Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Asthma - Management
What is the role of combination inhalers in asthma?

  • In general, inhaled corticosteroids/long-acting beta2-agonist (LABA) combination inhalers are reserved for use in people who are stabilized on the component drugs in the same dose ratio and who have difficulty using separate inhalers.
    • Three combined products are available in the UK [BNF 57, 2009]:
      • Symbicort® is a combination of budesonide and formoterol delivered as a dry-powder inhaler.
      • Seretide® is a combination of fluticasone and salmeterol and is delivered by a dry-powder inhaler or pressurized metered-dose inhaler (pMDI).
      • Fostair® is a combination of beclometasone and formoterol delivered as a CFC-free pMDI. It is licensed for use only in adults aged 18 years and older. It is not dose equivalent to beclometasone delivered by CFC pMDI; Fostair® 100/6 may be substituted for Clenil Modulite® (CFC-free beclometasone pMDI) at 1:2 dosing.
  • The Symbicort SMART® regimen (a combination inhaler as maintenance and reliever therapy) may be considered in adults who respond to LABAs but still have inadequate control of their asthma (step 3) [SIGN and BTS, 2009].
Basis for recommendation
  • Efficacy and adverse effects do not differ according to whether inhaled corticosteroids (ICS) and long-acting beta2-agonists (LABA) for maintenance therapy are given in combination or in separate inhalers [SIGN and BTS, 2009].
  • Potential benefits of giving ICS with LABA in a combination inhaler include:
    • Improved adherence to drug treatment, as fewer inhalations and inhaler devices are needed [Currie et al, 2005]. However, no direct evidence substantiates this idea.
    • Lower risk of serious asthma-related adverse effects, which can occur when a LABA inhaler is used on its own [MHRA, 2005].
  • The main disadvantage of the combination inhalers is that the doses of the component drugs cannot be individually titrated without changing the inhaler (e.g. during stepping-up or stepping-down of ICS). This is more easily done with separate inhalers.
  • There is evidence that using the combination inhaler, Symbicort® (budesonide and formoterol) as a maintenance and reliever therapy (Symbicort SMART®) is similarly effective to conventional methods at reducing exacerbation rates in people with moderate to severe asthma symptoms. It is recommended for use as Step 3 of the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009].

© NHS Institute for Innovation and Improvement