Step-Up Therapy for Asthma on Alvesco and Salbutamol
Add a long-acting beta-agonist (LABA) to your current inhaled corticosteroid (Alvesco/ciclesonide) rather than increasing the ICS dose alone—this is the preferred step-up approach for moderate persistent asthma. 1, 2
Current Treatment Status
Your patient is currently on:
- Alvesco (ciclesonide): an inhaled corticosteroid (ICS) providing anti-inflammatory control
- Salbutamol: a short-acting beta-agonist (SABA) for quick symptom relief
The need for step-up therapy indicates inadequate asthma control, typically evidenced by using salbutamol more than 2 days per week for symptom relief (not counting pre-exercise use). 1, 2
Recommended Step-Up Strategy
First-Line Step-Up: Add LABA to Current ICS
The preferred approach is adding a LABA to the current low-to-medium dose ICS rather than doubling the ICS dose. 1 This combination provides:
- Greater improvement in lung function compared to increasing ICS dose alone 1, 3
- Better symptom control and reduced exacerbation rates 1, 4
- Lower treatment failure rates compared to ICS monotherapy 1
Specific Combination Options
Use a single combination inhaler containing both ICS and LABA rather than two separate inhalers. 5 Evidence shows:
- Fluticasone/salmeterol (e.g., Advair, Wixela): well-established efficacy with salmeterol 50 μg twice daily 1, 4
- Budesonide/formoterol (e.g., Symbicort): rapid onset allowing flexible dosing options 4, 6
Combination inhalers provide better asthma control than administering ICS and LABA via separate devices. 5
Alternative Step-Up Options (If LABA Contraindicated or Refused)
If LABA cannot be used, consider these alternatives in order of preference:
- Increase to medium-dose ICS (e.g., increase Alvesco dose) 1
- Add leukotriene receptor antagonist (montelukast 10 mg once daily or zafirlukast twice daily) to current ICS 1, 7
- Add tiotropium (long-acting muscarinic antagonist) to ICS 7
However, these alternatives are less effective than ICS/LABA combination for most patients. 1, 3
Critical Safety Warning
Never prescribe LABA as monotherapy—LABAs must always be combined with ICS. 1, 2 Using LABA without ICS increases the risk of:
Before Stepping Up Therapy: Essential Checks
Verify these factors before escalating treatment:
- Inhaler technique: Poor technique is a common cause of apparent treatment failure 2, 8
- Medication adherence: Confirm the patient is actually taking Alvesco regularly 1, 8
- Environmental triggers: Address allergen exposure, smoking, occupational exposures 1
- Comorbidities: Rule out GERD, rhinosinusitis, vocal cord dysfunction 1
Implementation Algorithm
Step 1: Confirm inadequate control (salbutamol use >2 days/week, nighttime awakenings, activity limitation) 1, 2
Step 2: Verify proper Alvesco technique and adherence 2, 8
Step 3: If technique and adherence are good, add LABA via combination inhaler 1, 2
Step 4: Reassess control in 2-6 weeks 8
Step 5: If still uncontrolled on ICS/LABA, increase to medium-dose ICS/LABA combination 1
Step 6: If uncontrolled on medium-dose ICS/LABA, increase to high-dose ICS/LABA and consider referral to pulmonology 1, 7
Monitoring After Step-Up
- Assess response within 2-6 weeks of initiating combination therapy 8
- Evaluate: symptom frequency, nighttime awakenings, SABA use, activity limitation 1, 8
- Once controlled for 3 months, consider stepping down to lowest effective dose 2, 8
Common Pitfalls to Avoid
- Don't rely solely on increasing SABA frequency: This masks poor control and delays appropriate step-up 2
- Don't use LABA monotherapy: Always combine with ICS in same or separate inhaler 1, 2
- Don't skip adherence assessment: Many "treatment failures" are actually adherence failures 1, 8
- Don't forget inhaler technique: Verify at every visit, as poor technique negates medication efficacy 2, 8