Symbicort is the preferred medication for this patient
For a patient with both Symbicort (budesonide/formoterol) and Breo (fluticasone/vilanterol) ordered, Symbicort should be selected as the preferred agent because it uniquely allows for both maintenance and reliever therapy (SMART regimen), which has demonstrated superior exacerbation reduction compared to fixed-dose ICS/LABA combinations 1.
Key Advantages of Symbicort Over Breo
SMART Capability
- Symbicort can be used as both maintenance therapy AND as-needed reliever therapy, a strategy that significantly reduces exacerbation rates and rescue medication use compared to fixed-dosing regimens 1, 2, 3.
- The 2020 NAEPP guidelines specifically recommend ICS-formoterol as the preferred reliever therapy at Steps 3 and 4 for patients ≥5 years old 1.
- Formoterol's rapid onset of action (within 1 minute) makes it suitable for symptom relief, unlike salmeterol in Breo which has a slower onset and should not be used for acute relief 1, 4.
Evidence-Based Superiority
- Direct comparison studies show budesonide/formoterol SMART provides better control of airway inflammation, improved small airway function (R5-R20 on impulse oscillometry), lower ACQ scores, and reduced rescue medication use compared to fixed-dose fluticasone/salmeterol 5.
- Adjustable maintenance dosing with budesonide/formoterol achieves equivalent or better asthma control with significantly lower overall drug exposure compared to fixed-dose salmeterol/fluticasone 3.
Clinical Implementation
Prescribing Strategy
- Write for two canisters of Symbicort: one for twice-daily maintenance dosing and one for as-needed use (up to 12 puffs total daily including maintenance and rescue doses) 1.
- If insurance denies dual canisters, advocate for coverage citing the 2020 NAEPP guideline recommendations for SMART therapy 1.
Patient Education Points
- Instruct the patient to use Symbicort for both scheduled doses AND whenever they would normally reach for a rescue inhaler 1.
- This approach provides immediate bronchodilation plus anti-inflammatory benefit with each rescue use 4, 2.
- Monitor for increasing use (>8 rescue puffs/day suggests inadequate control requiring step-up) 1.
Important Caveats
When Breo Might Be Considered
- If the patient cannot understand or adhere to the SMART regimen complexity, a simpler once-daily fixed-dose regimen like Breo may be more appropriate in real-world practice.
- If insurance absolutely refuses dual Symbicort canisters and the patient needs once-daily dosing for adherence reasons.
Safety Monitoring
- Both medications carry similar ICS-related risks (oral candidiasis, dysphonia, pneumonia risk in COPD) 6.
- Advise mouth rinsing after each use 6.
- Monitor for beta-agonist effects including tachycardia, tremor, and hypokalemia 6.
Guideline Alignment
- GINA 2019 guidelines specifically highlight budesonide-formoterol as the preferred ICS-LABA combination due to SMART capability 1.
- The 2020 NAEPP update elevated ICS-formoterol to preferred status at multiple treatment steps 1.
Discontinue the Breo prescription and optimize Symbicort dosing using the SMART approach to maximize exacerbation prevention and symptom control while minimizing overall corticosteroid exposure 1, 3, 5.