What are the first line inhalers for newly diagnosed asthma and Chronic Obstructive Pulmonary Disease (COPD)?

First-Line Inhalers for Newly Diagnosed Asthma and COPD

Asthma

For newly diagnosed asthma in adults and adolescents aged 12 years and older, initiate low-dose inhaled corticosteroids (ICS) as first-line therapy, specifically fluticasone propionate 100 mcg or beclomethasone 400 mcg/day, with a short-acting beta-2 agonist (SABA) for rescue use. 1, 2

Initial Controller Therapy

• Inhaled corticosteroids are the most effective first-line anti-inflammatory therapy for persistent asthma, controlling symptoms, improving lung function, and preventing exacerbations 1, 2
• Start with low-dose ICS: fluticasone propionate 100 mcg twice daily or equivalent beclomethasone 400 mcg/day 3, 4
• ICS should be administered twice daily, approximately 12 hours apart 3
• Patients should rinse mouth with water after inhalation to reduce risk of oral candidiasis 3

Rescue Therapy

• Add a SABA (albuterol/salbutamol) for immediate relief of breakthrough symptoms 1, 5
• SABA should be used as needed, not as monotherapy for persistent asthma 1

Pediatric Considerations (Ages 4-11)

• For children aged 4-11 years with persistent asthma, use ICS 100 mcg twice daily 3
• Monitor growth periodically in pediatric patients on ICS 3

Device Selection

• Dry powder inhalers (DPIs) should be offered as first-line options alongside metered-dose inhalers (MDIs), as they are equally effective and have lower environmental impact 1
• For adolescents, DPIs are preferred as spacers are often unpopular in this age group 1

Critical Pitfall to Avoid

• Never use long-acting beta-agonists (LABAs) as monotherapy in asthma, as this increases risk of serious asthma-related events and mortality 3
• LABAs should only be added if asthma remains uncontrolled on ICS alone 3

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COPD

For newly diagnosed COPD, initiate a short-acting bronchodilator—either a short-acting beta-2 agonist (SABA) or short-acting anticholinergic (ipratropium bromide)—as first-line therapy based on symptom severity and patient response. 1

Mild COPD

• Start with either a SABA (salbutamol 200-400 mcg or terbutaline 500-1000 mcg) or ipratropium bromide as needed 1, 5
• Choice depends on symptomatic response—some patients respond better to anticholinergics 1
• Use handheld inhaler when patient can use it properly, as this route has fewer adverse effects 5

Moderate COPD

• Regular bronchodilator therapy with SABA or anticholinergic, or combination of both 1
• Consider a corticosteroid trial in all moderate COPD patients: 30 mg prednisolone daily for 2 weeks with pre- and post-spirometry 1
• Objective improvement is defined as FEV1 increase ≥200 mL and ≥15% from baseline 1
• Only 10-20% of COPD patients show objective response to corticosteroids 1

Severe COPD

• Combination therapy with regular SABA plus anticholinergic is recommended 1, 5
• For severe presentations: salbutamol 2.5-10 mg plus ipratropium bromide 250-500 mcg via nebulizer 5
• If corticosteroid trial shows objective benefit, add ICS (e.g., fluticasone/salmeterol 250/50 mcg twice daily) 3

Important Safety Considerations

• Beta-agonists may precipitate angina in elderly patients—first treatment should always be supervised 5
• Ipratropium can worsen glaucoma—use mouthpiece rather than face mask to minimize ocular exposure 5
• Optimize inhaler technique and select appropriate device to ensure efficient delivery 1

When to Add ICS in COPD

• ICS are not first-line for COPD unless corticosteroid trial demonstrates objective benefit 1
• For maintenance treatment in COPD patients who respond to steroids: fluticasone/salmeterol 250/50 mcg twice daily 3
• ICS increase pneumonia risk in COPD—monitor for signs and symptoms 3

Critical Distinction from Asthma

• If FEV1 reversibility >10% predicted after bronchodilators, consider asthma diagnosis and follow asthma guidelines instead 1
• Measure peak flow diurnal variation and consider bronchial challenge testing if asthma suspected 1