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Combo Inhaler May Give Better Relief for Some With Asthma

By Steven Reinberg
HealthDay Reporter

MONDAY, March 4 (HealthDay News) -- Asthma patients typically use two inhaled drugs -- one a fast-acting "rescue inhaler" to stem attacks and another long-lasting one to prevent them.

However, combining both in one inhaler may be best for some patients, two new studies suggest.

Patients with moderate to severe asthma who used a combination inhaler had fewer attacks than those on two separate inhalers, researchers report. Both studies tested the so-called SMART (single maintenance and reliever therapy) protocol.

"The SMART regime was more effective as a treatment for asthma than the conventional treatment, where you just use a inhaler at a fixed maintenance dose and a short-acting inhaler for the relief of symptoms," said Dr. Richard Beasley, director of the Medical Research Institute of New Zealand in Wellington and lead researcher of one of the studies.

These drugs are a combination of a corticosteroid (such as budesonide or fluticasone) and a long-acting beta-2 agonist (such as salmeterol or formoterol) and are sold under various brand names including Seretide, Symbicort and Advair.

In asthma, treatment increases as the severity of the condition does, Beasley said. So, this combination therapy isn't the first choice. When the asthma is difficult to control with other methods, "we are now recommending the SMART regime," he said.

"You treat the patients according to their needs," Beasley said. "This is certainly not what you start them on -- it is something you would use on moderate to severe patients."

In the United States, use of these combination inhalers is also not considered first-line therapy for asthma, according to Dr. Len Horovitz, a pulmonary specialist at Lenox Hill Hospital in New York City.

"Patients, however, are currently using these combination inhalers," he said. If the asthma is moderate to severe, then a combination inhaler is appropriate, said Horovitz, who was not involved with either new study.

The reports were published in the March issue of the journal Lancet Respiratory Medicine.

One study was funded by Italian pharmaceutical company Chiesi Farmaceutici, whose products include asthma medications. The multi-center European study was led by Dr. Klaus Rabe, a professor of pulmonary medicine at the University of Kiel, in Germany.

The study included more than 1,700 patients with moderate asthma. Researchers found that participants using the single, combination inhaler had significantly fewer severe asthma attacks and were seen at a hospital or urgent medical facility less than those patients using the two inhalers.

Rabe and colleagues wrote that although drugs like Symbicort (the specific budesonide/formoterol combination used in the study) can be more expensive than separate inhalers, the ability to prevent asthma attacks and reduce hospital and emergency room visits may be cost-saving in the end.

In the second trial, funded by the Health Research Council of New Zealand, Beasley's team randomly assigned 303 patients to the single-inhaler protocol or to usual care with two inhalers. Over six months, the researchers found that those using Symbicort had fewer severe asthma attacks.

One concern had been that patients using the combination inhaler would get overexposed to corticosteroid or would overuse the inhaler, Beasley said.

They found, however, that patients using the combination inhaler reduced their overuse of corticosteroid by 40 percent, compared to those using separate inhalers.

While those in the SMART program took in more corticosteroids a day, they had fewer asthma attacks so their overall exposure to corticosteroid was the same as for people in the two-inhaler group, the New Zealand researchers explained.

More information

For more about asthma, visit the U.S. National Library of Medicine.

SOURCES: Richard Beasley, M.B., director, Medical Research Institute of New Zealand, Wellington; Len Horovitz, M.D., pulmonary specialist, Lenox Hill Hospital, New York City; March 2013 Lancet Respiratory Medicine

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