What are the maintenance inhalers for allergic (atopy) induced asthma with wheezing?

From the Guidelines

Maintenance inhalers for allergy-induced asthma with wheezing should typically include inhaled corticosteroids (ICS) as first-line therapy, such as fluticasone (Flovent), budesonide (Pulmicort), or beclomethasone (QVAR), used daily to reduce airway inflammation. For patients with moderate to severe symptoms, a combination inhaler containing both an ICS and a long-acting beta-agonist (LABA) may be more effective, such as fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort), or mometasone/formoterol (Dulera) 1. These medications are preferred due to their ability to attenuate the underlying inflammation characteristic of asthma, reduce airway hyperresponsiveness, and inhibit inflammatory cell migration and activation 1.

The use of ICS is supported by the expert panel report 3 (EPR-3) guidelines, which state that ICS are the most consistently effective long-term control medication at all steps of care for persistent asthma 1. Additionally, the guidelines recommend that LABA be used in combination with ICS for long-term control and prevention of symptoms in moderate or severe persistent asthma 1.

Some key points to consider when prescribing maintenance inhalers for allergy-induced asthma with wheezing include:

• Proper inhaler technique is crucial for medication effectiveness—patients should inhale slowly and deeply, hold their breath for 10 seconds, and use a spacer device if coordination is difficult.
• Regular use is essential even when symptoms are not present, as these medications prevent rather than rescue from symptoms.
• For patients with significant allergic components, adding a leukotriene modifier like montelukast (Singulair) 10mg daily can help target the allergic pathway 1.
• Increasing use of short-acting beta agonists or using them more than two days per week or more than two nights per month generally indicates inadequate control of asthma and the need to initiate or intensify anti-inflammatory therapy 1.

Overall, the goal of maintenance inhaler therapy for allergy-induced asthma with wheezing is to reduce airway inflammation, prevent symptoms, and improve quality of life. By following the guidelines and considering individual patient needs, healthcare providers can help patients achieve optimal control of their asthma symptoms.

From the FDA Drug Label

In clinical trials comparing fluticasone propionate and salmeterol inhalation powder with its individual components, improvements in most efficacy endpoints were greater with fluticasone propionate and salmeterol inhalation powder than with the use of either fluticasone propionate or salmeterol alone Trials Comparing Fluticasone Propionate and Salmeterol Inhalation Powder with Fluticasone Propionate Alone or Salmeterol Alone Three (3) double-blind, parallel-group clinical trials were conducted with fluticasone propionate and salmeterol inhalation powder in 1,208 adult and adolescent subjects (aged 12 years and older, baseline FEV1 63% to 72% of predicted normal) with asthma that was not optimally controlled on their current therapy. Statistically significantly fewer subjects receiving fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg were withdrawn due to worsening asthma compared with fluticasone propionate, salmeterol, and placebo.

Maintenance Inhalers for Allergy-Induced Asthma with Wheezing:

• Fluticasone propionate and salmeterol inhalation powder is effective in improving lung function and reducing asthma symptoms in patients with allergy-induced asthma with wheezing.
• The combination of fluticasone propionate and salmeterol inhalation powder has been shown to be more effective than either component alone in clinical trials 2.
• This inhaler can be used as a maintenance therapy for patients with asthma that is not optimally controlled on their current therapy.

From the Research

Maintenance Inhalers for Allergy-Induced Asthma with Wheezing

• Inhaled corticosteroids (ICS) are a primary treatment for asthma, including allergy-induced asthma with wheezing, as they decrease the risk of asthma exacerbations 3.
• The Global Initiative for Asthma guidelines recommend daily maintenance doses of ICS, with a proposed reclassification of ICS doses based on a "standard daily dose" of 200-250 μg of fluticasone propionate or equivalent 4.
• Combination ICS-formoterol in a single inhaler is recommended as the preferred therapy for moderate persistent asthma, and can be used as a single maintenance and reliever therapy 5.
• As-needed ICS strategies, in which patients receive ICSs whenever they take their reliever inhaler, can improve asthma morbidity outcomes and reduce the risk of adverse effects of oral corticosteroids 3, 6.
• The use of ICSs in low to medium dose over many years is well tolerated, but high doses of ICSs can be associated with significant risk of systemic adverse effects, such as hypothalamic-pituitary-adrenal axis suppression, reduction in growth velocity, osteoporosis, diabetes, and respiratory infections 4, 7.

Treatment Options

• Daily low-dose ICS plus as-needed short-acting β2-agonists (SABAs) therapy is recommended for mild persistent asthma 5.
• As-needed concomitant ICS and SABA therapy is also recommended for mild persistent asthma 5.
• Formoterol in combination with an ICS in a single inhaler is recommended for moderate persistent asthma 5.
• Add-on long-acting muscarinic antagonists are recommended for individuals whose asthma is not controlled by ICS-formoterol therapy 5.

Safety and Adverse Effects

• ICSs can be associated with adverse effects, such as hypothalamic-pituitary-adrenal axis suppression, reduction in growth velocity, osteoporosis, diabetes, and respiratory infections, particularly at high doses 7.
• The use of biologic agents earlier for severe asthma has the potential to prevent or reduce the occurrence of corticosteroid-related adverse effects 7.