From the Guidelines
For a pregnant patient with asthma currently using albuterol twice daily, an inhaled corticosteroid (ICS) such as budesonide would be the recommended maintenance therapy to reduce albuterol dependence. The typical starting dose would be budesonide 180-360 mcg twice daily via inhaler, as recommended by the NAEPP expert panel report 1. Budesonide is preferred during pregnancy because it has the most safety data in pregnant women, with studies showing no increased risk of adverse perinatal outcomes 1. The patient should continue to use her albuterol inhaler as needed for breakthrough symptoms, but with proper ICS therapy, these rescue needs should decrease over time. It's essential to maintain good asthma control during pregnancy, as uncontrolled asthma poses greater risks to both mother and fetus than potential medication side effects. The ICS works by reducing airway inflammation, which addresses the underlying cause of asthma, while albuterol only provides temporary bronchodilation without treating inflammation. Some key points to consider when initiating ICS therapy include:
- Starting with a low dose and titrating as needed to achieve symptom control
- Monitoring for potential side effects, such as oral thrush, and taking steps to minimize them
- Educating the patient on proper inhaler technique to ensure effective medication delivery The patient should be reassessed after 2-4 weeks to evaluate symptom control and adjust the ICS dose if needed. If asthma remains poorly controlled on ICS alone, adding a long-acting beta-agonist (LABA) in a combination inhaler may be considered as a step-up therapy, with salmeterol being a potential option due to its longer availability in the United States 1. However, the primary goal should be to establish effective control with the ICS, as this addresses the underlying inflammatory component of asthma. By prioritizing ICS therapy and adjusting as needed, we can minimize the patient's reliance on albuterol and reduce the risks associated with uncontrolled asthma during pregnancy.
From the FDA Drug Label
Pregnant women should be closely monitored and medication adjusted as necessary to maintain optimal control of asthma.
The FDA drug label does not answer the question about the specific maintenance dose for a pregnant patient with asthma who is currently using an albuterol inhaler. However, it emphasizes the importance of closely monitoring pregnant women with asthma and adjusting medication as necessary to maintain optimal control of the condition.
- Key consideration: The goal is to maintain optimal control of asthma.
- Action: Monitor the patient closely and adjust medication as necessary. 2
From the Research
Maintenance Dose for Pregnant Patient with Asthma
To reduce reliance on albuterol, a pregnant patient with asthma can be started on a maintenance dose of a combination inhaler containing a long-acting beta2-adrenoceptor agonist (LABA) and an inhaled corticosteroid (ICS). The following options are available:
- Salmeterol/fluticasone propionate (Seretide/Advair Diskus) administered twice daily via a multidose dry powder inhaler or metered-dose hydrofluoroalkane inhaler 3, 4, 5
- The combination inhaler is available in different strengths of fluticasone propionate (100,250, and 500 microg) and a fixed dose of salmeterol (50 microg) 4
Key Considerations
When selecting a maintenance dose, consider the following:
- The patient's current symptoms and lung function
- The patient's previous response to asthma medications
- The potential for corticosteroid-sparing effects with combination therapy 5
- The cost-effectiveness of combination therapy compared to monotherapy with ICS or LABA 6, 7
Available Strengths and Dosing
The available strengths of salmeterol/fluticasone propionate are: