Management of Asthma Not Well Controlled on Symbicort
For a patient with uncontrolled asthma on Symbicort, first verify medication adherence and inhaler technique, then step up therapy by increasing the Symbicort dose or adding a third controller medication according to the stepwise approach. 1, 2
Immediate Assessment Before Stepping Up
Before escalating therapy, systematically evaluate these modifiable factors that account for most treatment failures:
- Medication adherence: 40-50% of patients underuse prescribed medications due to concerns about long-term inhaled corticosteroid adverse effects 1
- Inhaler technique: At least 50% of patients use inhalers incorrectly 1
- Environmental triggers: Identify and eliminate allergens, occupational exposures, and tobacco smoke 1
- Comorbid conditions: Assess for rhinosinusitis, GERD, obesity, and obstructive sleep apnea that worsen asthma control 2
Confirm "Not Well Controlled" Status
Asthma is classified as "not well controlled" if the patient has any of the following 3, 1:
- Symptoms >2 days/week
- Nighttime awakenings 1-3 times/week
- Some limitation of normal activity
- Short-acting β-agonist use >2 days/week
- FEV1 or peak flow 60-80% predicted
- ≥2 exacerbations requiring oral corticosteroids in the past year (regardless of other symptoms) 3, 2
Stepwise Pharmacologic Escalation
Step up therapy by 1-2 steps based on the degree of poor control 3, 1:
Option 1: Increase Symbicort Dose
- Move from lower strength (80/4.5 mcg) to higher strength (160/4.5 mcg) budesonide/formoterol twice daily 4
- This increases the inhaled corticosteroid component while maintaining the long-acting β-agonist 3
Option 2: Add a Third Controller
- Add a leukotriene receptor antagonist (montelukast) to current Symbicort regimen 3, 2
- Consider adding a long-acting muscarinic antagonist (tiotropium) for additional bronchodilation 5
Option 3: Consider SMART Therapy
- Switch to budesonide/formoterol as both maintenance (twice daily) AND as-needed reliever therapy 6, 7
- This approach reduces severe exacerbations by 26% compared to fixed-dose therapy and reduces hospitalizations/ER visits 7
- Patients use budesonide/formoterol 160/4.5 mcg two inhalations twice daily plus additional inhalations as needed for symptoms 7
Critical Safety Considerations
Never add a second long-acting β-agonist (such as salmeterol) to Symbicort, as this violates FDA warnings about LABA overdose and increases cardiovascular risk 4
LABAs must never be used as monotherapy due to FDA black box warnings regarding increased risk of severe exacerbations and asthma-related deaths 2, 4
Management of Acute Worsening
If the patient experiences acute symptom deterioration while adjusting therapy 1:
- Prescribe prednisolone 30-40 mg daily until lung function returns to baseline (typically 7 days, up to 21 days if needed) 1
- Short courses do not require tapering 1
- Reassess in 2 weeks after stepping up therapy 3, 1
Ongoing Monitoring Requirements
- Written asthma action plan detailing medications and when to escalate care 3
- Planned follow-up visits every 2-6 months (not just PRN visits) 3, 1
- Spacer use with all metered-dose inhalers to enhance drug distribution 3
- Objective assessment at each visit, as 39-70% of patients with moderate symptoms incorrectly believe their asthma is well controlled 1
When to Refer to Specialist
Refer for specialty evaluation if 2:
- Asthma remains uncontrolled despite appropriate step-up therapy
- Patient requires ≥2 bursts of oral corticosteroids in 1 year
- Consideration needed for biologic agents (omalizumab, mepolizumab, benralizumab) for severe allergic or eosinophilic asthma 5
Common Pitfall to Avoid
Do not assume the patient is taking Symbicort correctly or regularly. Directly observe inhaler technique at the visit and use validated adherence tools, as these factors explain most cases of apparent treatment failure before true pharmacologic escalation is needed 1, 2