Treatments Beyond Albuterol

The Studies

Several international trials have looked at using ICS-LABA as a rescue inhaler. The results have been very impressive. One such study has been the Novel START trial. This trial was designed to replicate real world scenarios. It was a 52 week trial including 675 adults who were diagnosed with mild intermittent and persistent asthma. The participants were randomized to one of three groups, the albuterol group (only used PRN albuterol), the budesonide maintenance group (budesonide twice daily with albuterol PRN), and budesonide-formoterol group (budesonide-formoterol PRN). What was very impressive was the 51% decrease in asthma exacerbations with the budesonide-formoterol group to the albuterol group. Comparing the budesonide-formoterol group to the budesonide twice daily with albuterol PRN saw no difference. 

The SYGMA 1 and SYGMA 2 trials saw similar results. These trials demonstrated that budesonide-formoterol PRN was as effective in preventing exacerbations as maintenance budesonide. The SYGMA and START trials, along with similar results in the SIENNA trial have led Dr Gary Wong and others, to the conclusion that using budesonide-formoterol as a rescue inhaler is an acceptable alternative to budesonide as a maintenance treatment in mild asthma. This followed with the conclusion that using a PRN budesonide-formoterol treatments could reduce the risk of exacerbations by 50% compared to PRN SABA treatments. 

The SMART strategy trial yielded similar results. 22,500 patients were enrolled in this trial, including children. The budesonide-formoterol as maintenance and rescue group saw 32% fewer exacerbations than the budesonide-formoterol as maintenance (at the same dosing) with albuterol rescue group. They also saw fewer emergency room visits and hospitalizations. What is interesting is that even when the dosing of the budesonide-formoterol was increased in the group with albuterol as the rescue inhaler, there was still a 23% fewer exacerbations in the group with budesonide-formoterol as a rescue. 

There were two other important points in the SMART trial. When compared to just using budesonide as maintenance with albuterol as a rescue, the budesonide-formoterol as maintenance and rescue was superior. The other more significant point was the effect in children between the ages of 4 and 11. These asthmatics saw a reduction of 50% using budesonide-formoterol as maintenance and also as a rescue compared to just maintenance with albuterol as rescue, which could lead to a drastic reduction in pediatric asthma exacerbations.

Conclusion

As the guidelines for asthma are updated, the use of Symbicort as a rescue inhaler should increase. Some institutions have already adopted this off-label use in the US, as the overwhelming evidence points to the superiority of it compared to albuterol.  

The one consideration is how the medication is delivered. In the US budesonide-formoterol is commonly known as Symbicort and comes in an aerosolized metered dose inhaler. In the above listed studies Symbicort Turbuhaler was used. Symbicort Turbuhaler is a dry powder inhaler.