Using a combination inhaler (budesonide plus formoterol) as rescue therapy improves asthma control

doi:10.1136/bmj.39273.537778.AD

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Peter J Barnes, professor of thoracic medicine

National Heart and Lung Institute, Imperial College, London

P J Barnes, Airway Disease Section, National Heart and Lung Institute, Dovehouse St, London SW3 6LY p.j.barnes{at}imperial.ac.uk

The clinical problem

Asthma is one of the commonest chronic diseases worldwide and is effectively controlled in most patients with maintenance treatment. In those with moderate or severe persistent asthma, control may be achieved with an inhaled corticosteroid or a combination inhaler containing a corticosteroid and a long acting β₂agonist. The combination inhaler is more effective, but patients still require short acting β₂agonists such as salbutamol or terbutaline to relieve symptoms. I describe a new approach for acute exacerbation—SMART (single inhaler maintenance and reliever therapy). This uses the combination inhaler, rather than the short acting β₂agonist, as the reliever.

The evidence for change

Using a formulation of budesonide plus formoterol (budesonide/formoterol) both as a reliever and as maintenance therapy once or twice daily is more effective in controlling asthma than conventional approaches using budesonide/formoterol, fluticasone/salmeterol, or high dose corticosteroids (budesonide or fluticasone) as the maintenance treatment with short acting β₂agonists as relievers (table⇓).1 2 3 4 5 The most striking benefits are fewer exacerbations (severe exacerbations, defined as needing a course of oral corticosteroids, are …