What is the best combination inhaler for step-up therapy in asthma exacerbation due to viral respiratory infection?

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 doses as needed for symptoms (not exceeding 8 inhalations daily) 1. This approach helps control the increased airway inflammation caused by viral infections while providing bronchodilation.

Key Considerations

• The combination of ICS and LABA has been shown to improve lung function and asthma control in patients inadequately controlled with low-to-medium doses of inhaled corticosteroids 1.
• During an exacerbation, patients should also continue using their short-acting beta-agonist (like albuterol) as needed for immediate symptom relief.
• If symptoms worsen despite this step-up therapy, patients should contact their healthcare provider as oral corticosteroids may be necessary 1.
• Adequate hydration and monitoring of symptoms for any signs of deterioration are also important components of management.

Management Approach

• Patients should be instructed on how to use a written asthma action plan that notes when and how to treat signs of an exacerbation 1.
• Early treatment by the patient at home is the best strategy for managing asthma exacerbations, including recognizing early indicators of an exacerbation and adjusting medications accordingly 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Combination Inhalers for Asthma Step-Up Therapy

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, finding that add-on tiotropium significantly decreased the risk and rate of exacerbations.
• Another study from 2022 3 found that initiation of once-daily fluticasone furoate/vilanterol was associated with lower use of short-acting beta-2-agonist and fewer asthma-related exacerbations compared with twice-daily budesonide/formoterol.
• A systematic review and meta-analysis from 2022 4 suggested that single inhaler combination inhaled corticosteroid-formoterol as both maintenance and reliever (SMART) was associated with longer time to first severe asthma exacerbation compared with a step up or continuation of maintenance inhaled corticosteroid-long-acting beta-2-agonist plus short-acting beta-2-agonist reliever.
• A historical, matched cohort study from 2016 5 compared asthma-related outcomes for patients prescribed step-up therapy as a increased dose of ICS or add-on LABA, finding that increased dose of extrafine-particle ICS, or add-on LABA via ICS/LABA combination inhaler, was associated with significantly better outcomes than ICS+LABA via separate inhalers.
• A review article from 2012 6 summarized the pharmacological characteristics of various ICSs and LABAs available for the treatment of asthma, highlighting the potential for ICS and LABA synergy.

Key Findings

Some key points to consider when selecting a combination inhaler for asthma step-up therapy include:

• The use of add-on tiotropium or increased ICS plus LABA dose can be effective in reducing exacerbations 2.
• Once-daily fluticasone furoate/vilanterol may be associated with better outcomes compared with twice-daily budesonide/formoterol 3.
• SMART may be a preferred option for patients with poorly controlled asthma 4.
• The use of extrafine-particle ICS or add-on LABA via ICS/LABA combination inhaler may be associated with better outcomes compared with separate inhalers 5.
• The pharmacological profiles of ICSs and LABAs can influence treatment outcomes 6.