Should I add Berodual (fenoterol and ipratropium) or Budesonide to a patient's treatment regimen if their asthma is not adequately controlled on Seretide (salmeterol and fluticasone)?

Management of Inadequately Controlled Asthma on Seretide

Neither Berodual nor additional budesonide should be added to Seretide (salmeterol/fluticasone) for inadequately controlled asthma; instead, increase the dose of Seretide itself or consider switching to budesonide/formoterol with a maintenance-and-reliever therapy (SMART) regimen. 1

Why Not Add These Medications

Berodual (Fenoterol/Ipratropium) Should Not Be Added

• Berodual contains a short-acting beta-agonist (fenoterol) and anticholinergic (ipratropium), which are rescue medications, not maintenance therapy. 1
• Adding another long-acting beta-agonist on top of the salmeterol already in Seretide provides no additional benefit and violates safety principles - LABAs should never be used without inhaled corticosteroids, and doubling LABA therapy is not evidence-based. 1
• The evidence clearly demonstrates that long-acting beta-agonists cannot substitute for or enhance the effect of existing LABA/ICS combinations when control is inadequate. 1

Additional Budesonide Should Not Be Added

• Adding budesonide to Seretide means using two different inhaled corticosteroids simultaneously (budesonide + fluticasone), which is not supported by evidence and creates unnecessary complexity. 1
• If more corticosteroid is needed, the appropriate approach is to increase the fluticasone dose within the existing Seretide formulation, not add a second corticosteroid. 1

The Correct Approach: Step Up Therapy

First-Line Option: Increase Seretide Dose

• For patients with inadequate control on low-to-medium dose Seretide, increase to a higher strength formulation (e.g., from 50/250 mcg to 50/500 mcg twice daily). 1
• Evidence shows that for patients at higher risk for exacerbations (history of emergency visits, hospitalizations, or frequent oral steroid courses), both increasing the inhaled corticosteroid dose AND maintaining the LABA provides the best protection against exacerbations. 1

Alternative Option: Switch to Budesonide/Formoterol SMART

• Consider switching from Seretide to budesonide/formoterol 160/4.5 mcg using the SMART (Single Maintenance And Reliever Therapy) regimen - one inhalation twice daily for maintenance plus additional inhalations as needed for symptoms. 2, 3
• This approach has been shown to reduce severe exacerbations and hospitalizations/emergency room visits compared to high-dose salmeterol/fluticasone (50/500 mcg twice daily) plus separate rescue medication. 3
• The SMART regimen achieves better exacerbation control with substantially lower total corticosteroid exposure (792 mcg/day budesonide vs 1000 mcg/day fluticasone). 3
• Formoterol's rapid onset of action (within minutes) makes it suitable for both maintenance and reliever use, unlike salmeterol which has slower onset. 2, 3

Key Clinical Considerations

Why This Matters for Outcomes

• Increasing inhaled corticosteroid dose within a LABA/ICS combination significantly reduces asthma exacerbations, which directly impacts morbidity and mortality. 1
• Meta-analyses demonstrate that combination therapy with LABA plus ICS at lower corticosteroid doses produces significantly fewer exacerbations than higher-dose ICS alone. 1

Common Pitfalls to Avoid

• Never add a LABA (like the fenoterol in Berodual) to existing LABA/ICS therapy - this doubles LABA exposure without evidence of benefit and increases cardiovascular risk. 1, 2
• Do not mix different inhaled corticosteroid products - this creates dosing confusion and poor adherence. 4
• Frequent rescue inhaler use (>2 days/week) indicates inadequate control and mandates treatment intensification, not addition of rescue medications. 2

Additional Controller Options (If Step-Up Fails)

If increasing Seretide dose or switching to budesonide/formoterol SMART fails to achieve control:

• Consider adding a leukotriene modifier (montelukast) to the LABA/ICS combination, though evidence is less robust than for LABA addition. 1
• Consider adding theophylline as adjunctive therapy, though LABAs show superior improvement in lung function and symptoms. 1
• For severe persistent asthma, oral corticosteroids may ultimately be required alongside high-dose LABA/ICS. 2

Monitoring After Treatment Adjustment

• Reassess symptom control, exacerbation frequency, and lung function at regular intervals after any treatment change. 2
• Once control is achieved, titrate down to the lowest effective dose to minimize corticosteroid exposure. 1, 2, 4
• Instruct patients on proper inhaler technique and mouth rinsing after use to reduce local side effects like oral thrush. 2, 4