Is Symbicort (budesonide and formoterol) okay for an asthma patient with a Upper Respiratory Infection (URI)?

Is Symbicort Safe to Continue During an Upper Respiratory Infection in Asthma Patients?

Yes, Symbicort (budesonide/formoterol) should be continued and potentially intensified during an upper respiratory infection in asthma patients, as maintaining or increasing inhaled corticosteroid therapy during URIs is critical for preventing asthma exacerbations. 1

Primary Recommendation: Continue and Consider Intensification

• The American College of Chest Physicians recommends maintaining or intensifying inhaled corticosteroids during URI in asthma patients, as URIs are common triggers for asthma exacerbations 1
• Symbicort contains both budesonide (an inhaled corticosteroid) and formoterol (a long-acting beta-agonist), making it appropriate for ongoing asthma control during respiratory infections 2
• Do not discontinue controller therapy during a URI, as this increases the risk of severe exacerbation 1

What to Add for URI-Related Symptoms

For Cough Management

• Ipratropium bromide is the only first-line agent recommended for URI-related cough with Grade A evidence and substantial benefit 1, 3
• Ipratropium can be added to the existing Symbicort regimen without interaction concerns 2, 1
• Dosing: Ipratropium nasal spray 0.03% (42 mcg per nostril three times daily) for rhinorrhea/postnasal drip, or ipratropium MDI for bronchospasm 3

For Severe Symptoms or Exacerbation

• If the patient develops severe asthma symptoms, combine ipratropium with short-acting beta-agonists (albuterol) for superior bronchodilation 1
• The National Asthma Education and Prevention Program recommends this combination for severe exacerbations, with the combination providing superior symptom relief compared to albuterol alone 1
• Initial treatment: ipratropium 0.5 mg combined with albuterol 2.5 mg via nebulizer every 20 minutes for 3 doses if needed 1

What NOT to Use

• Do not use central cough suppressants (codeine or dextromethorphan) for URI-related cough in asthma patients—Grade D recommendation 1, 4
• Do not stop the inhaled corticosteroid component thinking it might worsen the infection; this is a dangerous misconception 1
• Antibiotics have no role unless bacterial superinfection develops 3

Critical Monitoring Points

• Reassess for bacterial superinfection or inadequate asthma control if symptoms worsen or persist beyond the expected timeframe (typically 1-3 weeks for viral URI) 1, 4
• Watch for signs requiring escalation: increased rescue inhaler use (>2 days/week), nocturnal awakening, or activity limitation 2
• Consider adding a leukotriene receptor antagonist before escalating to systemic corticosteroids if cough remains refractory 1

Clinical Algorithm

1. Continue Symbicort at current dose (or increase if symptoms worsen) 1
2. Add ipratropium bromide for URI-related cough and rhinorrhea 1, 3
3. Ensure patient has albuterol rescue inhaler available for acute symptoms 2, 5
4. If severe exacerbation develops, combine ipratropium + albuterol nebulization 1
5. Reassess in 3-5 days; if worsening, consider bacterial superinfection or need for systemic corticosteroids 1

Important Safety Considerations

• The FDA label for budesonide warns about potential worsening of existing infections, but this refers to untreated tuberculosis, fungal, or parasitic infections—not common viral URIs 5
• Viral URIs do not contraindicate continued inhaled corticosteroid use; in fact, discontinuation increases exacerbation risk 1
• Symbicort has a rapid onset of effect (within 1 minute due to formoterol), making it suitable for both maintenance and symptom control 6, 7