What is the recommended combination of inhaled corticosteroids (ICS) and bronchodilators for asthma management?

From the Guidelines

Combination steroid inhalers for asthma, such as fluticasone/salmeterol (Advair) or budesonide/formoterol (Symbicort), are the preferred treatment for patients with moderate to severe asthma who are not well-controlled on an inhaled corticosteroid (ICS) alone. These combinations work effectively because the ICS reduces inflammation while the long-acting beta-agonist (LABA) keeps airways open for 12-24 hours 1. The typical starting dose depends on asthma severity, but often begins with medium-strength formulations like Advair 250/50 mcg or Symbicort 160/4.5 mcg, taken twice daily (except Breo, which is once daily) 1.

Key Considerations

• Patients should rinse their mouth after use to prevent thrush and carry a rescue inhaler for breakthrough symptoms 1.
• Regular follow-up is important to adjust dosing based on symptom control, with the goal of using the lowest effective dose to minimize side effects while maintaining asthma control 1.
• LABAs should not be used as monotherapy for long-term control of asthma, and should only be used in combination with an ICS 1.
• The combination of an ICS and a 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.

Treatment Options

• Fluticasone/salmeterol (Advair) is a common combination steroid inhaler for asthma, available in various strengths, including 100/50 mcg, 250/50 mcg, and 500/50 mcg 1.
• Budesonide/formoterol (Symbicort) is another common combination, available in strengths such as 160/4.5 mcg and 320/4.5 mcg 1.
• Mometasone/formoterol (Dulera) and fluticasone/vilanterol (Breo Ellipta) are also available, with once-daily dosing for Breo Ellipta 1.

Evidence-Based Recommendations

• The Expert Panel Report 3 (EPR-3) guidelines recommend the use of combination therapy with an ICS and a LABA for patients with moderate to severe asthma who are not well-controlled on an ICS alone 1.
• The American Family Physician guidelines also recommend the use of combination therapy with an ICS and a LABA, citing strong evidence for its effectiveness in improving lung function and symptoms, and reducing the need for quick-relief medications 1.

From the FDA Drug Label

The recommended starting dose and highest recommended dose of budesonide inhalation suspension, based on prior asthma therapy, are listed in the following table. Previous Therapy Recommended Starting Dose Highest Recommended Dose Bronchodilators Alone 0.5 mg total daily dose administered twice daily in divided doses 0.5 mg total daily dose Inhaled Corticosteroids 0. 5 mg total daily dose administered twice daily in divided doses 1 mg total daily dose Oral Corticosteroids 1 mg total daily dose administered as 0.5 mg twice daily 1 mg total daily dose

The budesonide inhalation suspension is used as a steroid inhaler for asthma maintenance treatment. The recommended dosing is based on previous therapy, with options including:

• Bronchodilators alone: 0.5 mg once daily or 0.25 mg twice daily
• Inhaled corticosteroids: 0.5 mg once daily or 0.25 mg twice daily up to 0.5 mg twice daily
• Oral corticosteroids: 0.5 mg twice daily 2 2

From the Research

Steroid Inhaler Combinations for Asthma

• The combination of inhaled corticosteroids and other medications is a common approach in the management of moderate to severe persistent asthma 3.
• Current guidelines recommend adding a long-acting beta 2-agonist, such as salmeterol, to the inhaled corticosteroid 3.
• Leukotriene receptor antagonists and theophylline can also be used in conjunction with inhaled steroids 3.

Comparison of Different Steroid Inhaler Combinations

• A post hoc analysis compared the efficacy of budesonide/formoterol and salmeterol/fluticasone propionate in adults with persistent asthma, and found that budesonide/formoterol maintenance and reliever therapy prolonged time to first severe exacerbation 4.
• A systematic review compared the clinical effectiveness and tolerability of fluticasone propionate and budesonide, and formoterol fumarate and salmeterol xinafoate, and found that fluticasone and formoterol appeared to provide improved therapeutic benefits 5.
• A study compared the efficacy and safety of fluticasone/formoterol combination therapy with the individual components, and found that fluticasone/formoterol combination therapy was superior to the individual components and placebo for all co-primary endpoints 6.

Patient Perspectives and Adherence

• Patient perspectives on combination inhaler therapy can affect adherence to therapy, with patients preferring an effective reliever with a fast onset and long duration of action 7.
• Adherence is higher with combination ICS/LABAs than when the components are administered separately 7.
• Future research should be directed at therapy that offers both anti-inflammatory activity and a rapid onset of bronchodilator effect, and should investigate the effect of these characteristics on adherence 7.