From the Guidelines
For step up therapy during an asthma exacerbation triggered by a viral respiratory infection, a combination inhaler containing an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA) is recommended. Specifically, fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort), or mometasone/formoterol (Dulera) are excellent options 1. Budesonide/formoterol is particularly advantageous as it can be used both as a maintenance and rescue medication (MART approach) due to formoterol's rapid onset of action. For adults, typical dosing would be budesonide/formoterol 160/4.5 mcg, 2 inhalations twice daily, with additional inhalations as needed for rescue (not exceeding 8 total daily inhalations) 1.
Key Considerations
- The combination of ICS and LABA has been shown to lead to clinically meaningful improvements in lung function and symptoms, and a reduced need for quick-relief short-acting beta2 agonists 1.
- Adding a leukotriene receptor antagonist or theophylline also improves outcomes, but the evidence is not as substantial as with the addition of long-acting beta agonists 1.
- During an exacerbation, patients should also continue using their short-acting beta-agonist (like albuterol) as needed for immediate symptom relief.
- If symptoms persist or worsen despite this step-up therapy, patients should contact their healthcare provider as they may need a short course of oral corticosteroids or additional interventions.
Step-Up Therapy Options
- Budesonide/formoterol (Symbicort): This combination inhaler is particularly advantageous due to formoterol's rapid onset of action, allowing it to be used as both a maintenance and rescue medication (MART approach) 1.
- Fluticasone/salmeterol (Advair): Another excellent option for step-up therapy, with a proven track record of improving lung function and symptoms in patients with asthma 1.
- Mometasone/formoterol (Dulera): A third option for combination therapy, offering a different formulation of ICS and LABA for patients who may require alternative treatment options 1.
From the FDA Drug Label
BREO ELLIPTA is a combination of fluticasone furoate, a corticosteroid, and vilanterol, a long-acting beta2-adrenergic agonist (LABA), indicated for: • the maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). • the maintenance treatment of asthma in patients aged 5 years and older.
The FDA drug label does not answer the question.
From the Research
Combination Inhalers for Asthma Exacerbation
The best combination inhaler for step-up therapy for asthma exacerbation due to a viral respiratory infection can be considered based on several studies:
- A study published in 2020 2 compared the effectiveness of add-on tiotropium versus an increased inhaled corticosteroid (ICS) plus long-acting beta-2-agonist (LABA) dose in patients with asthma. The results showed that add-on tiotropium significantly decreased the risk and rate of exacerbations.
- Another study from 2022 3 compared the effectiveness of fluticasone furoate/vilanterol (FF/VI) with budesonide/formoterol (B/F) in patients with asthma. The results showed that FF/VI was associated with lower use of short-acting beta-2-agonist (SABA) and fewer asthma-related exacerbations.
- A systematic review and meta-analysis published in 2022 4 evaluated the effectiveness of budesonide-formoterol as both maintenance and reliever therapy (SMART) compared with maintenance ICS-LABA plus SABA reliever therapy. The results showed that SMART was associated with a longer time to first severe asthma exacerbation.
- A review article from 2012 5 discussed the pharmacological profiles of ICS and LABA combinations, highlighting the potential advantages of using specific combinations.
- A systematic review and meta-analysis from 2018 6 evaluated the effects of SMART compared with ICS with or without LABA as controller therapy and SABA as relief therapy. The results showed that SMART was associated with a lower risk of asthma exacerbations.
Key Findings
Some key findings from these studies include:
- Add-on tiotropium can decrease the risk and rate of exacerbations in patients with asthma 2.
- FF/VI can be associated with lower use of SABA and fewer asthma-related exacerbations compared with B/F 3.
- SMART can be associated with a longer time to first severe asthma exacerbation compared with maintenance ICS-LABA plus SABA reliever therapy 4.
- The choice of ICS and LABA combination can affect treatment outcomes, with some combinations showing potential advantages over others 5.
- SMART can be associated with a lower risk of asthma exacerbations compared with ICS with or without LABA as controller therapy and SABA as relief therapy 6.
Combination Inhaler Options
Based on these studies, some combination inhaler options for step-up therapy for asthma exacerbation due to a viral respiratory infection include: