In an 18-year-old female with mild intermittent asthma who requires daily and nocturnal use of albuterol (salbutamol), would the next best add-on therapy be Symbicort (budesonide/formoterol) or steroids?

From the Guidelines

For an 18-year-old female with mild intermittent asthma requiring daily and nocturnal albuterol use, the next best add-on therapy would be Symbicort (budesonide/formoterol). This combination inhaler contains both an inhaled corticosteroid (budesonide) to reduce airway inflammation and a long-acting beta-agonist (formoterol) to provide sustained bronchodilation. The typical starting dose would be Symbicort 80/4.5 mcg, 2 inhalations twice daily. The patient should continue to use her albuterol inhaler as needed for breakthrough symptoms, but with proper Symbicort use, she should require it less frequently.

Key Points to Consider

• The need for daily and nocturnal albuterol indicates that her asthma is not well-controlled despite being classified as mild intermittent, suggesting she has progressed to at least mild persistent asthma.
• Symbicort provides both immediate symptom relief and addresses the underlying inflammation, making it more appropriate than oral steroids which would only be indicated for short-term use during acute exacerbations.
• According to the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma, inhaled corticosteroids are the most consistently effective long-term control medication at all steps of care for persistent asthma 1.
• The addition of a long-acting beta-agonist to an inhaled corticosteroid has been shown to reduce exacerbations and improve asthma control, as seen in studies such as the FACET study 1.
• It is essential to reassess the patient after 4-6 weeks to evaluate response to therapy and potentially adjust the treatment plan if needed, considering the patient's response to Symbicort and any potential side effects.

Additional Considerations

• The patient's asthma classification may need to be revised based on her current symptoms and treatment requirements.
• Regular follow-up appointments are crucial to monitor the patient's asthma control, adjust the treatment plan as necessary, and ensure the patient is using her inhalers correctly.
• Patient education on proper inhaler technique, medication adherence, and recognition of asthma exacerbations is vital for effective asthma management. The patient should be informed about the potential benefits and risks of Symbicort, including the risk of exacerbations and the importance of using the medication as prescribed 1.

From the FDA Drug Label

Because of this risk, use of FORADIL AEROLIZER for the treatment of asthma without concomitant use of a long-term asthma control medication, such as an inhaled corticosteroid, is contraindicated Use FORADIL AEROLIZER only as additional therapy for patients with asthma who are currently taking but are inadequately controlled on a long-term asthma control medication, such as an inhaled corticosteroid.

The next best add-on therapy for an 18-year-old female with mild intermittent asthma who requires daily and nocturnal use of albuterol would be steroids (inhaled corticosteroids), as the use of a long-acting beta2-adrenergic agonist (LABA) like formoterol (a component of Symbicort) without a concomitant inhaled corticosteroid is contraindicated 2. Inhaled corticosteroids, such as budesonide, are recommended as the first-line treatment for patients with persistent asthma who require more than occasional use of bronchodilators, and the addition of a LABA like formoterol should only be considered for patients whose asthma is not adequately controlled on inhaled corticosteroids alone 3.

From the Research

Asthma Management

The patient in question has mild intermittent asthma and is experiencing an increase in symptoms, requiring daily and nocturnal use of albuterol. The next step in management would be to add a controller medication to reduce inflammation and prevent exacerbations.

Treatment Options

• Symbicort (budesonide/formoterol): This is a combination inhaler that contains an inhaled corticosteroid (budesonide) and a long-acting beta2-agonist (formoterol) 4, 5, 6, 7. It is used for both maintenance and relief of asthma symptoms.
• Steroids: Inhaled corticosteroids are the preferred treatment for long-term control of asthma, but the addition of a long-acting beta2-agonist (such as formoterol) is recommended for patients who are not well-controlled on inhaled corticosteroids alone 6.

Recommendation

Based on the evidence, the next best add-on therapy for this patient would be Symbicort (budesonide/formoterol) 4, 5, 6, 7. This is because Symbicort has been shown to be effective in reducing asthma symptoms and exacerbations, and is a convenient and easy-to-use treatment option. Additionally, the combination of budesonide and formoterol in Symbicort provides both anti-inflammatory and bronchodilator effects, making it a suitable treatment for patients with mild intermittent asthma who require daily and nocturnal use of albuterol.

Key Benefits of Symbicort

• Reduces asthma symptoms and exacerbations 4, 8, 7
• Convenient and easy-to-use treatment option 5, 6
• Provides both anti-inflammatory and bronchodilator effects 5, 6
• Can be used for both maintenance and relief of asthma symptoms 4, 7