Symbicort Dosing for Asthma and COPD
For asthma in patients ≥12 years, start with Symbicort 80/4.5 mcg (2 inhalations twice daily) or 160/4.5 mcg (2 inhalations twice daily) based on asthma severity, with a maximum dose of 160/4.5 mcg (2 inhalations twice daily); for COPD, use Symbicort 160/4.5 mcg (2 inhalations twice daily). 1
Asthma Dosing
Adults and Adolescents (≥12 years)
Starting dose selection: Choose between 80/4.5 mcg or 160/4.5 mcg (2 inhalations twice daily) based on asthma severity and current level of symptom control 1
Maximum recommended dose: 160/4.5 mcg, 2 inhalations twice daily 1
Onset of action: Improvement can occur within 15 minutes, though maximum benefit may require 2 weeks or longer 1
Dose adjustment: If inadequate response after 1-2 weeks on the 80/4.5 mcg strength, switch to 160/4.5 mcg for additional control 1
Pediatric Patients (6 to <12 years)
Recommended dose: 80/4.5 mcg, 2 inhalations twice daily 1
This is the only approved strength for this age group 1
Important Prescribing Considerations
Do not exceed 2 inhalations twice daily of the prescribed strength, as higher doses increase the risk of formoterol-related adverse effects 1
No additional LABA use: Patients should not use any additional long-acting beta-agonists while on Symbicort 1
Rescue medication: Use a short-acting beta-agonist (not additional Symbicort) for acute symptoms between doses 1
COPD Dosing
Recommended dose: 160/4.5 mcg, 2 inhalations twice daily 1
Rescue medication: Use a short-acting beta-agonist for acute shortness of breath between doses 1
This is the only approved strength and regimen for COPD 1
Alternative Dosing Strategy: SMART Regimen (Asthma Only)
While the FDA label specifies fixed dosing, research demonstrates that budesonide/formoterol can be used as both maintenance and reliever therapy (SMART regimen) in asthma patients 2, 3:
Maintenance dose: 160/4.5 mcg, 1-2 inhalations twice daily, plus additional inhalations as needed for symptom relief 2
Efficacy: This approach reduces exacerbations by 19% compared to fixed dosing, with 31% fewer hospitalizations/ER visits, while using 30-40% less total medication 3
Cost-effectiveness: SMART regimen significantly reduces treatment costs while maintaining equal asthma control 2
Important caveat: The once-daily maintenance option (1 inhalation twice daily) resulted in more symptomatic days, so 2 inhalations twice daily is the minimum appropriate maintenance dose for moderate persistent asthma 2
Clinical Context from Guidelines
The 2020 NAEPP guidelines position ICS-LABA combinations like Symbicort at Step 3 and higher for asthma management, with LABAs being the preferred adjunctive therapy to combine with ICS in patients ≥12 years 4. The guidelines emphasize that LABAs should never be used as monotherapy for asthma 4.
Common Pitfalls to Avoid
Never prescribe more frequent dosing than twice daily or more than 2 inhalations per dose, as this increases adverse effects without additional benefit 1
Do not use Symbicort as a rescue inhaler in the standard FDA-approved regimen—patients need a separate short-acting beta-agonist 1
Avoid combining with other LABAs (salmeterol, formoterol alone), as this increases cardiovascular and tremor risks 1
Monitor for inadequate response: If a previously effective regimen fails, consider stepping up to the higher strength, adding additional ICS, or initiating oral corticosteroids rather than increasing frequency 1