What is the proper use of preventer and reliever medications, such as inhaled corticosteroids (ICS) and short-acting beta-agonists (SABA), for mild to moderate asthma?

Management of Mild to Moderate Asthma: Proper Use of Preventer and Reliever Medications

For mild to moderate asthma, inhaled corticosteroids (ICS) should be used as the primary preventer medication, while short-acting beta-agonists (SABAs) should be used as needed for symptom relief, with consideration of ICS-formoterol combinations for both prevention and relief in appropriate patients. 1

Understanding Preventer and Reliever Medications

Preventer Medications

• Inhaled Corticosteroids (ICS): The cornerstone of asthma management

  • Reduce airway inflammation
  • Prevent exacerbations
  • Improve lung function
  • Examples: Fluticasone, Beclomethasone, Budesonide, Mometasone

• Long-Acting Beta-Agonists (LABAs): Used in combination with ICS

  • Should NEVER be used alone due to increased risk of asthma-related death 2
  • Examples: Salmeterol, Formoterol
  • Provide bronchodilation for 12+ hours

Reliever Medications

• Short-Acting Beta-Agonists (SABAs)
  • Used for immediate symptom relief
  • Examples: Albuterol (salbutamol), Terbutaline
  • Increasing use (more than twice weekly) indicates poor asthma control 3

Treatment Algorithm for Mild to Moderate Asthma

Step 1: Mild Intermittent Asthma

• Preferred treatment: As-needed SABA for symptom relief
• Alternative option: Low-dose ICS-formoterol as needed 1
• Key point: Increasing SABA use (>2 days/week) indicates need for regular preventer therapy 3

Step 2: Mild Persistent Asthma

• Preferred treatment: Daily low-dose ICS plus as-needed SABA 3, 1
• Alternative options:
  • Leukotriene receptor antagonists (less effective than ICS) 3
  • As-needed ICS-formoterol combination 4
• Dosing: One inhalation of low-dose ICS twice daily 2

Step 3: Moderate Persistent Asthma

• Preferred treatment: Low-dose ICS-LABA combination plus as-needed SABA 3, 1
• Evidence: Adding LABA to low-medium dose ICS improves outcomes more effectively than doubling ICS dose 3
• Dosing: One inhalation of ICS-LABA twice daily, approximately 12 hours apart 2

Proper Use of Inhalers

Preventer (ICS or ICS-LABA) Use

• Take regularly as prescribed (typically twice daily)
• Use even when feeling well
• Rinse mouth after use to prevent oral candidiasis 2
• May take 1-2 weeks to achieve maximum benefit 2

Reliever (SABA) Use

• Use only when experiencing symptoms
• Carry at all times for emergency symptom relief
• Increasing use indicates poor asthma control and need for treatment adjustment 3
• Can be used before exercise to prevent exercise-induced bronchospasm 1

Monitoring Asthma Control

Signs of Poor Control

• Using reliever medication more than twice weekly 3
• Nighttime symptoms
• Activity limitation due to asthma
• Frequent exacerbations requiring oral corticosteroids

When to Step Up Treatment

• If symptoms persist despite adherence to current therapy
• If experiencing exacerbations despite current treatment
• Consider stepping up to higher ICS dose or adding additional medications 1

Important Cautions and Considerations

• Never use LABAs alone for asthma management due to increased risk of asthma-related death 2
• Increasing use of SABAs indicates inadequate control and need to intensify anti-inflammatory therapy 3
• ICS-formoterol combinations may be used both as maintenance and reliever therapy in appropriate patients 4
• For patients not responding to initial therapy, consider:
  • Checking inhaler technique
  • Assessing adherence
  • Identifying and addressing triggers
  • Increasing ICS dose or adding additional controller medications 1

Special Considerations for Children

• For children aged 4-11 years with mild to moderate asthma not controlled on ICS alone:
  • Recommended dosage is one inhalation of ICS-LABA 100/50 twice daily 2
• Children may require spacer devices to improve medication delivery

By following this structured approach to using preventer and reliever medications, most patients with mild to moderate asthma can achieve good symptom control and reduce the risk of exacerbations.