How many times per day should a Long-Acting Beta Agonist (LABA) with an Inhaled Corticosteroid (ICS) be used to treat moderate asthma?

LABA/ICS Dosing Frequency for Moderate Asthma

For moderate asthma, LABA/ICS combination therapy should be administered twice daily as the standard maintenance regimen. 1

Standard Twice-Daily Dosing

The 2020 National Asthma Education and Prevention Program (NAEPP) guidelines establish that ICS-LABA combinations are recommended as daily controller therapy for moderate to severe persistent asthma, with the standard administration being twice daily. 1 This applies to all commonly used LABA/ICS combinations including:

• Fluticasone/salmeterol - administered twice daily 1, 2
• Budesonide/formoterol - administered twice daily 3
• Mometasone/formoterol - administered twice daily 1

The FDA labeling for salmeterol-containing products specifically indicates twice-daily administration for asthma management. 2

Alternative Regimen: ICS-Formoterol as Maintenance and Reliever

For patients aged 4 years and older with moderate to severe persistent asthma, the NAEPP Expert Panel strongly recommends ICS-formoterol in a single inhaler used as both daily controller (twice daily) and reliever therapy (as-needed for symptoms), with high certainty of evidence. 1 This approach:

• Provides twice-daily maintenance dosing plus additional as-needed doses for symptom relief
• Reduces severe exacerbations compared to same-dose ICS-LABA as fixed twice-daily therapy plus SABA for rescue 1
• Reduces hospitalizations and emergency room visits compared to higher-dose fixed regimens 4

Once-Daily Dosing: Not Recommended for Moderate Asthma

While one study examined once-daily LABA/ICS dosing, once-daily administration failed to maintain lung function improvements for 24 hours compared to twice-daily dosing. 5 The research demonstrated that fluticasone/salmeterol 100/50 mcg twice daily provided superior efficacy compared to a higher strength (250/50 mcg) given once daily. 5

Once-daily LABA/ICS products (such as fluticasone furoate/vilanterol) exist but lack sufficient evidence for moderate asthma management compared to established twice-daily regimens. 6

Critical Safety Consideration

LABAs must never be used as monotherapy for asthma. 1, 2 The FDA has issued a black-box warning against LABA monotherapy due to increased risk of asthma-related deaths, hospitalizations, and intubations. 1, 2 LABAs should only be used in combination with ICS therapy. 1

Practical Dosing Algorithm

For moderate persistent asthma in patients ≥12 years:

1. Start with low-to-medium dose ICS-LABA twice daily (e.g., fluticasone/salmeterol 250/50 mcg or budesonide/formoterol 160/4.5 mcg, two inhalations twice daily) 1, 3

2. Consider ICS-formoterol maintenance and reliever therapy if patient has history of exacerbations - administer twice daily as maintenance plus as-needed for symptoms 1, 4

3. Avoid once-daily dosing for moderate asthma as it does not maintain 24-hour control 5

4. Monitor for increasing SABA use (>2 days/week for symptom relief), which indicates inadequate control requiring treatment intensification 1, 7