Can Rapihaler (formoterol and budesonide) 200/6 be discontinued and replaced with Budesonide (budesonide) and Singulair (montelukast)?

Replacing Rapihaler 200/6 with Budesonide and Singulair in Asthma Management

Replacing Rapihaler (budesonide/formoterol) 200/6 with separate budesonide and Singulair (montelukast) is not recommended as this would likely result in reduced asthma control and increased risk of exacerbations. 1, 2

Rationale for Maintaining Combination Therapy

• Combination therapy with inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) is more effective at preventing severe exacerbations than ICS alone in patients with persistent asthma 1
• Budesonide/formoterol (Rapihaler) provides both maintenance anti-inflammatory effect and bronchodilation, which is superior to ICS alone for symptom control 3
• Montelukast (Singulair) is a leukotriene receptor antagonist that acts as a controller medication but is less effective than LABA as an add-on therapy to ICS 2, 4
• The British Thoracic Society guidelines indicate that long-acting beta-2-agonists (like formoterol in Rapihaler) may be beneficial in patients with symptoms of breathlessness 1

Comparative Effectiveness

• Budesonide/formoterol combination has been shown to reduce severe exacerbations compared to budesonide maintenance therapy alone (rate ratio 0.69,95% CI 0.48-1.00) 5
• Budesonide/formoterol used as needed has demonstrated non-inferiority to twice-daily budesonide with respect to severe asthma exacerbations 6
• Montelukast is recommended as an alternative therapy for mild persistent asthma, not as a replacement for combination ICS/LABA therapy in patients already established on this regimen 2, 4

Safety Considerations

• Budesonide alone carries the same risks of systemic effects as when used in combination, including potential for hypercorticism and adrenal suppression 7
• Montelukast is not suitable as a rescue medication for acute asthma symptoms due to its delayed onset of action 2
• Switching from a combination inhaler to separate medications may increase the risk of poor adherence due to increased medication burden 1

Algorithm for Decision-Making

1. Assess current asthma control with Rapihaler:

   • If well-controlled with no exacerbations → maintain current therapy 1
   • If experiencing side effects specific to formoterol → consider alternative options 1
   • If concerned about steroid dose → consider that combination therapy often allows for lower total steroid exposure 3, 6

2. If change is being considered:

   • Better alternative would be adjusting the dose of current combination therapy rather than splitting into separate medications 1, 5
   • If stepping down is appropriate due to sustained good control, consider reducing frequency or dose of combination therapy before splitting components 1, 6

3. If separate medications are strongly preferred:

   • Consider budesonide plus a LABA (not montelukast) to maintain equivalent efficacy 1
   • Montelukast could be added as a third agent, not as a replacement for LABA 2, 4

Conclusion

Maintaining the budesonide/formoterol combination (Rapihaler) is likely to provide better asthma control than switching to budesonide and montelukast separately. The combination provides both anti-inflammatory and bronchodilator effects in a single device, which simplifies the regimen and may improve adherence 3, 5.