Few years ago, a child was seen at the local emergency department for shortness of breath and wheezing. He was diagnosed with reactive airway / mild asthma and was prescribed both salbutamol (Ventolin) and fluticasone (Flovent) inhalers. A month later, the father called the clinic, requesting that the family doctor to re-prescribe the salbutamol inhaler. He stated he didn’t need the fluticasone inhaler.

I don’t know what happened to this patient. But this is a common scenario where patients only take the reliever inhaler (salbutamol) as it can relieve any shortness of breath very quickly. Unfortunately, many are reluctant to take the controller inhaler (e.g. fluticasone) due to the potential side effects.

But I have also seen enough cases of children presenting with severe asthma at the hospital, requiring immediate intubation and admission to intensive care unit. Poor adherence to controller therapy (such as fluticasone inhaler) is one reason patient eventually develops severe asthma. I feel this is exactly why the new recommendation is ditching VENTOLIN as the treatment of choice for mild asthma.

Earlier this year, Global Initiative for Asthma (GINA) has released a set of strategy recommendations. Among them, a major change is with the management of mild asthma in adolescents and adults (Step 1 where patients with symptoms < twice a month and no exacerbation risk factors). Instead of prescribing a short acting beta agonist inhaler (SABA) as needed (e.g. Ventolin [salbutamol]), the recommended therapy is the use low dose inhaled corticosteroid (ICS)-formoterol.

In Canada, there are currently two commercial available inhalers that come in this combination:

  • Zenhale MDI which contains mometasone as the ICS and formoterol
  • Symbicort Turbuhaler which contains budesonide as the ICS and formoterol.

This shift in recommendation is based primarily from two recent studies as published in New England Journal of Medicine in 2018. (SYMGA 1 and SYGMA 2). The Canadian Thoracic Society has also released a Q&A document, addressing how the 2019 GINA strategy recommendations are applicable to the Canadian Context.

We finally realize that we need to rethink how we treat mild asthma?

Here are some of my thoughts so far:

  • There isn’t enough emphasis placed on understanding the importance in choosing the correct inhalation device based on age. For most pediatric patients before the age of 7, the ideal inhalation device is MDI (metered dose inhaler) plus a spacer (e.g AERO-chamber). This is because they either do not have good hand-to-mouth coordination or sufficient inspiratory flow to use the dry powdered inhaler (e.g. Symbicort Turbuhaler) [For more information on this topic, check out this article here]
    • Before the age of 7, Zenhale MDI is the inhaler of choice if clinician wants to prescribe ICS-formoterol.
    • For age 7 or older, Symbicort Turbuhaler can be used.
    • There are other dry-powdered inhalers containing ICS-LABA but it seems the evidence points to using an inhaler containing formoterol rather than other LABA.
    • I suspect other ICS-LABA should offer similar benefits but this is purely my opinion. It is interesting to note that formoterol has been demonstrated to offer quick symptoms relief, as if they were taking salbutamol (e.g. short acting beta-agonist). For this reason, a ICS-formoterol combination is recommended throughout the GINA document. For other ICS-LABA inhalers, we have the following available in Canada:
      • ADVAIR MDI Inhaler (Fluticasone propionate / salmeterol)
      • ADVAIR Diskus (Fluticasone propionate / salmeterol)
      • BREO ELLIPTA (Fluticasone furoate / vilanterol)
  • There will be financial or reimbursement challenges to prescribing ICS_formoterol inhalers for mild asthma.
    • Currently, a generic salbutamol Metered Dose inhaler is listed to cost $5 from the Ontario Drug Benefits Formulary.
    • Zenhale Metered Dose Inhaler 100mcg/5mcg costs $95/ unit. Zenhale Metered Dose Inhaler 200mcg/5mcg costs $115.13/unit.
    • Symbicort Turbuhaler 100mcg/6mcg costs $69.54/ unit. Symbicort Turbuhaler 200mcg/6mcg costs $90.35 / unit.
  • In Ontario, the Ontario Drug Benefits Program requires Limited Use code for prescribing Zenhale or Symbicort.
    • The Code is 330 – which means these inhalers should be currently prescribed for the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms. (e.g. not for mild asthma)
    • If we want to encourage prescribers and patients to follow this latest guideline, we need to address the high cost issues with these inhalers as well as revising the reimbursement coverage criteria to be consistent with the GINA 2019 recommendations.

What do you think of the latest recommendations from Global Initiative for Asthma (GINA) 2019? Thanks for reading!