Should I discontinue Breo (fluticasone propionate/formoterol) in an adult with asthma or chronic obstructive pulmonary disease who has an acute respiratory syncytial virus infection?

Should You Avoid Breo in RSV?

No, you should not discontinue Breo (fluticasone propionate/vilanterol) in adults with asthma or COPD who develop acute RSV infection—instead, continue the medication as part of standard exacerbation management while adding appropriate supportive therapy.

Rationale for Continuing Breo During RSV Infection

The management of RSV in adults with underlying respiratory disease focuses on treating the exacerbation itself rather than the viral trigger. Continue maintenance inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) therapy during acute viral respiratory infections, as these medications address the underlying inflammatory pathology and bronchospasm that beta-agonists alone cannot impact 1.

Key Management Principles

Primary Treatment Approach:

• RSV acts as a trigger for asthma or COPD exacerbations in adults with underlying respiratory disease, with adults with asthma having 7-8 times greater risk of RSV-associated hospitalization 1
• Management focuses on treating the exacerbation with standard therapy including systemic corticosteroids, bronchodilators, and oxygen 1
• Maintain regular bronchodilator therapy during viral illness 2

Augmented Therapy During Exacerbation:

• Add systemic corticosteroids immediately: prednisolone 40-60 mg orally (or IV hydrocortisone 200 mg if unable to take oral) 1
• For COPD exacerbations specifically, prednisone 40 mg daily for 5 days improves lung function, oxygenation, and shortens recovery time 3
• Administer short-acting bronchodilators: albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses 1
• Add ipratropium bromide 0.5 mg via nebulizer (or 8 puffs via MDI) every 20 minutes for 3 doses in severe cases, which reduces hospitalizations particularly in patients with severe airflow obstruction 1

Important Distinctions from Influenza Management

Unlike influenza, where zanamivir (an inhaled antiviral) is contraindicated in patients with asthma or COPD due to significant risk of bronchospasm 4, 2, 3, there is no similar contraindication for continuing ICS/LABA therapy during RSV infection. The concern with zanamivir relates to the inhaled powder formulation causing acute bronchospasm, not to the underlying principle of using inhaled corticosteroids 4.

Evidence Supporting ICS/LABA Continuation

Corticosteroid Effects:

• Inhaled corticosteroids have clinically significant effects on symptoms, exacerbations, health status, and lung function in both asthma and COPD 5
• The combination of fluticasone propionate and formoterol (similar to Breo's fluticasone/vilanterol) improves FEV₁ over treatment with individual components 5
• ICS/LABA combinations like fluticasone propionate/formoterol demonstrate superior efficacy over monotherapy and comparable safety profiles 6

Critical Caveat:

• Recent research shows glucocorticoids may suppress interferon-stimulated genes and potentially enhance viral replication in rhinovirus-infected bronchial epithelial cells 7
• However, this laboratory finding has not translated into clinical recommendations to discontinue ICS during viral infections, as the benefits of controlling airway inflammation outweigh theoretical antiviral concerns 1

Supportive Care During RSV Infection

Oxygen Management:

• Administer oxygen via nasal cannula or mask to maintain SpO₂ >90% (>95% in pregnant patients or those with heart disease) 1
• For COPD patients, maintain target SpO₂ of at least 92% with controlled oxygen and repeated arterial blood gas monitoring to avoid CO₂ retention 3

Monitoring Parameters:

• Check vital signs at least twice daily 3
• Observe for 30-60 minutes after the last bronchodilator dose to ensure stability before discharge 1
• Do not discharge until peak expiratory flow reaches ≥70% of predicted or personal best, symptoms are minimal or absent, and oxygen saturation is stable on room air 1

Prevention Considerations

Adults with asthma should receive RSV vaccination according to local immunization schedules, with efficacy of 82.6% against RSV-associated lower respiratory tract disease in the first season for adults ≥60 years 1, 4.

Common Pitfalls to Avoid

• Do not discontinue maintenance ICS/LABA therapy during acute viral infections—this removes the anti-inflammatory foundation needed to control exacerbations 1
• Do not assume all coughs require additional bronchodilators; use short-acting bronchodilators only for documented bronchospasm, not cough alone 2
• Do not use Breo as rescue therapy for acute symptoms; prescribe a separate short-acting beta-agonist for symptomatic relief 8
• Continue oral corticosteroids for 5-10 days after discharge; when used in short courses up to two weeks, they do not need to be tapered 1