From the Guidelines
For moderate persistent asthma, the recommended treatment approach includes daily controller medications with a combination of an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA). The most effective combination therapy for moderate persistent asthma in patients 12 years and older is the combination of inhaled corticosteroids and long-acting beta agonists, which leads to clinically meaningful improvements in lung function and symptoms and a reduced need for quick-relief short-acting beta2 agonists 1.
Key Treatment Options
- Preferred options include fluticasone/salmeterol (Advair) 250/50 mcg twice daily, budesonide/formoterol (Symbicort) 160/4.5 mcg twice daily, or mometasone/formoterol (Dulera) 200/5 mcg twice daily.
- These should be used consistently every day, not just during symptoms.
- Additionally, patients should have a rescue inhaler such as albuterol (ProAir, Ventolin) 2 puffs every 4-6 hours as needed for breakthrough symptoms.
- For patients with allergic components to their asthma, adding a leukotriene modifier like montelukast (Singulair) 10 mg daily may provide additional benefit, although the evidence is not as substantial as with the addition of long-acting beta agonists 1.
Treatment Approach
Proper inhaler technique is essential for medication effectiveness. These medications work by reducing airway inflammation (ICS component) while providing bronchodilation (LABA component), addressing both the inflammatory and bronchospasm aspects of asthma. Treatment should be reassessed every 3-6 months, with the goal of achieving good symptom control while using the lowest effective medication dose. Step-down strategies in combination therapy may be considered, such as changing to a new device with a lower dose of inhaled steroid or reducing the frequency of fluticasone/salmeterol therapy to once-daily dosing, which can help maintain good control of asthma symptoms 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Moderate Persistent Asthma Medications
- The combination of inhaled corticosteroids (ICSs) and long-acting beta2-agonists (LABAs) is effective in achieving asthma control, as it treats both components of asthma pathophysiology, namely inflammation and smooth muscle dysfunction of the airways 2.
- Leukotriene receptor antagonists (LTRAs) can also be used as add-ons to ICS therapy in patients whose asthma is not controlled by ICSs alone 2.
- The addition of an LABA to ICS therapy provides greater improvements in pulmonary function and overall control of asthma as measured by use of rescue medication and the number of exacerbations of the asthma, symptom-free days and symptom-free nights 2.
Treatment Options
- ICSs plus LABAs are more effective than ICSs plus LTRAs for the treatment of persistent asthma that is not controlled by ICSs alone 2.
- The salmeterol-fluticasone propionate combination (SFC) produces consistently greater improvements in pulmonary lung function and control of asthma than does the addition of an LTRA to fluticasone propionate 2.
- ICS therapy in combination with long-acting beta-adrenergic agonists represents the most important treatment for chronic airways diseases such as asthma and chronic obstructive pulmonary disease (COPD) 3.
Patient Perspectives
- Adherence is higher with the combination ICS/LABAs than when the components are administered separately 4.
- Patients prefer an effective reliever with a fast onset and long duration of action, which may lead to improved adherence 4.
- The combination of an ICS and LABA is preferred in patients with moderate persistent asthma, irrespective of the brand of medicine, and this combination is better than doubling or even quadrupling the dose of ICS to achieve better asthma control and reduce exacerbation risks 5.
Comparison of Combination Inhalers
- Combination inhalers improve pulmonary function without potentiating anti-inflammatory effects on exhaled NO and serum ECP as compared with ICS alone, but delay acute salbutamol recovery after bronchoconstriction 6.
- FEV1 increase from pretreatment baseline was significantly higher for combination inhalers (BUD + FM and FP + SM) vs ICS alone (BUD and FP) 6.