What maintenance inhalers are used for adult patients with persistent asthma?

Maintenance Inhalers for Adult Asthma

Inhaled corticosteroids (ICS) are the preferred first-line maintenance therapy for all adults with persistent asthma, with combination ICS/long-acting beta-agonist (LABA) therapy recommended when low-dose ICS alone does not achieve adequate control. 1

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Primary Maintenance Inhaler Categories

1. Inhaled Corticosteroids (ICS) - Monotherapy

The cornerstone of asthma maintenance therapy, demonstrating superior efficacy compared to all other single-agent options 1, 2:

Available ICS formulations:

• Fluticasone propionate (MDI or DPI) 3
• Budesonide (nebulizer solution or DPI) 1, 3
• Beclomethasone dipropionate 2
• Fluticasone furoate (once-daily formulation) 4

Standard dosing approach:

• Low-dose ICS (fluticasone propionate 100-250 mcg/day or equivalent) achieves 80-90% of maximum therapeutic benefit and represents the preferred starting dose for mild persistent asthma 3, 5
• Medium-dose ICS (fluticasone propionate >250-500 mcg/day) for moderate persistent asthma when low-dose fails 1, 3
• High-dose ICS (fluticasone propionate >500 mcg/day) carries increased systemic adverse effect risk with minimal additional efficacy benefit 6, 5

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2. ICS/LABA Combination Inhalers - Preferred for Moderate-to-Severe Asthma

Combination therapy is more effective than doubling ICS dose alone and represents preferred therapy at Step 3 and above 1:

Available combinations:

• Fluticasone propionate/salmeterol (Advair): 100/50,250/50, or 500/50 mcg twice daily 7, 8
• Budesonide/formoterol (Symbicort): 160/4.5 mcg, two inhalations twice daily for moderate-to-severe asthma 7
• Fluticasone furoate/vilanterol (Breo Ellipta): 100/25 or 200/25 mcg once daily 4

Critical safety warning: LABAs must NEVER be used as monotherapy for asthma—they are contraindicated without concurrent ICS due to increased risk of severe exacerbations and asthma-related deaths 1, 7, 4

SMART therapy (Single Maintenance And Reliever Therapy):

• ICS/formoterol can be used both as daily maintenance AND as-needed reliever therapy (preferred at Steps 3-4 for patients ≥5 years) 1, 9
• This approach reduces exacerbations more effectively than traditional fixed-dose ICS/LABA plus separate SABA reliever 1, 9

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3. Leukotriene Receptor Antagonists (LTRAs)

Alternative (but NOT preferred) maintenance option 1:

Available agents:

• Montelukast (approved for adults and children ≥2 years) 1
• Zafirlukast (approved for adults and children ≥7 years) 1

Key evidence:

• LTRAs provide statistically significant but modest improvement in lung function 1
• ICS are clearly superior to LTRAs across all outcome measures including lung function, symptom control, and exacerbation reduction 1, 2
• LTRAs may be considered when patient circumstances warrant oral therapy over inhaled medications, or as add-on therapy to ICS at Step 3 1

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4. Long-Acting Muscarinic Antagonists (LAMAs)

Adjunctive therapy for severe asthma 1:

• Tiotropium can be added to ICS/LABA for additional efficacy in patients ≥5 years on Step 5 therapy 1
• LAMAs are NOT standard first-line or second-line maintenance therapy 7

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5. Cromolyn and Nedocromil

Historical alternatives with limited current use 1:

• Demonstrate some effectiveness but significantly less than ICS 1
• Strong safety profile but not preferred therapies due to inferior efficacy 1
• May be considered when ICS cannot be used, though this is uncommon in modern practice 1

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Stepwise Treatment Algorithm for Adults

Step 1 (Intermittent asthma):

• Short-acting beta-agonist (SABA) as needed only—no maintenance inhaler required 3

Step 2 (Mild persistent asthma):

• Preferred: Low-dose ICS (fluticasone 100-250 mcg/day or equivalent) twice daily 1, 3, 10
• Alternative: As-needed ICS plus SABA used concomitantly for patients ≥12 years with adherence concerns 1, 9
• Alternative: LTRA (less effective than ICS) 1

Step 3 (Moderate persistent asthma):

• Preferred: Low-to-medium-dose ICS plus LABA (e.g., fluticasone/salmeterol 100-250/50 mcg twice daily) 1, 3, 7
• Alternative: Medium-dose ICS monotherapy 1, 3
• Alternative: Low-to-medium-dose ICS plus LTRA or theophylline 1
• Preferred for patients ≥5 years: ICS/formoterol as both maintenance and reliever therapy (SMART) 1

Step 4 (Severe persistent asthma):

• Preferred: Medium-dose ICS plus LABA 1, 3
• Consider adding LAMA (tiotropium) to ICS/LABA for patients ≥5 years 1

Step 5 (Very severe persistent asthma):

• Preferred: High-dose ICS plus LABA 1, 3
• Add LAMA for additional control 1

Step 6 (Refractory severe asthma):

• High-dose ICS plus LABA plus oral corticosteroids 1, 3
• Consider biologics (omalizumab, mepolizumab, etc.) before chronic oral steroids

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Critical Administration Techniques

For all ICS-containing inhalers:

• Rinse mouth with water and spit after each use to prevent oral candidiasis and dysphonia 3, 4
• Use spacer or valved holding chamber with MDIs to enhance lung deposition and reduce local side effects 3
• Administer at same time daily for consistency 4

Common pitfalls to avoid:

• Never increase ICS dose during acute exacerbations in adherent patients—use systemic oral corticosteroids instead 1, 3
• Never prescribe LABA without ICS 1, 7, 4
• Do not use nebulized bronchodilators as maintenance therapy for chronic persistent asthma at Steps 1-3—reserve for Step 4 or above 1
• Frequent SABA use (>2 days/week) indicates inadequate control requiring step-up therapy 3, 10

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Monitoring and Reassessment

• Assess asthma control every 2-6 weeks initially after starting or adjusting therapy 3
• Verify proper inhaler technique at every visit—most patients use inhalers incorrectly 3
• Step down to minimum effective dose after 2-4 months of sustained control 3
• Discontinue therapy if no clear benefit within 4-6 weeks despite proper technique and adherence 3