What is the recommended reliever dose for Symbicort (budesonide and formoterol) in acute asthma or COPD exacerbations?

Symbicort Reliever Dosing

Symbicort (budesonide/formoterol) is NOT indicated as a reliever medication for COPD exacerbations, but IS recommended as both maintenance and reliever therapy (SMART regimen) for asthma at a dose of 160/4.5 μg, one inhalation as needed for symptom relief, up to a maximum of 12 total inhalations per day in adults and adolescents. 1

SMART Regimen for Asthma (Single Maintenance and Reliever Therapy)

Dosing Strategy

• For asthma patients on SMART: Take budesonide/formoterol 160/4.5 μg (delivered dose), one inhalation whenever needed for symptom relief, in addition to the regular maintenance dose 1
• Maximum daily dose: Up to 12 total inhalations in any single day for adults and adolescents (delivering 54 μg formoterol total) 1
• Maintenance dosing: One inhalation once or twice daily (step 3) or two inhalations twice daily (step 4), plus additional as-needed inhalations 1

Clinical Evidence Supporting SMART

• The SMART regimen provides quick relief of asthma symptoms similar to short-acting β2-agonists like albuterol, while simultaneously reducing the risk of severe asthma exacerbations at an overall lower inhaled corticosteroid exposure 1
• Budesonide/formoterol has a rapid onset of effect, apparent within 1 minute of treatment, due to the properties of formoterol 2
• SMART therapy reduced total exacerbations from 31 to 25 events per 100 patients per year compared to high-dose salmeterol/fluticasone plus separate reliever therapy 3
• Exacerbations requiring hospitalization or emergency room treatment were reduced from 13 to 9 events per 100 patients per year with SMART 3

Important Caveats for SMART Use

• Only budesonide/formoterol and beclometasone/formoterol have been studied for SMART - other ICS/LABA combinations have not been validated for this approach 1
• The SMART regimen requires careful patient education with a customized written asthma action plan to ensure proper understanding of the dual role (maintenance and reliever) 1
• Most clinical trials supporting SMART were conducted in adults and adolescents aged ≥12 years 1

COPD: Symbicort is NOT a Reliever

Acute COPD Exacerbations Require Different Treatment

• For acute COPD exacerbations: Use nebulized short-acting β-agonists equivalent to 2.5-5 mg salbutamol or 5-10 mg terbutaline 4
• Additional benefit in acute asthma can be obtained by adding anticholinergic treatment such as 500 μg ipratropium bromide, though this has not been demonstrated for acute COPD exacerbations 4
• Treatment may be repeated within a few minutes if suboptimal response, or continuous nebulized therapy may be administered until the patient is stable 4

COPD Maintenance Therapy

• Symbicort may be used as maintenance therapy in COPD, but never as a reliever medication for acute symptoms or exacerbations 4
• Long-acting bronchodilators (including formoterol in Symbicort) reduce moderate and severe exacerbations in COPD when used as scheduled maintenance therapy (OR 0.73,95% CI 0.61-0.87) 4

Critical Distinction

• The formoterol component in Symbicort provides rapid bronchodilation in asthma patients, making SMART feasible 2
• However, acute COPD exacerbations require higher doses of bronchodilators than can be safely delivered through multiple actuations of a combination inhaler, necessitating nebulized short-acting bronchodilators instead 4
• Hand-held inhalers with spacer devices and nebulizers are equally effective for bronchodilation in acute exacerbations when proper technique is used, but nebulizers are preferred for very breathless patients 4