Symbicort - Why Use Adjustable Maintenance Dosing? - Maintain Optimal Asthma Control

1.	Why use adjustable dosing?

2.	Why can Symbicort be used in an adjustable manner?

3.	Is there clinical data to support Symbicort adjustable dosing?

1. Why use adjustable dosing?

Asthma is a highly variable disease. On top of the underlying chronic inflammation, episodes of acute inflammation occur, causing worsening of symptoms and exacerbations. This acute inflammation may also lead to an increased sensitivity to triggers and a worsening in airway hyperresponsiveness.

Maintaining optimal asthma control is challenging due to the fact that asthma is a variable disease

The variable nature of asthma means that fixed dosing results in periods of over treatment, in which there is unnecessary drug intake and periods of undertreatment, in which asthma control is poor.

With adjustable maintenance dosing approach with Symbicort, patients can increase the dose when having an asthma worsening, and when asthma is under control, patients can decrease the dose. Large studies have shown that Symbicort adjustable maintenance dosing reduces the number of exacerbations compared to fixed dosing, despite using less medication (Aalbers et al 2004, Ställberg et al 2003, Fitzgerald et al 2003 )

2. Why can Symbicort be used in an adjustable manner?

Due to its unique properties, Symbicort is the only inhaled corticosteroid/ß2-agonist combination that enables patients to adjust the dose according to the variability of their asthma using the same inhaler. The inhaled steroid budesonide and the ß2-agonist formoterol show a clear dose response (i.e. higher doses have a greater effect).

Budesonide
Dose-response studies have shown that even low doses of inhaled budesonide significantly improve lung function and reduce exacerbations. Higher doses of budesonide provide further dose-dependent improvements in lung function at doses up to 800µg twice daily (Busse et al, 1998).

Inhaled budesonide show a dose-response relationship (12-week data)

Read more about budesonide

Formoterol
Formoterol is a ß2-agonist with unique properties. It is both rapid-acting and long-lasting and shows a clear dose response in asthmatic patients (Ringdal N et al, 1998; Ketchell RI et al, 2002).

The dose of Symbicort (budesonide/formoterol) can be adjusted to provide optimal asthma control, due to the unique properties of the mono components. This can not be achieved with combination products containing the other long-acting ß2-agonist salmeterol, since increasing the dose has not been shown to increase bronchodilation, and an increase in steroid dose thus require a new inhaler.

Read more about formoterol

3. Is there clinical data to support Symbicort adjustable dosing?

Yes. Adjustable and fixed dosing have been compared in several studies.

A study of 995 asthmatic patients (Fitzgerald et al, 2003) with a need for an inhaled corticosteroid (ICS) and long-acting ß2-agonist (LABA), showed that Symbicort adjustable maintenance dosing resulted in fewer exacerbations at a lower overall drug load than Symbicort fixed dosing. This has been confirmed in another large study by Ställberg et al 2003.

Symbicort adjustable maintenance dosing improves exacerbation control more effectively than fixed-dose Symbicort, at an overall lower drug load

Symbicort adjustable maintenance dosing has also been compared to Seretide and Symbicort fixed dosing. A study involving 658 asthmatic patients with moderate to severe asthma (ICS dose of approximately 750 µg/day, >70% of the patients used long-acting b2-agonists), aged 12 years and above, compared Symbicort adjustable maintenance dosing with Symbicort fixed dosing and Seretide fixed dosing (Aalbers et al, 2004). Well-controlled asthma weeks*, exacerbations**, and as needed medication use were meassured in this study.

This study showed that:

- Well-controlled asthma weeks were similar between groups (primary variable)

- Patients on Symbicort adjustable maintenance dosing had a 40% lower rate of severe exacerbations, and lower use of reliever medication for symptom control, than patients on Seretide fixed dosing

- Symbicort adjustable maintenance dosing provides superior asthma control compared with Symbicort or Seretide fixed dosing

- This means that switching five patients from Seretide fixed dosing to Symbicort adjustable dosing would prevent one exacerbation per year

A 2- or 4 -fold temporary increase in maintenance dose, as is possible with Symbicort adjustable maintenance dosing, at an onset of worsening symptoms may prevent the development of an exacerbation.

Severe exacerbations and reliever use are lower with Symbicort adjustable maintenance dosing than with Seretide fixed dosing

*Definition: a week with no nighttime awakenings, no exacerbations, no change in asthma treatment due to adverse events and at least two of the following; asthma symptoms (score >1) on ≤2 days or ≤2 days of reliever use (maximum 4 occasions/week)

**Definition: Oral steroids ≥ 3 days, emergency visits or hospitalisation

Aalbers et al 2004
Fitzgerald et al

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