What's the next step for a known asthmatic patient on Symbicort (budesonide/formoterol) 200/6 mcg one puff once daily and salbutamol (albuterol) inhaler as needed, who remains wheezy most days?

Management of Persistent Asthma with Inadequate Control on Current Therapy

For a patient with persistent asthma who remains wheezy most days despite Symbicort 200/6 mcg once daily and salbutamol as needed, the next step should be to increase the Symbicort dosage to twice daily (morning and evening). 1

Assessment of Current Control

The patient is experiencing persistent symptoms (wheezing most days) despite maintenance therapy, indicating inadequate asthma control. This requires stepping up treatment according to established guidelines.

Current Regimen Analysis:

• Symbicort 200/6 mcg once daily (budesonide/formoterol combination)
• Salbutamol inhaler as needed for rescue
• Persistent wheeze indicates poor symptom control

Recommended Treatment Adjustment

Step 1: Increase Inhaled Corticosteroid/Long-Acting Beta-Agonist Dose

• Increase Symbicort to twice daily dosing
  • Symbicort contains budesonide (inhaled corticosteroid) and formoterol (long-acting beta-agonist)
  • Twice daily dosing is more effective than once daily for controlling persistent asthma 2
  • This approach addresses both airway inflammation and bronchospasm

Step 2: Ensure Proper Inhaler Technique

• Verify patient can use their inhaler correctly 1
• Consider using a spacer device if technique is suboptimal

Step 3: If No Improvement After 2-4 Weeks

• Consider increasing to higher strength Symbicort (400/12 mcg twice daily) 2
• Add a spacer device to improve drug delivery 1

Step 4: For Continued Poor Control

• Consider a trial of nebulized therapy if symptoms persist despite optimized inhaler therapy 1
  • Formal assessment should include:
    • Review of diagnosis
    • Peak flow monitoring at home
    • Sequential testing of different regimens using PEF and subjective responses

Monitoring Response

• Monitor peak expiratory flow (PEF) twice daily before treatment
• Document symptom frequency and rescue inhaler use
• A successful response is defined as:
  • Increase of >15% in PEF over baseline 1
  • Reduction in wheeze frequency
  • Decreased need for rescue medication

Common Pitfalls to Avoid

1. Underdosing: Symbicort once daily is often insufficient for patients with persistent symptoms 2
2. Poor inhaler technique: Ensure proper device usage before concluding treatment failure
3. Failure to address compliance: Check if patient is taking medication as prescribed 1
4. Delayed escalation: Persistent symptoms require prompt treatment adjustment to prevent exacerbations
5. Overlooking comorbidities: Consider conditions that may mimic or worsen asthma (GERD, allergic rhinitis)

Additional Considerations

• If symptoms remain poorly controlled despite these measures, consider:
  • Adding a leukotriene receptor antagonist
  • Referral to a respiratory specialist for consideration of additional therapies
  • Assessment for severe asthma requiring biological therapies

The evidence strongly supports that increasing the frequency of Symbicort to twice daily is the most appropriate next step for this patient with persistent asthma symptoms, as this addresses both the inflammatory and bronchospastic components of asthma while maintaining a favorable risk-benefit profile.