Direct healthcare cost comparison of fluticasone/salmeterol and budesonide/formoterol maintenance and reliever therapy for moderate to severe asthma in the South African public sector

Abstract

Background. Moderate to severe asthma poses significant health and economic challenges in South Africa (SA), with varying asthma treatment costs. Inhaled corticosteroids/long-acting beta-2-agonists remain the cornerstone of asthma management. However, cost comparisons between fluticasone/salmeterol (FP/salm) and budesonide/formoterol (bud/form) as maintenance and reliever therapy (MART) are limited in low- and middle-income settings.

Objective. To compare the direct treatment costs of regular FP/salm plus as-needed short-acting beta-2-agonist (SABA) with bud/form MART in the SA public sector.

Methods. A comparative cost analysis was conducted from the SA public health sector perspective. Costs from the National Department of Health pharmaceutical tender and Uniform Patient Fee Schedule, and clinical effectiveness data on severe exacerbations avoided from three randomised controlled trials (AHEAD, COMPASS, COSMOS), informed annual per-patient costs. Univariate sensitivity analyses assessed the robustness of the findings.

Results. Annual direct per-patient treatment costs for bud/form MART were probably comparable to FP/salm plus as-needed SABA in COMPASS and COSMOS (USD145.84 and USD157.81). In the AHEAD study, a higher-dose bud/form MART regimen was more expensive (USD149.14 v. USD122.65). On average across studies, FP/salm was 0.58% less expensive. Medication costs were the primary cost driver, with variation in bud/form 160/4.5 μg pricing significantly influencing overall cost outcomes.

Conclusion. In SA’s public sector, FP/salm plus as-needed SABA is comparable to bud/form MART for moderate to severe asthma in terms of cost. Bud/form’s price sensitivity suggests potential for improved procurement. Future research should integrate real-world data, include indirect costs, and assess full-spectrum asthma management to inform efficient, equitable policy and evaluate economic impact.