Fluticasone Furoate Inhaled

Fluticasone furoate is a long-acting inhaled corticosteroid given once daily, mostly in fixed combination with vilanterol or with umeclidinium and vilanterol. It has the highest glucocorticoid receptor affinity among the inhaled corticosteroids.

Classification. Inhaled corticosteroid, glucocorticoid.

Mechanism. Glucocorticoid receptor agonist suppressing airway inflammation; prolonged retention supports once daily use.

Pharmacokinetics. Oral bioavailability about 1%. Cleared by CYP3A4. Effective half-life after inhalation is about 24 hours.

First-line, asthma. Fluticasone furoate with vilanterol 92/22 micrograms once daily (labelled 100/25 in some regions), increased to 184/22 micrograms (200/25) in more severe disease in adults. As a single agent, 100 or 200 micrograms once daily where it is marketed.

First-line, COPD with frequent exacerbations. Fluticasone furoate with vilanterol 92/22 micrograms once daily. For COPD, the 184/22 strength is not used.

Specialist, COPD triple therapy. Fluticasone furoate, umeclidinium and vilanterol 92/55/22 micrograms once daily.

Children. Asthma from 12 years in the combination at 92/22. Single-agent 50 micrograms once daily from 5 years where licensed.

Emergency. Not used.

Titration. Step up to the 184/22 strength only when the lower strength fails; step down if control holds for 3 months. No loading dose.

Boxed-warning-level risk. Combination products carry the LABA risk of asthma-related death if used without a corticosteroid; the corticosteroid is part of the same inhaler.

Contraindications. Hypersensitivity, including severe milk protein allergy. Caution in active or quiescent tuberculosis.

Serious adverse effects. Adrenal suppression, pneumonia in COPD, cataract, glaucoma, reduced bone density, reduced growth velocity, paradoxical bronchospasm.

Common adverse effects. Oral candidiasis, headache, nasopharyngitis, hoarseness, arthralgia.

Interactions. Strong CYP3A4 inhibitors including ritonavir and cobicistat raise systemic exposure and lower cortisol; avoid unless the benefit outweighs the risk.

Common prescribing errors. Prescribing a second ICS or LABA inhaler on top. Using once daily dosing for twice daily products.

Special groups.

• Pregnancy: use only if the benefit outweighs risk. Breastfeeding: no data; use with caution.

• Older adults: monitor for pneumonia and bone effects.

• Kidney impairment: no adjustment. Liver impairment: in moderate to severe impairment, use the 92/22 strength only and monitor for corticosteroid effects.

• East Africa: avoid with ritonavir-boosted regimens where possible.

Formulations. Multidose dry powder inhaler, single agent in some regions, and fixed combinations.

Technique. One steady deep inhalation once daily at the same time. Rinse the mouth and spit after use.

Baseline. Spirometry, symptom score, exacerbation history.

Monitoring. Control, exacerbations, spirometry, technique, signs of pneumonia in COPD, bone and eye health with prolonged use.

Stop and reduce rules. Step down when control holds. Stop and reassess if pneumonia occurs. Therapeutic drug monitoring is not used.

Referral and escalation. Refer when control fails on the highest strength.