Chapter 10. Steroid-Sparing Strategies: Long-Acting Inhaled β₂-Agonists

Summary

In patients with moderate-to-severe asthma using moderate to high maintenance doses of inhaled corticosteroids (ICS), the addition of a long-acting β₂-agonist (LABA) has a steroid- sparing effect without jeopardizing the level of asthma control. When adding LABA, a consistent improvement in airway function and a reduction in symptoms and use of as-needed reliever medication has been found. The frequency of exacerbations appeared to be in the same range with a 50–60% lower ICS dose plus LABA compared with a higher dose of ICS alone. Applying an adjustable maintenance dose approach with budesonide/formoterol (BUD/FORM) (Symbicort^®) in clinical studies, has also shown the potential to reduce ICS dose 15–40% further versus fixed dose BUD/FORM, while still significantly lowering the risk of exacerbations. Similarly, significantly fewer exacerbations and less use of ICS medication (maintenance and as-needed) has been found when the SMART concept (Symbicort Maintenance And Reliever Therapy) has been compared to fixed-dose BUD/FORM. The proposed mechanisms for the advantageous and steroid sparing effect of ICS/LABA combination therapy include enhanced anti-inflammatory efficacy, improvement of steroid responsiveness in severe asthma by LABA, and increasing the dose and dosing frequency of the ICS at the right time in response to symptom worsening. This flexible dosing approach allows patients to achieve better asthma control and to reduce ICS doses as recommended by the Global Initiative for Asthma (GINA) guidelines.