What should be added to Symbicort (budesonide/formoterol) 160 for an asthma exacerbation in a patient already taking Symbicort (budesonide/formoterol) 160?

From the Guidelines

For an asthma exacerbation while already taking Symbicort 160, you should add a short-acting beta-agonist (SABA) like albuterol via inhaler and consider a short course of oral corticosteroids such as prednisone.

Key Considerations

• The most recent and highest quality study 1 suggests that there is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, and oral therapy is preferred over intravenous administration.
• According to the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1, patients should be instructed to use a written asthma action plan, recognize early indicators of an exacerbation, and adjust their medications by increasing SABA and, in some cases, adding a short course of oral systemic corticosteroids.
• The study 1 also recommends that all patients presenting with an asthma exacerbation should be evaluated and triaged immediately, with treatment instituted promptly on determination of a moderate, severe, or life-threatening exacerbation.

Treatment Approach

• Add a SABA like albuterol via inhaler, typically 2 puffs every 4-6 hours as needed for rescue relief.
• Consider a short course of oral corticosteroids such as prednisone (typically 40-60mg daily for 5-7 days) if symptoms are moderate to severe.
• It's also important to note that increasing the dose of ICSs, such as Symbicort, is not effective in managing asthma exacerbations 1.

Monitoring and Follow-up

• Monitor response to treatment and promptly communicate with the clinician about any serious deterioration in symptoms or peak expiratory flow (PEF) or about decreased responsiveness to SABA treatment.
• If symptoms don't improve within 24 hours of starting these additional treatments, or if you experience severe shortness of breath, bluish lips, confusion, or extreme difficulty breathing, seek immediate medical attention as you may need more intensive treatments like nebulizer therapy or hospitalization.

From the FDA Drug Label

Although many of the undesirable features of corticosteroid therapy can be minimized by alternate day therapy, as in any therapeutic situation, the physician must carefully weigh the benefit-risk ratio for each patient in whom corticoid therapy is being considered. The patient is already taking Symbicort 160 for asthma and is experiencing an exacerbation.

• The addition of a corticosteroid, such as prednisone, may be necessary to control the exacerbation.
• The dosage and duration of prednisone therapy should be determined by the physician, taking into account the severity of the exacerbation and the patient's response to treatment 2.
• It is essential to monitor the patient's condition closely and adjust the treatment plan as needed to minimize the risk of adverse effects.

From the Research

Asthma Exacerbation Management

If you are already taking Symbicort 160 and experiencing an asthma exacerbation, the following options can be considered:

• Adding a short-acting β2-agonist (SABA) as needed for quick relief of symptoms 3
• Using budesonide/formoterol as both maintenance and reliever therapy, which has been shown to reduce the risk of severe exacerbations compared to fixed-dose treatment with ICS/LABA plus SABA 3, 4
• Considering adjustable maintenance dosing with budesonide/formoterol, which may reduce the overall dosage and maintain control as effectively as fixed dosing 4

Treatment Options

Some studies suggest the following treatment options for patients with mild asthma:

• As-needed use of budesonide-formoterol, which has been shown to be noninferior to budesonide maintenance therapy for severe exacerbations, but inferior in controlling symptoms 5
• As-needed use of budesonide-formoterol, which provided superior asthma-symptom control to as-needed terbutaline, but was inferior to budesonide maintenance therapy 6

Severe Asthma Exacerbation Prevention

To prevent severe asthma exacerbations, the following can be considered:

• Switching to a single inhaler combination inhaled corticosteroid-formoterol as both maintenance and reliever (SMART) regimen, which has been associated with a reduced risk of severe exacerbations compared to a step up or continuation of GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever 7