Can a patient with chronic asthma be given a controller medication, such as an inhaled corticosteroid (ICS), and a reliever medication, such as a short-acting beta-agonist (SABA), at the same time?

Controller and Reliever Therapy for Chronic Asthma

Yes, patients with chronic asthma should receive both controller and reliever medications simultaneously—this is the standard of care, with inhaled corticosteroids (ICS) as the foundation controller therapy taken daily, combined with appropriate reliever medication for acute symptom relief. 1

Recommended Regimen for Chronic Asthma

Controller Therapy (Daily Maintenance)

For moderate chronic asthma, the optimal controller is low-to-medium dose ICS-LABA combination taken twice daily (e.g., fluticasone/salmeterol 250/50 mcg or budesonide/formoterol 160/4.5 mcg, two inhalations twice daily). 2

• ICS represents the cornerstone of asthma treatment and improves asthma control more effectively than any other single long-term medication 1
• Adding LABA to ICS increases efficacy in moderate-to-severe asthma—budesonide 800 mcg alone reduced severe exacerbations by 49%, while adding formoterol achieved 63% reduction 3
• Critical safety point: LABAs must never be used as monotherapy for asthma due to increased risk of asthma-related death and hospitalization 4

Reliever Therapy (As-Needed for Symptoms)

The preferred reliever option is as-needed low-dose ICS-formoterol, which provides both rapid symptom relief and anti-inflammatory protection with each use. 1

Primary Reliever Strategy: ICS-Formoterol (SMART Regimen)

• The NAEPP strongly recommends ICS-formoterol as both daily controller (twice daily) AND as-needed reliever therapy for patients ≥4 years with moderate-to-severe persistent asthma 2
• This "Single Maintenance and Reliever Therapy" (SMART) approach reduces severe exacerbations compared to fixed-dose ICS-LABA plus SABA 1, 2
• Formoterol is essential for this approach due to its rapid onset of action; salmeterol has delayed onset and should NOT be used as reliever therapy 1
• Studies primarily used budesonide/formoterol, though other ICS/formoterol combinations are theoretically effective 1

Alternative Reliever Strategy: SABA

• Short-acting beta-agonists (e.g., albuterol) remain an acceptable alternative reliever option 1
• However, SABA-only reliever therapy is increasingly discouraged because it provides no anti-inflammatory benefit and patients often overuse SABA while underusing their ICS controller 5, 6
• If using SABA as reliever, some guidelines suggest taking ICS whenever SABA is used (separate or combination inhalers) to ensure anti-inflammatory coverage 1

Practical Treatment Algorithm

Step-by-Step Approach:

1. Confirm diagnosis and assess severity before initiating therapy 1

2. For moderate chronic asthma (Step 3):

   • Prescribe low-dose ICS-LABA twice daily as maintenance controller 1, 2
   • Add ICS-formoterol as as-needed reliever (up to 8-10 additional puffs daily for symptoms) 1, 2
   • This requires prescribing two canisters of the same ICS-formoterol product 1

3. Monitor for inadequate control:

   • SABA or reliever use >2 days/week for symptom relief indicates inadequate control requiring treatment intensification 2, 7
   • Verify inhaler technique and adherence before escalating therapy 1, 7

4. If control remains inadequate on Step 3:

   • Escalate to medium-dose ICS-LABA twice daily 1
   • Continue ICS-formoterol as reliever if using SMART approach 1

Common Pitfalls and How to Avoid Them

Insurance Coverage Issues

• Many insurance plans resist covering two canisters of the same ICS-LABA product needed for SMART therapy 1
• Solution: Prescribe one canister for maintenance (twice daily) and a separate SABA for relief, OR advocate with insurance for SMART coverage given superior exacerbation reduction 1

LABA Monotherapy Risk

• Never prescribe LABA without ICS—this is associated with increased asthma-related deaths 4
• When LABA is combined with ICS in fixed-dose products, large trials show no significant increase in serious asthma-related events compared to ICS alone 4

Patient Adherence

• Poor adherence to daily ICS is the primary reason for treatment failure 6
• The SMART approach may improve adherence by ensuring patients receive ICS with every reliever use 8, 5

Salmeterol vs. Formoterol Confusion

• Salmeterol-containing products (e.g., fluticasone/salmeterol) should NOT be used for SMART therapy due to slow onset 1
• These products work well as twice-daily maintenance controllers with separate SABA reliever 2, 4

Evidence Quality Considerations

The 2019 GINA guidelines (published in 2020) represent the most current international consensus, strongly favoring ICS-formoterol as both controller and reliever 1. The NAEPP guidelines align with this approach for Steps 3-4 1, 2. FDA labeling confirms safety of ICS/LABA combinations when used together (not LABA alone) 4. The shift away from SABA-only reliever therapy reflects accumulating evidence of poor outcomes with SABA overreliance 5, 6.