Symbicort as Rescue Inhaler: Recommendations
For Asthma: Yes, Symbicort Can Be Used as Rescue Therapy
Symbicort (budesonide/formoterol) is recommended as rescue therapy in asthma patients with moderate to severe disease, using the SMART (Symbicort Maintenance and Reliever Therapy) approach, where it serves as both maintenance and as-needed relief medication. 1, 2
Evidence Supporting Rescue Use in Asthma
Clinical trials demonstrate that using budesonide/formoterol as both regular maintenance (twice daily) and rescue therapy for breakthrough symptoms provides more effective asthma control and reduces exacerbations compared to using short-acting beta-agonists (SABAs) alone as rescue 2
The rapid onset of formoterol (within 1 minute) allows effective symptom relief while the corticosteroid component prevents the increase in airway inflammation that occurs during exacerbation evolution 2, 3
The SMART approach has been enthusiastically adopted in guidelines for moderate to severe asthma patients, though evidence for mild asthma (GINA step 1-2) remains controversial 1
Important Caveats for Asthma
For mild asthma patients, the evidence supporting ICS-LABA as rescue instead of maintenance ICS therapy is insufficient and controversial 1
The SYGMA studies showed budesonide-formoterol as-needed provides better control than SABA alone but poorer control than regular maintenance ICS therapy in mild asthma 1
For COPD: No, Symbicort Should NOT Be Used as Rescue Therapy
Symbicort is recommended only as maintenance therapy in COPD, not as rescue medication—short-acting bronchodilators remain the appropriate rescue therapy for acute COPD symptoms. 4, 5, 6
COPD Maintenance Therapy Recommendations
The American College of Chest Physicians and Canadian Thoracic Society strongly recommend maintenance combination ICS/LABA therapy (like Symbicort) for patients with stable moderate, severe, and very severe COPD to prevent acute exacerbations (Grade 1B-1C) 4
Symbicort 320 μg/9 μg twice daily is specifically indicated for symptomatic treatment of adults with severe COPD (FEV1 <50% predicted) and history of repeated exacerbations despite regular long-acting bronchodilator therapy 6
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) and American Thoracic Society recommend prioritizing Symbicort for severe COPD patients with ≥2 moderate exacerbations or ≥1 severe exacerbation in the previous year 5
Patient Selection for COPD Maintenance Therapy
Patients with blood eosinophil counts >300 cells/μL may benefit more from ICS-containing regimens like Symbicort due to stronger predicted response 5
Consider Symbicort for patients with asthma-COPD overlap syndrome 5
Patients with eosinophils <100 cells/μL may have minimal ICS benefit with increased pneumonia risk and should likely avoid ICS-containing therapy 5
Safety Considerations in COPD
ICS use increases pneumonia risk, particularly in older patients and those with lower BMI—monitor closely for signs of pneumonia 5, 7
The number needed to treat is 4 patients for 1 year to prevent one moderate-to-severe exacerbation versus number needed to harm of 33 patients for 1 year to cause one pneumonia 7
Other potential adverse effects include oral candidiasis, hoarseness, dysphonia, and bruising 4, 7
COPD Treatment Algorithm
First-line for stable severe COPD: LABA/LAMA combination (not Symbicort) 5
Add ICS (triple therapy with Symbicort): If exacerbations continue despite LABA/LAMA or if eosinophil count >300 cells/μL 5, 8
For acute COPD exacerbations: Use short-acting bronchodilators as rescue plus systemic corticosteroids (40mg prednisone daily for 5 days), then return to maintenance therapy 5, 8