Consider a PRN Combo Inhaler for Some Adults With Mild Asthma

You'll hear buzz about using formoterol/inhaled corticosteroid combos (Symbicort, Dulera) AS NEEDED for adults with MILD asthma.

For years, we've been using albuterol PRN for many mild asthma patients with symptoms twice per week or less...and adding a daily low-dose inhaled corticosteroid (ICS) if symptoms occur nearly every day.

But over half of patients don't adhere to their inhaled steroid.

Now guidelines suggest PRN use of combos with the long-acting beta-agonist formoterol plus an inhaled steroid...as a middle ground.

This gives quick relief...since bronchodilation with formoterol happens within 5 minutes, similar to albuterol. Patients also get an inhaled steroid to treat inflammation...and just need one inhaler.

New evidence suggests using low-dose formoterol/budesonide (Symbicort) PRN avoids a severe exacerbation in about 1 in 16 adults with mild asthma per year versus albuterol alone. But this is mostly due to needing fewer steroid bursts...hospitalizations and ED visits are rare.

Patients also don't seem to have more exacerbations using this combo PRN than a daily low-dose inhaled steroid...at half the steroid exposure.

The obvious downside is cost. Formoterol/ICS combos run about $300 and may not be preferred by payers now that Advair Diskus is generic. Generic albuterol costs about $35...inhaled steroids $175 or more.

And for now, only Symbicort or Dulera (formoterol/mometasone) is an option. ICS combos with salmeterol (Advair, etc) or vilanterol (Breo) may not work fast enough...bronchodilation takes 15 to 30 minutes or more.

Despite the drawbacks, consider changing your practice for ADULTS with mild asthma. There's not much evidence in patients under 18.

When cost isn't a barrier, lean toward a PRN low-dose formoterol/ICS combo as the "rescue" inhaler...INSTEAD of PRN albuterol.

Or switch from a daily low-dose inhaled steroid to PRN formoterol/ICS...especially if patients aren't adherent to the steroid.

Use dosing similar to albuterol for mild asthma...formoterol/ICS 2 puffs every 4 to 6 hours PRN symptoms. Keep in mind to change the sig...since the e-Rx will likely be populated for scheduled BID dosing.

Advise patients to call if they regularly need it more than twice a day...and consider stepping up to scheduled BID use.

Expect labeling and patient handouts to take time to catch up.

Dig into our toolbox, Improving Asthma Care, for other strategies to prevent exacerbations...and how to treat asthma in kids.

Key References

  • https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/ (06-18-19)
  • N Engl J Med 2019;380(21):2020-30
  • N Engl J Med 2018;378(20):1865-76
  • Medication pricing by Elsevier, accessed Jun 2019
Prescriber's Letter. July 2019, No. 350702



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