Combination inhalers

Current situation

  • Asthma is poorly treated despite an increased awareness of the condition.
  • The dose–response curve for the effect of inhaled cortico-steroids on lung function becomes flat at moderate doses, indicating that higher doses may worsen the therapeutic ratio. This has led to widespread use of lower doses of inhaled corticosteroid in combination with long-acting beta-2 agonists.
  • Combined treatment means that patients can use it to prevent asthma attacks and for as-needed symptom relief.

What is the evidence?

  • Combined products containing inhaled corticosteroid and long-acting beta-2 agonist have the potential advantage of improving patients’ concordance and adherence to drugs, as fewer inhalations and inhaler devices are needed (BMJ 2005; 330: 585–9).
  • One study assessed asthma control using salmeterol plus fluticasone in combination versus salmeterol or fluticasone as monotherapy in patients with mild-to-moderate asthma (Respir Med 2006; 100: 2–10). The results showed that those patients using combination inhalers had fewer exacerbations and were less likely to need an increase in their medication.
  • A study has promoted the benefits of using budesonide/formeterol for patients with asthma. The results of this year-long study showed that treating patients with budesonide/ formeterol reduced the  risk of  suffering a first severe asthma attack by an impressive 25 per cent versus salmeterol/fluticasone plus salbutamol for relief (Eur Respir J 2005; 26: 819–28).
  • There has been some concern about the safety of long-acting beta-agonists. The SMART study found that there were more asthma-related deaths and life-threatening experiences in those taking salmeterol versus placebo without concomitant steroids (Chest 2006: 129: 15–26).
  • One study compared the use of rapid-acting beta-2 agonists with the use of budesonide/formeterol as a reliever in patients with asthma who were already taking budesonide/ formeterol maintenance treatment. The results of the study showed that the combination of budesonide/ formeterol was superior in reducing the rate of severe asthma exacerbations (Lancet 2006; 368: 744–53).

Implication for practice

  • Use of an inhaler for both maintenance and relief helps to improve adherence.

Available guidelines

  • The British Thoracic Society guidelines for the management of asthma: beta-agonists should be used in combination with inhaled corticosteroids.

Useful websites — GPs in asthma group —British Thoracic Society —Asthma UK

Dr Louise Newson is a GP in the West Midlands and author of ‘Hot Topics for MRCGP and General Practitioners’ PasTest 2006

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