Asthma Maintenance Inhalers
Inhaled corticosteroids (ICS) are the first-line maintenance therapy for persistent asthma, with specific brand names including fluticasone propionate, budesonide, mometasone, and beclomethasone. 1, 2
First-Line Controller Medications (ICS Monotherapy)
Inhaled Corticosteroid Options:
- Fluticasone propionate - Available as single-agent inhaler for maintenance therapy 2
- Budesonide - Available as single-agent inhaler for maintenance therapy 2
- Mometasone - Available as single-agent inhaler for maintenance therapy 2
- Beclomethasone - Available as single-agent inhaler for maintenance therapy 2
These are the most effective controllers because they suppress airway inflammation more effectively than any other single long-term medication. 3, 1, 4
Combination ICS-LABA Inhalers (Step 3 and Higher)
When asthma is not adequately controlled on ICS alone, combination inhalers containing both an inhaled corticosteroid and long-acting beta-agonist are recommended. 1, 2
Specific Combination Products:
- Wixela Inhub® (fluticasone propionate/salmeterol) - Available in three strengths: 100/50 mcg, 250/50 mcg, and 500/50 mcg, taken as one inhalation twice daily 5
- Dulera® (mometasone/formoterol) - Combines high-potency ICS with LABA for moderate to severe persistent asthma 6
- Budesonide/formoterol combinations - Can be used as both maintenance and reliever therapy (SMART approach) 1, 2, 7
Critical Safety Warning: LABAs like salmeterol and formoterol should never be used as monotherapy for asthma control due to increased risk of exacerbations and mortality. 1, 2, 6 They must always be combined with an ICS. 2
Alternative Controller Options
Leukotriene Receptor Antagonists:
- Montelukast - May be used as second-line alternative to ICS for mild persistent asthma, with good compliance rates 1, 8
Other Alternatives (Less Preferred):
- Cromolyn - Listed as alternative option but not preferred 3, 1
- Theophylline - Listed but not preferred due to inferior effectiveness compared to ICS 3, 1
Advanced Therapy Options (Step 4-6)
For Uncontrolled Asthma on ICS-LABA:
- Long-acting muscarinic antagonists (LAMA) - Tiotropium can be added to ICS when LABA is not used 2
- High-dose ICS-LABA combinations - For severe persistent asthma 1
- Biologic agents - Considered for Step 5-6 severe asthma 1
Important Clinical Considerations
Delivery Device Matters:
- All metered-dose inhalers should be used with spacers to enhance drug distribution and effectiveness 3
- Proper inhaler technique must be verified regularly, as most patients have difficulty with correct use 3
Common Pitfall to Avoid: Do not confuse maintenance inhalers with rescue inhalers. Short-acting beta-agonists (albuterol, levalbuterol) are for quick symptom relief only, not maintenance therapy. 3, 2 If patients use rescue medication more than twice weekly, this indicates inadequate control requiring initiation or intensification of controller therapy. 1, 2
Monitoring for Side Effects: