Recommended Inhaler Controller and Rescue Medications for Adult Asthma Management
For adults with asthma, the preferred controller medication is an inhaled corticosteroid (ICS), with ICS-formoterol in a single inhaler recommended as both daily controller and reliever therapy for moderate to severe persistent asthma. 1
Stepwise Approach to Asthma Management
Step 1 (Intermittent Asthma)
- Preferred: As-needed low-dose ICS-formoterol 1
- Alternative: As-needed ICS with SABA taken concomitantly 1
- Reliever: As-needed low-dose ICS-formoterol or SABA 1
Step 2 (Mild Persistent Asthma)
- Preferred: Daily low-dose ICS with as-needed SABA for quick relief 1
- Alternative: As-needed ICS and SABA used concomitantly 1
- Reliever: As-needed SABA or ICS-formoterol 1
Step 3-4 (Moderate Persistent Asthma)
- Preferred: Low to medium-dose ICS-formoterol as both daily controller and reliever therapy (SMART approach) 1
- Alternative: Medium-dose ICS with LABA as daily controller and SABA as reliever 1
- Reliever: ICS-formoterol (for those on maintenance ICS-formoterol) or SABA 1
Step 5-6 (Severe Persistent Asthma)
- Preferred: High-dose ICS-LABA 1
- Alternative: Add-on tiotropium (LAMA) to ICS-LABA 1, 2
- Reliever: ICS-formoterol (for those on maintenance ICS-formoterol) or SABA 1
Specific Controller Medications
Inhaled Corticosteroids (ICS)
- First-line controller therapy for persistent asthma 1
- Available options include fluticasone propionate, budesonide, mometasone, and beclomethasone 1
- Effectively reduce airway inflammation, improve lung function, and decrease asthma symptoms 1, 3
Long-Acting Beta-Agonists (LABAs)
- Should never be used as monotherapy for asthma control 1, 4
- Always use in combination with ICS 1, 3
- Options include formoterol (rapid onset) and salmeterol (slower onset) 5, 6
Combination ICS-LABA Inhalers
- Budesonide/formoterol (Symbicort): Can be used as both maintenance and reliever therapy due to formoterol's quick onset of action 2, 7
- Fluticasone/salmeterol (Advair): Maintenance therapy only with separate rescue inhaler 4
- Standard dosing for moderate to severe asthma: budesonide/formoterol 160/4.5 mcg, two inhalations twice daily 2
Leukotriene Receptor Antagonists (LTRAs)
- Alternative second-line controller option for mild persistent asthma 1
- Can be used as adjunctive therapy with ICS, but less effective than adding LABA to ICS 1
Rescue/Reliever Medications
Short-Acting Beta-Agonists (SABAs)
- Rapid-acting bronchodilators for quick symptom relief 1
- Examples include albuterol and levalbuterol 1
- Increasing use (>2 days/week) indicates inadequate asthma control 1
ICS-Formoterol as Reliever
- For patients on ICS-formoterol maintenance therapy, the same inhaler can be used for symptom relief 1
- This approach (SMART: Single Maintenance And Reliever Therapy) reduces exacerbation risk compared to using separate SABA reliever 1, 8
Important Clinical Considerations
- Strong recommendation: ICS-formoterol in a single inhaler used as both daily controller and reliever therapy is superior to higher-dose ICS with SABA for quick-relief in moderate to severe persistent asthma 1
- Formoterol has a more rapid onset of action than salmeterol, making it suitable for both maintenance and reliever therapy 5, 6
- If LABA is not used, adding a LAMA (tiotropium) to ICS is recommended for uncontrolled persistent asthma 1
- Frequent use of rescue medication (>2 days/week) indicates inadequate control and should prompt reassessment of controller therapy 1
- For patients concerned about ICS side effects, as-needed ICS with SABA may be an alternative to daily ICS in mild asthma 1
Common Pitfalls to Avoid
- Never prescribe LABA monotherapy for asthma due to safety concerns 1, 3
- Avoid using SABA alone for persistent asthma without controller medication 1
- Don't continue the same treatment regimen if a patient requires rescue medication more than twice weekly 1
- Recognize that dry powder inhalers (DPIs) may be preferred by many adult patients over metered-dose inhalers (MDIs) 1