Combination Inhalers for Asthma: A Rapidly Growing Class

James Thompson MD Health Pro
  • Combination controller inhalers continue to play a vital role in asthma management for many who have a history of moderate to severe asthma. Since Advair became available in 2001, as the first inhaler with a steroid and long-acting bronchodilator (a drug which relaxes tiny muscles which surround the small airways of the lung) two other inhalers have emerged. Symbicort and Dulera are now available for treatment of moderate to severe asthma, in addition to Advair.



    I remember being excited about the arrival of combination inhalers because patients would be able to experience the convenience of getting two important medications with one or two puffs, one device, and one copay. This relatively new class of inhalers for treating asthma seemed very practical because otherwise, patients were forced to purchase the inhalants separately.

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    When it comes to asthma management, "less is more" when referring to the number of medications you have to take, purchase, refill, and inhale (2-4 puffs at a time versus 1-2 with combination inhalers). For these and other reasons, combination inhalers are here to stay. You might be wondering, "What are those other reasons?" Just keep reading.



    Why combine inhaled steroids with long-acting bronchodilators (LABs)?


    Inhaled steroids are cornerstone to reducing inflammation, which is present in the airways of all people who have asthma. For many years experts have agreed that inhaled steroids are best positioned to control asthma that surpasses the intermittent level (the mildest level of severity). They have proven to be superior to other controllers such as LABs (when used as single controllers), theophylline, leukotriene modifiers (Singulair, Accolate and Zyflo) and Intal (Cromolyn, which is no longer available in the U.S.). NIH asthma management guidelines (latest revision in 2007) emphasize the role of inhaled steroids and combination inhalers at specific levels of severity in adults and children.



    Using combination steroid and LABs, may allow for lower doses of inhaled steroid. Several clinical studies have reported that adding a LAB to a low to medium dose of inhaled steroid results in a better response (reduction of asthma symptoms and improved lung function) compared to doubling the dose of inhaled steroid.

    Furthermore, the dose effect of inhaled steroid component of combo inhalers may be maintained at a lower level by avoiding the higher inhaled amounts required for treatment of poorly controlled asthma with inhaled steroid alone.



    Adherence is another concern in asthma management. Drug refill data on asthma medications reflect poor consistency in renewing (and therefore continuing to take) controller medication. Having fewer inhalers to renew (a single combination inhaler instead of two separate inhalers) makes more sense. As I mentioned above, the copay for one inhaler versus two is usually more desirable.



    Are combined steroid and LABs more effective than using them separately?

    This question was recently addressed in an article by Peter Barnes and others in Allergy and Asthma Proceedings, Vol. 33, March-April 2012. The investigators performed a medical search on published clinical trials comparing combination inhalers and single inhalers (this is called a meta-analysis). The bottom line was there was no significant difference in asthma control whether a combination inhaler was used, or inhaled steroid and LAB used separately.


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    Despite these findings, asthma care providers prefer the combination inhalers for reasons mentioned above. Additionally, concerns about using LABs as a single controller (without inhaled steroid) are diminished when using the combination inhaler because the inhaled steroid is mixed in with the LAB and cannot be separated.  If the inhalants are ordered separately a patient may intentionally or unintentionally end up taking only the LAB and have increased risk of worsening asthma or asthma death (which is addressed in the Black Box warnings that accompany all inhalants that contain LABs).



    Final Words


    Asthma control is a primary goal in asthma management. Achieving control can sometimes be difficult and challenging for the patient and doctor. For this reason a partnership approach is highly desirable. Doctors don't know ahead of time, what medication a patient will respond well to, or tolerate well. Trial and error is an unavoidable part of the process. But fortunately there are multiple agents to try, which are effective in many people and most often well tolerated. The combination inhalers have helped to achieve control in many people in America and around the world.


    I tell my patients there are three components to successful inhalant asthma control:

    • 1) Selection of the right inhaled controller (my job)
    • 2) Consistent use of controller medications, (as directed)
    • 3) Flawless inhaler technique(which should be reviewed at each office visit)

    What's your experience with combination inhalers?


    What interferes with you taking regularly scheduled doses of asthma controller?




    Disclosure: I am currently on a speaker's bureau for Glaxo Smith Kline (GSK) and Merck, the makers of Advair and Dulera respectively.


Published On: May 01, 2012