In the third issue of BPJ we discussed the current debate around the management of acute asthma for people on long acting beta agonists (LABAs). In this issue we pose four scenarios and ask Respiratory Physician, Professor Robin Taylor, for his advice in these situations.
Consider how you would respond to the scenarios and then read Professor Taylor’s comments.
Ms Rees is a 22-year-old retail assistant with asthma. You have recently been able to reduce her high inhaled corticosteroids (ICS ) dose by adding an inhaled LABA and she is currently taking fluticasone (Flixotide) 250 micrograms bd and salmeterol (Serevent) 25 micrograms bd in separate inhalers. She wants to combine these into a single inhaler (Seretide 250) for the sake of convenience and you agree.
In the past she has been in the habit of doubling her daily dose of fluticasone if she gets a mild exacerbation of her asthma or a URTI. She asks what she should do now she is on a combination inhaler. What do you recommend?
Professor Robin Taylor’s comments
The use of a combination inhaler is a logical step forward in most patients whose asthma is well controlled on both an ICS and a LABA (subject to Special Authority application). The fact that her total dose of ICS can be reduced is also an advantage.
Doubling the dose of inhaled steroid during an exacerbation has been shown not to provide any benefit in the management of exacerbations. It is now obsolete as a management strategy, thanks to the advent of evidence from appropriately designed trials.
More recently there has been a series of studies in which the use of regular plus as-required formoterol/budesonide has been compared with regular combination plus as required short acting beta-agonist (SABA). The strategy is known as adjustable maintenance therapy (AMT) - in which the patient needs to have only one type of inhaler (Symbicort). The results to date demonstrate an advantage in using the former regimen. This strategy is based on the fact that formoterol has a rapid onset of action and can be used as a ‘reliever’ and the patient simultaneously gets an additional dose of inhaled steroid. Thus Symbicort may be used in this way, but not Seretide.
What remains unclear is whether this approach is valid in all patients or only in selected groups. This question will probably be answered over the next 2-3 years. My own concern relates to the patients whose ‘prn’ use of beta-agonist is problematic. Those who rely on too much SABA and do not take enough inhaled steroid ought theoretically to gain from this - assuming that their asthma is steroid sensitive and current symptoms are due to poor asthma control and not something else. Some patients may be prone to taking reliever to excess for psychological as well as truly disease-related reasons, in which case the possibility of steroid overuse might arise. To date there has been only limited experience using AMT in New Zealand and it may be that increasing familiarity will help to identify where the potential problems really lie. However AMT is not suitable for this woman because she is on Seretide.
Secure resources login 
Printer friendly PDF
Ms Rees is a 22-year-old retail assistant with asthma. You have recently been able to reduce her high inhaled corticosteroids (ICS ) dose by adding an inhaled LABA and she is currently taking fluticasone (Flixotide) 250 micrograms bd and salmeterol (Serevent) 25 micrograms bd in separate inhalers. She wants to combine these into a single inhaler (Seretide 250) for the sake of convenience and you agree.