From the Guidelines
The child should restart Symbicort (budesonide/formoterol) 2 puffs twice daily immediately, while continuing to use the rescue inhaler as needed for breakthrough symptoms. Stopping controller medications like Symbicort during asthma exacerbations is a common mistake that often worsens symptoms, as it allows airway inflammation to persist 1. Symbicort contains both an inhaled corticosteroid (budesonide) that reduces airway inflammation and a long-acting bronchodilator (formoterol) that helps keep airways open. The rescue inhaler alone only provides temporary relief without addressing the underlying inflammation.
For this acute exacerbation, the child may benefit from a short course of oral steroids if symptoms are severe, and should be evaluated by a healthcare provider if wheezing and coughing don't improve within 24-48 hours of restarting Symbicort 1. Maintaining consistent use of controller medications is essential for preventing asthma exacerbations, reducing inflammation, and minimizing the need for rescue medications.
- Key considerations for the child's treatment include:
- Identifying and avoiding the child's asthma triggers
- Ensuring proper inhaler technique
- Following an updated asthma action plan
- Monitoring response to therapy closely, as treatment of young children is often in the form of a therapeutic trial 1
- The benefits of inhaled corticosteroids, such as budesonide, outweigh any concerns about potential risks of a small, nonprogressive reduction in growth velocity or other possible adverse effects 1.
From the FDA Drug Label
Budesonide and formoterol fumarate dihydrate should not be initiated in patients during rapidly deteriorating or potentially life-threatening episodes of asthma or COPD. Increasing use of inhaled, short-acting beta2-agonists is a marker of deteriorating asthma In this situation, the patient requires immediate re-evaluation with reassessment of the treatment regimen, giving special consideration to the possible need for replacing the current strength of budesonide and formoterol fumarate dihydrate with a higher strength, adding additional inhaled corticosteroid, or initiating systemic corticosteroids
The patient has stopped taking Symbicort (budesonide and formoterol) and is now only using a rescue inhaler, which may indicate deteriorating asthma. The patient requires immediate re-evaluation of their treatment regimen. Consideration should be given to:
- Replacing the current strength of budesonide and formoterol with a higher strength
- Adding additional inhaled corticosteroid
- Initiating systemic corticosteroids 2
From the Research
Asthma Treatment and Management
- The patient, a 7-year-old boy, is experiencing increased wheezing and cough, and was previously taking Symbicort 2 puffs BID and has a rescue inhaler 3, 4.
- Symbicort, a combination of budesonide and formoterol, is a common treatment for asthma, and can be used as both a maintenance and reliever therapy 3, 5.
- Studies have shown that budesonide/formoterol maintenance and reliever therapy can reduce severe exacerbations and maintain daily asthma control at a lower overall steroid load compared to traditional combination therapies 3, 5, 6.
Treatment Outcomes
- Research has demonstrated that budesonide/formoterol maintenance and reliever therapy can reduce the number of people having asthma exacerbations requiring oral steroids and hospitalization or an ER visit compared to fixed-dose combination inhalers 3.
- A study comparing fluticasone/salmeterol and budesonide/formoterol found that the odds ratio for exacerbations requiring oral steroids was lower with fluticasone/salmeterol, but did not reach statistical significance 4.
- Another study found that budesonide/formoterol anti-inflammatory reliever and maintenance therapy was more effective than fixed-dose fluticasone/salmeterol plus as-needed SABA in achieving asthma control 6.