Asthma Action Plan for Patients on ICS-Formoterol PRN According to GINA 2024
For patients using ICS-formoterol as needed (PRN), the asthma action plan should utilize the same inhaler for both maintenance and relief, with clear instructions for increasing use during worsening symptoms.
Green Zone (Well Controlled)
- Maintenance therapy: ICS-formoterol 1 puff PRN when symptomatic
- Symptoms: Minimal or no symptoms, no activity limitations, no nighttime symptoms
- Action: Continue using ICS-formoterol 1 puff only when needed for symptom relief
- Maximum daily dose: Up to 12 total inhalations in any single day for adults and adolescents (≥12 years) 1
Yellow Zone (Worsening Symptoms)
- Symptoms: Increasing shortness of breath, cough, wheezing, or chest tightness; symptoms affecting daily activities or sleep
- Action: Increase ICS-formoterol to 1-2 puffs as needed for symptom relief
- Monitoring: If using more than 2 puffs per day for more than 2 consecutive days, move to orange zone actions
- Contact provider: If symptoms persist for more than 3 days despite increased medication use
Orange Zone (Deteriorating Control)
- Symptoms: Significant worsening of symptoms, marked limitation of activities, nighttime awakenings
- Action: Increase to 2 puffs of ICS-formoterol every 4 hours as needed (maximum 8 puffs/day)
- Contact provider: Within 24-48 hours if not improving
- Additional medication: Consider adding oral corticosteroids if prescribed in advance by healthcare provider
Red Zone (Medical Alert)
- Symptoms: Severe shortness of breath, unable to speak in full sentences, lips or fingernails blue, severe chest tightness
- Action: Take 2 puffs of ICS-formoterol, repeat after 15 minutes if needed
- Emergency action: Seek immediate medical attention or call emergency services
- Start oral corticosteroids: If prescribed in advance by healthcare provider
Key Considerations for ICS-Formoterol PRN Plans
Evidence-Based Rationale
The GINA 2024 guidelines recommend ICS-formoterol as both maintenance and reliever therapy because:
Formoterol provides rapid symptom relief similar to short-acting β2-agonists (SABAs) while the ICS component reduces inflammation and exacerbation risk 2, 3
Using ICS-formoterol as needed ensures patients receive anti-inflammatory medication whenever they experience symptoms, addressing the underlying inflammation 2
This approach has demonstrated superior efficacy in reducing exacerbations compared to SABA-only relief therapy, even in mild asthma 3, 4
Important Patient Instructions
- Explain that ICS-formoterol provides both quick relief and preventive benefits in one inhaler
- Emphasize that increasing frequency of use during symptom worsening is appropriate and part of the self-management plan
- Instruct patients to rinse their mouth after use to prevent oral candidiasis 1
- Warn against exceeding the maximum daily dose (12 total inhalations for adults/adolescents)
- Ensure patients understand when to seek medical attention
Monitoring and Follow-Up
- Regular assessment of asthma control is essential
- Increased use of ICS-formoterol (more than twice weekly) generally indicates inadequate control and may require adjustment of therapy 1
- Schedule follow-up within 1-3 months after initiating this regimen to assess effectiveness
Cautions and Contraindications
- Formoterol should never be used as monotherapy for asthma due to increased risk of asthma-related death 1
- This approach is most studied with budesonide-formoterol, though other ICS-formoterol combinations may be used 3
- For children under 12 years, consult specific pediatric guidelines as evidence is more limited 2, 1
By following this structured asthma action plan, patients can effectively self-manage their asthma using ICS-formoterol as both maintenance and reliever therapy, which has been shown to improve outcomes and reduce exacerbation risk compared to traditional approaches.