Journals Club - Combination inhalers for asthma

Contributed by Dr Louise Newson, a GP in the West Midlands

Combined inhaler
Combined inhaler

RCGP Curriculum - 15.8 Respiratory Problems

Key trials

  • One study found that combined salmeterol and fluticasone propionate reduced the number of exacerbations in patients with mild to moderate asthma, compared with salmeterol or fluticasone as monotherapy (Respir Med 2006; 100: 2-10).
  • Another study compared the use of rapid-acting beta-2 agonists with using budesonide/formoterol as a reliever in patients already taking budesonide/formoterol maintenance treatment. Results showed that the combination of budesonide/formoterol was superior in reducing the rate of severe asthma exacerbations (Lancet 2006; 368: 744-53).
  • A review has highlighted that single inhaler therapy for asthma with combined budesonide and formoterol as maintenance and reliever provides better control of asthma than combination inhalers or higher doses of inhaled corticosteroids (ICS) as maintenance plus a short-acting beta-2 agonist as reliever (BMJ 2007; 335: 513).

Evidence base

  • A Cochrane review found single inhaler therapy with a combination inhaler can reduce the risk of asthma exacerbations needing oral corticosteroids in comparison with fixed dose maintenance inhaled corticosteroids (Cochrane Database Syst Rev 2009; (2): CD007313).
  • CKS state that using a combination budesonide/formoterol inhaler as a preventer and reliever is an alternative in selected adults who respond to a LABA but are poorly controlled or in adults who are taking an ICS alone but are poorly controlled.

Guidelines

  • The Commission on Human Medicines recommends that for the management of chronic asthma, LABA should only be added if regular use of standard-dose ICS has failed to control asthma adequately.
  • CKS recommend that careful explanation is needed about why a combination budesonide/formoterol inhaler can be used as a reliever as well as a preventer, and why it is important to arrange a review if it regularly needs to be used as a reliever.
Key Points
  • Combination inhalers improve compliance.
  • They can be used as both preventive and reliever treatment.
  • Combination inhalers should only be given if ICS have not adequately controlled symptoms.

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