Combination Inhalers for Asthma Control: A New Kid on the Block

by James Thompson, M.D. Health Professional, Medical Reviewer

Although asthma death rates have declined, it continues to be a leading cause of missed work and school in the United States. The National Institute of Health (NIH) revised their asthma diagnosis and management guidelines in 2007. This over 600 page document has become the Holy Grail of asthma treatment and clinical research in the United States.

Whether a child or adult with asthma should have a daily controller medication is dependent on a whether the asthma is "persistent".

When is asthma persistent? Great Question

Asthma is persistent when:

-There are limitations in normal routine (work/school) because of asthma. For example, huffing and puffing as you walk up one flight of stairs, noticing classmates or coworkers gliding by with ease.

-Symptoms of asthma (cough, wheezing, shortness of breath, or chest tightness) occur more than two days per week.

-Reliever inhaler is required more than two days per week (don't count the inhalations taken to prevent exercise-induced asthma).

-Night time awakenings from asthma symptoms occurs more than two nights per month.

-Lung function is less than 80 percent predicted by lung function test (Spirometry or Peak Flow Rate).

-There has been more than one severe asthma attack in the last 12 months.

The clincher here is that it only takes one of the above criteria to say your asthma is persistent, even if all the other criteria are fine.

When asthma control is not achieved with low-to-medium doses of inhaled steroids (for example: Flovent, Pulmicort, Asmanex, Qvar or Alvesco) the doctor must decide whether to:

-Prescribe a high dose of inhaled steroid

-Or use a combination of low-to-medium inhaled steroid and a Long Acting Beta Adrenergic Receptor Agonist (LABA)

-Or consider a combination of low-to-medium inhaled steroid and another asthma drug (for example Singulair or Theophyline).

The NIH guidelines emphasize the importance of inhaled steroids at every level of treatment for persistent asthma. But adding a LABA, or instead using another alternative combination is up to your doctor. The LABAs plus inhaled steroid have been readily available through combination inhalers (Advair Diskus, Advair HFA and Symbicort).

Any LABA containing inhalers have Boxed Warnings, which relate to the risk of asthma worsening and asthma death based on, primarily, a large clinical study that analyzed the adverse effects of LABAs (done years ago).

Nonetheless, asthma has become more manageable since the introduction of combination inhalers containing LABA plus inhaled steroid.

Last June, a third LABA containing inhalant became available. Dulera (Merck), a combination of Mometasone Furoate
(the main ingredient of the inhaled steroid Asmanex available since 2005) and Formoterol Fumarate (main ingredient of the LABA, Foradil available since 2001). Dulera is indicated for the treatment of asthma in ages 12 and above. It is an aerosol inhaler that has a digital dose counter and comes in two strengths. It is a controller inhaler that should be taken as two puffs twice daily. It should never be used to relieve symptoms. Short acting reliever inhalers should also be on hand for use as needed.

Dulera is another alternative for treating asthma that fails to respond to
medium or high dose inhaled steroids.

Does Dulera have any advantage over Advair or Symbicort?

There are no head-to-head clinical studies comparing these inhalers to Dulera. The inhaled steroid component (of Dulera) has very good pharmacologic properties in that, it avidly binds to the steroid receptor in tissues and does not distribute widely to other body tissues (two favorable points). But these characteristics have no documented correlation with greater clinical effectiveness or safety to date.

This means, trial and error is the order of the day. We cannot predict which inhaler combination will be successful for a given asthma patient. As they say "The proof is in the pudding". In other words, over time, if your asthma symptoms are better controlled, lung function is improved and there are fewer asthma attacks, the medicine has worked.

Asthma specialists are glad to have more to work with. It is clear that details of asthma management differ for each individual and is based on several factors. Advair and Symbicort have helped improve asthma control for lots of my patients. We (asthma specialists) all have patients that have not responded as well as desired. Dulera gives us another alternative to better manage our moderate to severe asthma patients with lower doses of inhaled steroid.

Are you presently on a combination inhaler?

Has it helped you in asthma control?

(Dr. Thompson is on the GSK and Merck speaker's bureau)

James Thompson, M.D.
Meet Our Writer
James Thompson, M.D.

Dr. Thompson completed medical school and specialty training in allergy and immunology at Washington University in Saint Louis. He is board certified in Internal Medicine, Allergy and Immunology. He sees adults and children in Chicago and greater Chicago area. He is also certified in Integrative Nutrition Coaching. Dr. Thompson is dedicated to incorporating holistic nutrition concepts into the treatment of asthma and other allergic diseases in order to achieve better health and reduce the need for medications.