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The ICS/Formoterol Reliever Therapy Regimen in Asthma: A Review

The Global Initiative for Asthma recommends that low-dose inhaled corticosteroid (ICS)/formoterol be preferred to short-acting beta2-agonists as reliever therapy in adolescents and adults with asthma, across the range of asthma severity. This recommendation represents the most fundamental change in asthma management for many decades... There is a substantial evidence base extending back more than 70 years that beta2-agonist reliever therapy may lead to increased asthma severity with long-term use. During an acute severe attack, SABA overuse may result in a delay in patients seeking medical review, and lead to cardiotoxicity in the situation of hypoxemia, increasing the risk of asthma-related…

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 Have asthma? You might not be using the most effective treatments

Thanks to emerging research, guidelines for asthma treatment have been shifting away from albuterol-only and toward steroid-containing inhalers. In 2022, the Global Initiative for Asthma (GINA) — a collaboration between the World Health Organization and the National Institutes of Health — issued landmark recommendations to change the paradigm of asthma care. These new guidelines no longer endorse treating asthma with albuterol, a short-acting medication. Instead, they recommend that all adults, adolescents and most children with asthma receive inhalers containing steroids and a long-acting medicine to relax lung muscles.

Articles of Interest

Combination Preventers

Combination preventers contain two or three asthma medications in combination: a preventer (corticosteroid) and one or two long-acting relievers (bronchodilator).

Albuterol–Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma

The risk of severe asthma exacerbation was significantly lower with as-needed use of a fixed-dose combination of 180 μg of albuterol and 160 μg of budesonide than with as-needed use of albuterol alone among patients with uncontrolled moderate-to-severe asthma who were receiving a wide range of inhaled glucocorticoid-containing maintenance therapies.

Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma

In this meta-analysis of patients with persistent asthma, the use of single maintenance and reliever therapy compared with inhaled corticosteroids as the controller therapy (with or without a long-acting β-agonist) and short-acting β-agonists as the relief therapy was associated with a lower risk of asthma exacerbations.

Combination corticosteroid/β-agonist inhaler as reliever therapy: A solution for intermittent and mild asthma?

The recommended treatment of mild asthma is regular maintenance inhaled corticosteroids (ICSs) with a short-acting β-agonist as a separate inhaler used when needed for symptom relief. However, the benefits of regular ICS use in actual clinical practice are limited by poor adherence and low prescription rates. An alternative strategy would be the symptom-driven (as-required or “prn”) use of a combination ICS/short-acting β-agonist or ICS/long-acting β-agonist inhaler as a reliever rather than regular maintenance use.

Combination Inhaled Corticosteroid/Long Acting Beta Agonist Therapy- An Evolving Role in Asthma Care

Overall, this meta-analysis supports the use of ICS/LABA as both maintenance and reliever therapy in persistent asthma given the significant reduction in exacerbation risk compared to conventional therapeutic strategies.

Combination inhalers for asthma

Patients whose asthma is not well controlled by inhaled corticosteroids may benefit from the addition of a long-acting beta2 agonist. The effects of inhaling a corticosteroid and a long-acting beta2 agonist can reduce symptoms, improve lung function and prevent exacerbations. Once the patient's asthma is controlled it may be appropriate for them to use one of the combination inhalers which contain both types of drug. These combination inhalers may not be more efficacious than inhaling the drugs separately, but they are more convenient.

Combination Inhalers for Asthma...

This report examines four combination inhalers available in Canada that are used to maintain control over asthma symptoms as part of a continuum of treatment.

Combination therapy in asthma: a review

Several studies have shown that combination therapy using long acting beta agonists (LABA) and inhaled corticosteroids (ICS) in a single inhaler device confers complementary and synergistic effect in the management of asthma. It further improves patient compliance and reduces the complexity of treatment and morbidity associated with the disease. Recent studies have shown the combination therapy to serve not only as maintenance but also a reliever therapy with same efficacy as the short acting beta agonists (SABA).

Combined inhaled beta‐agonist and anticholinergic agents for emergency management in adults with asthma

Overall, combination inhaled therapy with SAAC and SABA reduced hospitalisation and improved pulmonary function in adults presenting to the ED with acute asthma. In particular, combination inhaled therapy was more effective in preventing hospitalisation in adults with severe asthma exacerbations who are at increased risk of hospitalisation, compared to those with mild‐moderate exacerbations, who were at a lower risk to be hospitalised.

Combined Inhaled Short-Acting Beta2 Agonist and Anticholinergic Agents for Asthma

1 in 16 avoided hospitalization, 1 in 20 avoided relapse.

Drug Combination Reduces the Risk of Asthma Attacks

Results from the clinical trial called MANDALA, published in The New England Journal of Medicine, show that a combination of albuterol, which provides relief from an asthma attack by relaxing the smooth muscles and is used for immediate asthma relief, and the corticosteroid budesonide, taken via an inhaler, lower the number of sudden episodes of shortness of breath, wheezing and coughing in patients.

What are Bronchodilator combinations?

Bronchodilator combinations are generally inhalers or inhalation devices, which contain more than one bronchodilator, or a bronchodilator and a steroid. Bronchodilator combinations with more than one bronchodilator usually consist of a short acting and a long acting bronchodilator. The bronchodilators may work by different mechanisms to dilate the air passages, and makes air flow easier. Bronchodilator combinations with a steroid and bronchodilator act more like a preventative. Steroids block the body's inflammatory response and effectively improve lung function and reduce asthma symptoms. The bronchodilator in this combination is generally a long acting one and it also acts as a preventer.

Resources

Generic ICS/LABA Inhalers

There are now several generic maintenance inhalers on the market, all versions of fluticasone/salmeterol: