dose.4

Fostair 100/6, costing £29.32, is substantially cheaper than the dose equivalent to Seretide 125/25 (£35.00) and Symbicort 200/6 (£38.005). Articles published independently of Chiesi have highlighted that substantial savings could be made by reviewing and changing appropriate patients from Seretide and Symbicort to Fostair, ranging from £25,000 at CCG level6 to £7m at SHA level per annum.7

It is a significant deficiency of the methodology used that not all the available marketed products are reviewed, particularly ones that deliver equivalent efficacy at a lower nominal dose of steroid and at substantial saving to the NHS.


1 NICE. Inhaled steroids for the treatment of chronic asthma in adults and children aged 12 years and over. Technology Appraisal Guidance 138. London 2008

2 Papi A, Paggiaro P, Nicolini G et al. ICAT SE study group. Beclometasone/formoterol vs fluticasone/salmeterol inhaled combination in moderate to severe asthma. Allergy 2007;62;1182-8

3 Papi A, Paggiaro PL, Nicolini G et al. Beclomethasone/formoterol versus budesonide/formoterol combination therapy in asthma. Eur Respir J 2007;29:682-9

4 Summary of Product Characteristics. Fostair December 2011

5 MIMS. October 2011

6 Shailen R and Vinesh S. Reducing costs and raising quality of asthma prescribing. Prescriber 2011;22:39-417

7 East of England NHS PrescQipp Bulletin. June 2011.

From Dr Helen Phillips, Medical director, Chiesi