What They Are:
Combination asthma inhalers are controller medicines that combine an inhaled steroid with a long-acting beta agonist in the same device. Studies have shown that combination inhalers are a more effective asthma treatment approach than taking each medication separately. Experts are not sure why, but think it may be due to the added convenience and accuracy of only having to use one inhaler.How They Work:
Since combination inhalers consist of two different types of asthma medicine, they work in two different ways:- First, the inhaled steroid in the combination asthma inhaler has a broad action on airway inflammation. It reduces inflammation by blocking immune cells from making substances called cytokines. Inhaled steroids also cut down on the number of airway eosinophils , cells that are active in allergic responses. These actions lessen airway swelling and mucus production. In addition, steroids decrease the irritability of your airways, so they're less likely to overreact in response to asthma triggers.
- Second, the long-acting beta agonist (LABA for short) is a bronchodilator. That means it helps the smooth muscle in your airways to relax, thus reducing chest tightness and making it easier to breathe. LABA's effects can last as long as 12 hours after a single dose, but the usual length of action tends to be closer to 5 hours.
The Effects:
Combination asthma inhalers also offer the benefits of both types of asthma medicines. The inhaled steroid prevents asthma symptoms from occurring as frequently. If they do occur, they are less severe. LABAs relax the airways at the same time, offering further relief from asthma symptoms.Using the LABA with the steroid allows the dose of the inhaled steroid to be lower in many cases. Since long-term use of high doses of steroids does present some risk, using less is a good thing.
Examples:
Currently, there are only 2 combination asthma inhalers available in the U.S. They are:- Advair, which contains a steroid, Fluticasone (Flovent) and a LABA, Salmeterol (Serevent)
- Symbicort, which contains a steroid, Budesonide (Pulmicort) and a LABA, Formoterol (Foradil)
Combination inhalers can be paired together in either metered dose inhalers or in a dry powder inhaler.
Other Important Facts:
Many people worry about the risks and side effects of taking steroids. However, the kind of steroids used in asthma inhalers are similar to natural substances found in our own bodies and are quite safe. Though there is some risk of mild side effects, experts stress that the benefits of using an inhaled steroid far outweigh any risks.LABAs, however, currently carry what are known as "black box warnings" from the FDA. So, of course, this warning extends to any combination asthma inhalers that contain an LABA as well. This warning was issued because a few studies showed that the LABA, salmeterol, slightly increased the risk of breathing problems and death in people with asthma, especially African-Americans. However, the studies originally looked only at people taking salmeterol by itself. When they took a closer look, they found that there was no increased risk when salmeterol was taken with an inhaled steroid like Flovent (as it is in Advair).Like most asthma medicines, combination inhalers are usually well-tolerated. However, some of the more common side effects include:- upper respiratory infections
- lower bone density
- eye problems including glaucoma and cataracts
- slowed growth in children
- increased blood pressure
- fast and irregular heartbeat
- allergic reactions including, rash, hives, and swelling of the face, mouth, and tongue
- headache
- tremor
- nervousness
- throat irritation
In general, side effects lessen in frequency and intensity over time. However, if any of these side effects persist or become bothersome, be sure to talk with your doctor.
In Summary:
Combination asthma inhalers can be an important component of an asthma management plan for people who are not able to achieve asthma control with an inhaled steroid alone. Of course, the doctor and patient should carefully weigh the possible risks against the potential benefits when deciding to use a combination inhaler. And, as long as you and your doctor watch carefully for any worsening of asthma symptoms or unexpected effects, LABAs should be safe to use.Sources:
"Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma." NHLBI Guidelines for the Diagnosis and Treatment of Asthma. 28 Aug 2007. National Heart Lung and Blood Institute. 18 Dec. 2007 <http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf>
FDA Patient information sheet. <http://www.fda.gov/cder/drug/InfoSheets/patient/FluticasonePIS.htm>
Aaronson DW. The "Black Box" Warning and Allergy Drugs. J Allergy Clin Immunol. 2006;117:40-4.
Nelson HS, Weiss ST, Bleeker ER, et al. The Salmeterol Multicenter Asthma Research Trial. Chest. 2006;129:15-26.
Nelson HS. Long-Acting Beta-Agonists in Adult Asthma: Evidence that these Drugs are Safe. Primary Respiratory Care Journal. 2006;15:271-77.
