When should a maintenance inhaler be started for patients with respiratory symptoms?

When to Start a Maintenance Inhaler

Maintenance inhalers should be started in patients with persistent asthma symptoms occurring more than twice weekly or with nighttime awakenings more than twice monthly, or in COPD patients with moderate to severe symptoms or exacerbation history.

Asthma Patients

Assessment and Classification

• Evaluate symptom frequency, nighttime awakenings, and impact on daily activities
• Classify asthma severity based on symptoms and lung function:
  • Intermittent: Symptoms ≤2 days/week, nighttime awakenings ≤2x/month
  • Mild persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month
  • Moderate persistent: Daily symptoms, nighttime awakenings >1x/week but not nightly
  • Severe persistent: Symptoms throughout the day, frequent nighttime awakenings

Starting Maintenance Therapy

1. Mild Persistent Asthma:

   • Start with low-dose inhaled corticosteroid (ICS) as controller therapy 1
   • Alternative approach: As-needed ICS and SABA used concomitantly 1

2. Moderate Persistent Asthma:

   • Start with low-dose ICS-LABA combination 1
   • ICS-formoterol in a single inhaler can be used as both daily controller and reliever therapy 1

3. Severe Persistent Asthma:

   • Start with medium to high-dose ICS-LABA combination 1
   • Consider triple therapy with addition of LAMA for patients ≥12 years old with uncontrolled symptoms 1

Special Considerations

• For children aged 0-4 years with recurrent wheezing triggered by respiratory infections: Consider starting a short course of daily ICS at onset of respiratory infection 1
• For patients with mild persistent asthma: Either daily low-dose ICS with as-needed SABA OR as-needed ICS and SABA used concomitantly are acceptable approaches 1

COPD Patients

Assessment Factors

• Evaluate symptom burden (dyspnea, exercise limitation)
• Assess exacerbation history
• Review lung function (FEV1)

Starting Maintenance Therapy

1. Low Risk of Exacerbations:

   • Start LAMA/LABA dual therapy as initial maintenance therapy for symptomatic patients 1

2. High Risk of Exacerbations:

   • Start LAMA/LABA/ICS triple combination therapy as initial maintenance therapy 1
   • High risk defined as ≥2 moderate exacerbations or ≥1 severe exacerbation (hospitalization) in the past year 1

Important Considerations

• ICS should never be used as monotherapy in COPD 2
• Single-inhaler therapy improves adherence and reduces technique errors 2
• Triple therapy (LAMA/LABA/ICS) reduces mortality in high-risk COPD patients with FEV1 <80% predicted 1

Common Pitfalls to Avoid

1. Delaying maintenance therapy:

   • Relying too long on rescue medications alone can lead to poor symptom control and increased exacerbation risk
   • Early controller therapy helps prevent airway remodeling in asthma

2. Inappropriate device selection:

   • Match inhaler type to patient's ability to use correctly
   • Consider using single-inhaler therapy when possible to improve adherence 2

3. Inadequate follow-up:

   • Reassess response to therapy within 4-8 weeks of initiation 2
   • Adjust therapy based on symptom control and exacerbation frequency

4. Overlooking comorbidities:

   • Conditions like allergic rhinitis, GERD, or obesity can worsen respiratory symptoms
   • Address these conditions alongside respiratory treatment

5. Not educating patients about medication purpose:

   • Clearly distinguish between maintenance and rescue inhalers
   • Emphasize that maintenance inhalers must be taken regularly even when asymptomatic

Remember that maintenance inhalers are not meant to relieve acute symptoms or exacerbations 3, 4. Patients should continue to use short-acting bronchodilators for quick symptom relief while maintaining their controller therapy regimen.