What is the recommended step-up treatment for a patient with asthma using albuterol (short-acting beta-agonist) daily and Symbicort (budesonide/formoterol) inhaler, which is ineffective for control?

Step-Up Treatment for Uncontrolled Asthma on Symbicort

For a patient using albuterol daily and reporting ineffective control with Symbicort, the recommended step-up treatment is to increase to a higher-dose ICS/LABA combination or add a third controller medication such as a long-acting muscarinic antagonist (LAMA).

Assessment of Current Control

When a patient reports daily albuterol use and inadequate control with Symbicort (budesonide/formoterol), this indicates:

• The patient is at Step 3 or 4 of asthma treatment but experiencing poor control
• Daily rescue medication use (>2 days/week) signals inadequate control 1
• The patient is experiencing treatment failure on current therapy

Step-Up Options in Order of Preference

1. Increase ICS/LABA Dose

• Increase to a higher dose of budesonide/formoterol (medium to high dose)
• Current guidelines recommend increasing ICS dose when control is inadequate 2
• Higher doses of ICS component provide greater anti-inflammatory effect

2. Add a Third Controller Medication

• Add a long-acting muscarinic antagonist (LAMA) such as tiotropium
• Alternative: Add a leukotriene receptor antagonist (LTRA) such as montelukast
• These options are particularly useful when higher ICS doses are not effective or tolerated

3. Consider Alternative ICS/LABA Combination

• Switching to a different ICS/LABA combination (e.g., fluticasone/salmeterol) may be beneficial
• Different ICS molecules have varying potencies and may provide better control 1
• Fluticasone 250 mcg is equivalent to mometasone 200 mcg based on relative potency 1

Implementation Steps

1. Verify inhaler technique - Poor technique is a common cause of treatment failure
2. Check adherence to current regimen
3. Assess for triggers that may be worsening asthma control
4. Implement the step-up therapy based on options above
5. Schedule follow-up within 2-6 weeks to assess response to therapy 1

Important Considerations

• Never use LABA monotherapy due to increased risk of asthma-related death 1, 3
• If symptoms remain uncontrolled despite step-up therapy, consider referral to an asthma specialist 1
• Assess for comorbidities that may worsen asthma control (GERD, rhinosinusitis)
• Consider a short course of oral corticosteroids if the patient is experiencing an acute exacerbation 2

Special Considerations for Symbicort

Symbicort contains formoterol, which has a more rapid onset of action than salmeterol 1. This allows for a potential alternative approach:

• Symbicort SMART (Single Maintenance And Reliever Therapy) approach may be considered, where the same Symbicort inhaler is used for both maintenance and rescue 4
• This approach has been shown to reduce severe exacerbations compared to fixed-dose regimens 5

Monitoring Response

After implementing step-up therapy:

• Assess control using criteria such as symptoms ≤2 days/week, nighttime awakenings ≤2 times/month
• Monitor frequency of rescue medication use
• If control is achieved and maintained for at least 3 months, consider stepping down therapy 2

If the patient continues to have poor control despite appropriate step-up therapy, consider referral to a specialist for further evaluation and consideration of advanced therapies.