Despite the availability of seven types of inhaled corticosteroids, nearly every patient and friend I meet takes Flovent (fluticasone). Even my daughter takes Flovent. I can rattle off the mcg/puff of the available formulations for Flovent, but I can’t do this for any other inhaled steroid.

I’ve been fascinated with this phenomenon for years. Unpublished data from one health plan found that the vast majority of patients who receive an inhaled steroid receive Flovent.

Possible reasons I’ve come up with for the medical establishment’s preference for Flovent (some are myths, some may be true) include:

Flovent is better? False. Flovent has been demonstrated to bind more tightly to its receptor in the lung in basic science studies with tissues, but Flovent hasn’t been demonstrated to be better in clinical studies of patients.

Flovent is cheaper? False. Flovent is actually more expensive. The wholesale price for a canister of Flovent 220 is is $251.43 and the counterpart Qvar 80 is $160.16.

Flovent spends more money on drug reps? Maybe. When I was in private practice in Connecticut, drug reps regularly dropped off samples of Flovent. They dropped off slick brochures on the dosing guidelines. It makes me cringe to think this could be the reason I know the dosing for Flovent.

Some health insurers are more likely to cover Flovent? True. When I posed the question of why providers choose Flovent on Twitter, one response was Medicaid covers Flovent but not other inhaled steroids. Heidi Roman MD (@hkroman) wrote, “Most of my patients are Medicaid. Decision sadly dictated by which med currently contracted by patient’s insurance co.”

Hospitals have contracts with the makers of Flovent? Maybe. One health plan administrator told me this but I haven’t been able to follow up.

A recent study found that patients started on Qvar did better than patients started on Flovent. Patient taking Qvar had higher odds of achieving asthma control with fewer hospitalizations, need for oral corticosteroids, need for antibiotics, and need for albuterol compared to patients taking Flovent. The authors studied a large population of patients who were 12-80 years old in a health care claims database. The authors studied patients on Qvar or Flovent and tried to match the two populations so that they were comparable.

The authors propose one reason for the differences between Qvar and Flovent could be the formulation characteristics. Qvar is designed to give warm, soft, and long-duration aerosol spray with small particle sizes; thus it is more likely to be delivered to the lungs despite poor technique use. Qvar is more likely to be delivered to the small-airways compared to Flovent.

So, a study has even demonstrated that Qvar may achieve better outcomes than Flovent. Why is everyone on Flovent?

Available inhaled steroids: Fluticasone (Flovent), Budesonide (Pulmicort), Beclomethasone (Qvar), Ciclesonide (Alvesco), Flunisolide (Aerobid), Mometasone (Asmanex), Triamcinolone (Azmacort)