Asthma without ICS

One of the mainstays of asthma treatment at home is the use of inhaled corticosteroids (ICS). They are so effective that we even branch out to using them for asthma-like symptoms on infants and toddlers during the cold season. We use them in nebulizers in the office, and prescribe them for use at home. Once kids are needing a lot of albuterol this is how we can treat asthma and breathing problems from another direction. Used short term, or in low doses, there aren't a whole lot of side effects to worry about, making them a much safer choice than systemic steroids, which can have a whole bunch of nasty adverse reactions.

In school and in practice we are taught that when a person is having a certain number of exacerbations, and needing albuterol at certain intervals, we need to bump them up to the use of ICS. From there we can manage the dose, and get them on any combination or taper necessary.

But what do you do when the pharmacy only carries albuterol and Advair (a combination, not first line)? And not just in inhaler form, there seems to be nothing but saline and albuterol for the neb, too.

Twice in the last week I have seen two children who I would consider using ICS for, but I had nothing to offer. So today I went to two pharmacies after clinic to fully research the options. This is something that I try to do every once in a while, because I need to be able to accurately tell my patients what to buy, and how to get it cheapest. Many of the families are unable to afford an expensive medication, but when I find that a pharmacy sells the old generic (CFC containing) version of albuterol, I send them there where it costs about 2/3 of the price at the other pharmacies.

Today's pharmacy results:
Albuterol inhalers cost about $6, which is expensive, but not entirely unreasonable.
Pulmocort is available in nebulized form, but costs $3 per dose, which adds up fast!
There's one combination ICS with albuterol, pretty pricey at around $18 per inhaler. Other combos with LABAs like Advair are well over $20.
Spacers w/ and w/o masks cost about $15
There's no inhaled ICS in inhaler form that is not combined with anything.



My new ideas are that it's possible to consider that one combination ICS if really truly needed, and prescriber a spacer, too, for the young ones. I checked out the pharmacies so that I can recommend the right places to go, and wrote it all out on a list to share with the clinic. If someone really needs pulmocort it's possible that we could have them come into the clinic 5 days a week, and they could buy it and bring it to put in the nebulizer we have. But I'm going to try to pursue routes of asking for donations from the US to both fund purchases here, and bring us some goods from home that are not being used.