Cost-Effectiveness of Asthma Step-Up Therapy as an Increased Dose of Extrafine-Particle Inhaled Corticosteroid or Add-On Long-Acting Beta2-Agonist

Nicolas Roche, Gene Colice, Elliot Israel, Richard J. Martin, Paul M. Dorinsky, Dirkje S. Postma, Theresa W. Guilbert, Jonathan Grigg, Willem M. C. van Aalderen, Francesca Barion, Elizabeth V. Hillyer, Victoria Thomas, Anne Burden, R. Brett McQueen, David B. Price

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Data from different healthcare systems on relative cost-effectiveness of asthma step-up therapy strategies are required to inform decision-makers and clinicians. Our objective was to compare cost-effectiveness from the United Kingdom National Health Service perspective of three step-up strategies for patients with asthma uncontrolled by inhaled corticosteroid (ICS) monotherapy.


This was a historical matched cohort cost-effectiveness analysis of anonymized medical records for patients with asthma of age 12–80 years. We conducted two-way comparisons of step-up therapy using increased dose (≥50%) of extrafine-particle ICS or add-on long-acting β2-agonist (LABA) via fixed-dose combination (FDC) ICS/LABA inhaler or via separate inhaler. The incremental cost-effectiveness ratio (ICER) was calculated using asthma-related direct costs during one outcome year and a composite measure of risk-domain asthma control (no asthma-related hospital attendance, acute oral corticosteroids, or consultation for lower respiratory tract infection).


Patients prescribed ICS dose step-up (n = 3036) had significantly lower baseline-adjusted, mean asthma-related healthcare costs during the outcome year than those prescribed FDC ICS/LABA (n = 3036; mean difference, £124/year). ICS dose step-up had 56% probability of being less costly and marginally less effective (a trade-off), with ICER of £51,449 per additional patient controlled with FDC; and ICS dose step-up had 44% probability of being the preferred treatment strategy (less costly and more effective). In a second comparison, ICS step-up (n = 3232) had 100% probability of being cheaper and more effective than adding LABA to ICS via separate inhalers (n = 6464).


For asthma step-up therapy, increasing ICS dose using extrafine-particle ICS is significantly less costly from the payer perspective and marginally (non-significantly) less effective than FDC ICS/LABA therapy containing standard fine-particle ICS. These findings apply primarily to the UK healthcare system but warrant consideration when developing guidelines in settings with strong economic constraints.
Original languageEnglish
Pages (from-to)73-89
Number of pages17
JournalPulmonary Therapy
Issue number1
Early online date21 Mar 2016
Publication statusPublished - Jun 2016

Bibliographical note

The analyses were funded by an unrestricted grant from Teva Pharmaceuticals Limited of Petach Tikva, Israel. Access to data from the Optimum Patient Care Research Database was co-funded by Research in Real-Life Ltd (RiRL), Cambridge, UK. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. The authors thank Julie von Ziegenweidt for assistance with data extraction.


  • asthma
  • Beclometasone dipropionate hydrofluoroalkane
  • Budesonide/formoterol fumarate dehydrate
  • cost-effectivness
  • extrafine-particle inhaled corticosteroid
  • fixed-dose combination inhalers
  • fluticasone propionate/salmeterol xinafoate
  • long-acting β2-agonist


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