Can Foracort (budesonide and formoterol) 200, 2 puffs every 6 hours, be used as initial treatment for a child above 12 years with an asthma exacerbation?

Management of Asthma Exacerbation in Children Above 12 Years

Foracort 200 (budesonide/formoterol) 2 puffs every 6 hours is not recommended as initial treatment for asthma exacerbation in children above 12 years. Instead, short-acting beta-agonists (SABAs) should be the first-line treatment for acute symptom relief during exacerbations 1.

Recommended First-Line Treatment for Asthma Exacerbations

• For children above 12 years with asthma exacerbation, the recommended initial treatment is a short-acting beta-agonist (SABA) such as albuterol/salbutamol administered via MDI with spacer: 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed 2, 1
• High-flow oxygen should be administered via face mask if oxygen saturation is low 2
• Systemic corticosteroids (prednisolone 1-2 mg/kg/day, maximum 60 mg/day) should be added for moderate to severe exacerbations 2, 1
• For severe exacerbations not responding to initial SABA treatment, adding ipratropium bromide to nebulized treatment (0.5 mg every 20 minutes for 3 doses, then as needed) can provide additional bronchodilation 2

Why Foracort is Not Appropriate for Initial Exacerbation Management

• Foracort contains budesonide (an inhaled corticosteroid) and formoterol (a long-acting beta-agonist), which is primarily intended for maintenance therapy in moderate to severe persistent asthma, not for acute symptom relief during exacerbations 1
• Long-acting beta-agonists (LABAs) like formoterol are not recommended as monotherapy for acute symptom relief during exacerbations 1
• Using combination ICS/LABA products like Foracort as rescue medication instead of SABAs during initial treatment of exacerbations is not aligned with current guidelines 1

Monitoring and Escalation of Treatment

• Repeat measurement of peak expiratory flow (PEF) should be done 15-30 minutes after starting treatment 2
• Oxygen saturation should be monitored to maintain SpO2 >92% 2
• If the patient is not improving after 15-30 minutes of initial treatment:
  • Continue oxygen and systemic corticosteroids 2
  • Give nebulized beta-agonist more frequently (every 15-30 minutes) 2
  • Consider adding ipratropium to the nebulizer and repeat every 6 hours until improvement starts 2

When to Consider Hospital Transfer

• Transfer to intensive care should be considered if there is:
  • Deteriorating PEF, worsening or persistent hypoxia, confusion, or drowsiness 2
  • Exhaustion, coma, or respiratory arrest 2
  • Persistent hypercapnia 2

Appropriate Use of Budesonide/Formoterol

• While not appropriate as initial treatment for exacerbations, budesonide/formoterol has been shown to be effective as maintenance and reliever therapy in a single inhaler for ongoing asthma management in patients 12 years and older with moderate to severe persistent asthma 2, 3
• For maintenance therapy, the Global Initiative for Asthma and other guidelines support using budesonide/formoterol as both maintenance and reliever therapy in appropriate patients, which can reduce exacerbation rates compared to other regimens 2, 4
• This approach (using budesonide/formoterol for both maintenance and as-needed relief) has been shown to reduce exacerbations requiring oral corticosteroids compared to using SABA alone for relief 5, 3

Important Considerations

• Ensure proper education on medication use, inhaler technique, and provide a written action plan for managing exacerbations 1
• Monitor response to therapy closely, especially in children 1
• For children with asthma exacerbations, the treatment approach should prioritize rapid relief of symptoms with short-acting bronchodilators rather than long-acting agents 1

Remember that the primary goal in managing asthma exacerbations is to relieve bronchospasm quickly and reduce airway inflammation, which is best achieved with SABAs and systemic corticosteroids as first-line therapy 2, 1.