From the Guidelines
For a 31-year-old female with persistent shortness of breath despite being on Symbicort (budesonide/formoterol) 320/9 twice daily, the next step in treatment would be to add a long-acting muscarinic antagonist (LAMA) such as tiotropium (Spiriva) 18 mcg once daily via inhaler. This recommendation is based on the principle of adding a medication with a complementary mechanism of action to provide additional bronchodilation and symptom relief, as suggested by the guidelines for asthma management 1. The patient's current symptoms despite medium-to-high dose ICS/LABA therapy indicate inadequate control of the underlying inflammatory and bronchoconstrictive processes, necessitating escalation of therapy. Before starting this medication, it would be essential to confirm adherence to the current regimen and proper inhaler technique, as emphasized in the management of asthma 1. Additionally, a pulmonary function test should be performed to assess the severity of airflow limitation and response to bronchodilators, as recommended in the guidelines for diagnosing and managing asthma 1. The patient should be monitored for potential side effects, including dry mouth, urinary retention, and worsening of narrow-angle glaucoma if present. This approach aligns with the guidelines for managing asthma, which emphasize the importance of balancing the benefits and risks of different therapies, including the use of LABAs in combination with ICSs, and the consideration of alternative therapies such as LAMAs for patients with persistent symptoms despite medium-to-high dose ICS/LABA therapy 1.
From the Research
Next Steps in Treatment
The patient is currently on Symbicort (budesonide/formoterol) 320/9 twice daily and continues to experience shortness of breath. Considering the patient's symptoms, the next steps in treatment could be:
- Adjusting the dose of Symbicort: Studies have shown that adjustable maintenance dosing with budesonide/formoterol can provide equivalent or better asthma control with a significantly lower amount of study drug use compared with fixed dosing 2, 3.
- Using Symbicort as both a maintenance and reliever medication: The Symbicort maintenance and reliever therapy (SMART) dosing regimen has been shown to be effective in reducing exacerbations and reliever medication use compared with fixed-dosing regimens in asthma 3, 4, 5.
- Adding other medications: If the patient's symptoms persist, other medications such as oral corticosteroids or other bronchodilators may be considered.
Considerations for Treatment
When considering the next steps in treatment, the following should be taken into account:
- The patient's current dose of Symbicort: The patient is currently on a high dose of Symbicort, and adjusting the dose may be necessary to achieve better asthma control.
- The patient's response to treatment: The patient's response to Symbicort should be monitored, and adjustments made as necessary to achieve optimal asthma control.
- The risk of exacerbations: The patient's risk of exacerbations should be considered, and treatment adjusted accordingly to minimize this risk.
Evidence for Treatment
Studies have shown that budesonide/formoterol is effective in reducing exacerbations and improving asthma control in patients with asthma 2, 3, 4, 5, 6. The SMART dosing regimen has been shown to be effective in reducing exacerbations and reliever medication use compared with fixed-dosing regimens in asthma 3, 4, 5. Adjustable maintenance dosing with budesonide/formoterol has been shown to provide equivalent or better asthma control with a significantly lower amount of study drug use compared with fixed dosing 2, 3.