a blue asthma inhaler with a black top

What the Advair Warning Means

Asthma is pain enough by itself. Then you learn that the medications you take for it might, well, kill you.

You might be concerned because Advair, for instance, has a black box warning, the worst the FDA can do short of withdrawing a drug.

The good news, however, is that it seems that the main concerns about Advair’s safety are in one of its ingredients and is addressed by its dual formulation.

What is Advair?

Advair is a combo drug of albuterol or salmeterol, a long acting Beta agonist (LABA), and fluticasone, a steroid.

The problem comes from the salmeterol component of Advair. The chemical action of this drug is to go into the lungs and target beta receptors. By activating them, the drug causes your lungs to relax, which eases the asthma. Good, right?

Well, yes. Problems arose, however, when a researcher comparing use of salmeterol to another drug noticed that the risk of death of those using salmeterol was three times higher than the other medication. Concerned, the US government in the form of the FDA helped organize a much larger examination of salmeterol.

And what they found was pretty bad. People who used it a LABA as their sole asthma treatment were four times as likely to die as those using inhaled steroids. So how on earth can your doctor tell you to take Advair?

The biological explanation

The answer? Well, let’s step back a little.

The probable reason that salmeterol was associated with increased risk of death was because of how it works. It goes to the lungs and tells them to relax; it doesn’t, however, help control inflammation. So it might make you feel better while the serious biological problem of inflammation is happening.

It’s symptom control without controlling the underlying disease.

This is supported by the possibility that the very same study the FDA ran seems to show that, in combination with steroid treatment, LABA doesn’t significantly increase your risk of dying.  (Though that doesn’t sound very reassuring!)

To top it off, several major analyses including the Cochrane database of systematic Reviews show that use of a LABA with a steroid, dual therapy like that in Advair, is not associated with increased problems.

And dual therapy may have a slight advantage in lung function and, possibly, have less effect on growth in a child.

Conclusion

We still aren’t 100% of how safe Advair is.  That said, the logic behind its combination is solid and seems to have some good medical support.  From what I’ve seen, it makes sense not to take salmeterol by itself, which is exactly what Advair addresses.

On the other hand, it may be possible to treat asthma with steroids alone, just by increasing the dose.  Still, steroids are potent and can have significant side effects.

Thanks for reading!