Can Breo Ellipta Be Taken With Albuterol for Acute Cough in an Asthmatic Patient with Viral URI?
Yes, Breo Ellipta (fluticasone furoate/vilanterol) can and should be continued with albuterol for acute symptoms in an asthmatic patient with viral URI-related cough, as albuterol is the recommended rescue medication for acute bronchospasm while Breo provides maintenance control.
Key Management Principles
Continue Breo Ellipta as Maintenance Therapy
- Breo Ellipta should not be stopped during acute exacerbations. The FDA labeling explicitly states that patients should not discontinue therapy without physician guidance since symptoms may recur after discontinuation 1.
- Breo is a maintenance medication combining an inhaled corticosteroid (fluticasone furoate) with a long-acting beta-agonist (vilanterol) for once-daily use 1.
- This combination provides anti-inflammatory control and sustained bronchodilation, which is essential for underlying asthma management 2.
Use Albuterol for Acute Symptom Relief
- Albuterol is specifically indicated as the rescue medication for acute asthma symptoms. The FDA labeling for Breo explicitly instructs patients to "treat acute symptoms with an inhaled, short-acting beta2-agonist such as albuterol" 1.
- In acute bronchitis with underlying bronchial hyperresponsiveness (as in asthma), albuterol has demonstrated efficacy in reducing cough duration and severity, with approximately 50% fewer patients reporting cough after 7 days 3.
- Albuterol delivered by metered-dose inhaler significantly reduces the likelihood of persistent cough at 7 days (61% vs 91% with placebo, P=0.02) 4.
Important Caveats About Albuterol Use
When Albuterol Is Beneficial vs. Not Beneficial
- Albuterol is effective for cough in asthmatic patients or those with bronchial hyperresponsiveness 3.
- However, albuterol is NOT recommended for acute or chronic cough not due to asthma (Grade D recommendation) 3.
- In unselected patients with acute nonspecific cough without asthma or COPD, oral albuterol showed no benefit and caused more side effects (shakiness, nervousness) 5.
Clinical Context Matters
Since your patient has asthma with a viral URI triggering acute cough, this represents an asthma exacerbation scenario where albuterol is appropriate. The viral URI is likely causing bronchial hyperresponsiveness in the context of underlying asthma 3.
Monitoring for Treatment Failure
Watch for signs that indicate the need for escalation beyond rescue albuterol 1:
- Decreasing effectiveness of the short-acting beta2-agonist
- Need for more inhalations than usual
- Significant decrease in lung function
- Symptoms not improving within expected timeframe
If these occur, the patient requires immediate medical attention and may need systemic corticosteroids or other interventions 1.
Additional Considerations for Cough Management
What NOT to Use for Viral URI-Related Cough
- Central cough suppressants (codeine, dextromethorphan) have limited efficacy for cough due to URI and are not recommended (Grade D) 3.
- Peripheral cough suppressants have limited efficacy for URI-related cough and are not recommended (Grade D) 3.
- Over-the-counter combination cold medications (except older antihistamine-decongestant combinations) are not recommended until proven effective (Grade D) 3.
What MAY Help for URI-Related Cough
- Ipratropium bromide is the only inhaled anticholinergic recommended for cough suppression in URI (Grade A recommendation) 3.
- First-generation antihistamines may provide modest benefit through anticholinergic effects in the nasal airways 3.
Safety Profile
- Fluticasone furoate/vilanterol is generally well tolerated with fewer than 15% of patients experiencing treatment-related adverse events 2.
- The most common adverse events include oral/oropharyngeal candidiasis, dysphonia, extrasystoles, and cough 2.
- Advise the patient to rinse mouth with water without swallowing after Breo inhalation to reduce the risk of oral candidiasis 1.