Clinical Implications of a Formulary Conversion From Budesonide/formoterol to Fluticasone/salmeterol at a VA Medical Center

Background: Chronic obstructive pulmonary disease (COPD) is a respiratory disorder associated with chronic and slowly progressive systemic inflammation. The Global Initiative for Chronic Obstructive Lung Disease recommends a combination inhaler of a long-acting β-2 agonist and inhaled corticosteroid for patients with a history of frequent exacerbations. In 2021, the US Department of Veterans Affairs transitioned patients who were prescribed budesonide/formoterol inhaler to a fluticasone/salmeterol inhaler.

Methods: The primary objective of this study was to compare clinical outcomes including COPD exacerbations and hospitalizations 6 months before vs 6 months after the inhaler transition. Secondary outcomes included adverse effects, treatment failure, tobacco use, and antimicrobial/systemic corticosteroid use. A retrospective chart review was conducted on patients with a prescription for a budesonide/formoterol or fluticasone/salmeterol inhalers between February 1, 2021, and May 30, 2022, at the Hershel "Woody" Williams Veterans Affairs Medical Center, Huntington, West Virginia.

Results: In a convenience sample of 100 patients who transitioned from the budesonide/formoterol inhaler to the fluticasone/salmeterol inhaler, exacerbations increased from 24 before the transition to 29 after the transition, which was not a statistically significant change (P = .56). There were no statistically significant differences in the secondary endpoints including active tobacco use. Three patients had adverse reactions to fluticasone/salmeterol, while 18 patients experienced a therapeutic failure to fluticasone/salmeterol.

Conclusions: Patients with COPD that transitioned from budesonide/formoterol to fluticasone/salmeterol during the formulary conversion yield no clinical or statistically significant change in their clinical outcomes. Switching between these inhalers in the same therapeutic class may not impact clinical efficacy of the therapy for veterans with COPD but some intolerances and treatment failures should be expected.