The 2019 update of the Global Initiative For Asthma (GINA) recommends a major change of approach in asthma. For the first time, it is now recommended that adult and adolescent patients with asthma never be prescribed a short acting bronchodilator alone. For decades, patients with intermittent asthma have been prescribed short acting bronchodilators (short acting beta agonists or SABA) alone for as-needed use, and patients with persistent asthma were prescribed SABA plus controller medications such as inhaled corticosteroids, leukotriene modifiers like Singulair, or combination inhaled corticosteroid - long-acting beta agonists (ICS-LABA).
Due to the known dangers of overuse of short acting bronchodilators, and evidence that even mild asthma involves inflammation, and other research, the GINA guidelines now recommend that adult and adolescent patients with asthma be prescribed a low dose ICS-LABA to be used for symptom relief, and for asthma that is more than mild, use of this type of medication regularly plus either a SABA or ICS-LABA for quick relief.
The only low dose ICS-LABA in the U.S. with a rapid enough acting LABA component to be included in this new paradigm is Symbicort 80, which contains formoterol, a quick acting and long-lasting bronchodilator. Dulera also contains formoterol, but the corticosteroid doses available are only medium and high dose, without a low dose option. Other ICS-LABAs, such as Advair and Breo, which are excellent medications, contain a LABA that has a slower onset-of-action, making it inappropriate for reliever therapy.
Therefore, this new GINA strategy, if applied in the United States, would lead to most asthma patients over age 12 being prescribed Symbicort 80, 2 puffs as needed for symptom relief, plus either use of this regularly for asthma control, or other additional asthma medications.
This represents a dramatic paradigm shift in asthma care. A recent New England Journal of Medicine article, published May 23, 2019, provided further support for this new approach. This article, titled "A controlled trial of budesonide-formoterol as needed for mild asthma, found that use of this medication combination as needed was superior to albuterol for the prevention of asthma exacerbations, a primary goal of asthma care.
References: Global Initiative for Asthma 2019; New England Journal of Medicine 380:21, May 23, 2019
Dr. Kenneth Backman of Allergy and Asthma Care of Fairfield County comments: "This represents a dramatic shift in management of asthma, one that is supported by decades of research, and will likely lead to improved asthma control, while at the same tim reducing the need for higher doses of inhaled and oral corticosteroids. Over the coming months and years, it is likely that fewer patients will carry albuterol inhalers, and more will carry ICS-LABA inhalers such as Symbicort, for relief of their asthma symptoms. "