Which inhaler to start initially

This page goes beyond objective information and provides some suggestions to initial inhaler choice based on evidence and guidelines.

In general, it’s important to distinguish if one is treating asthma or chronic obstructive pulmonary disease (COPD). Asthma is a reactive inflammatory disease. In the past, albuterol PRN was used as initial therapy for asthma. However, recent studies show that compared to inhaled corticosteroid (ICS), albuterol as monotherapy has been associated with more exacerbations in mild asthma patients, possibly as it only masks symptoms and does not treat the underlying inflamation.^{1, 2} Thus, the use of ICS in asthma is now recommended. On the other hand, ICS is only recommended in COPD when there is an inflammatory component (e.g. elevated blood eosinophil count).³ The use of ICS is associated with elevated pneumonia risk in COPD patients.⁴

For Asthma

A good initial inhaler to use for asthma is Symbicort. It contains an ICS with a fast onset bronchodilator. For well controlled asthma, this can be used as needed, in place of albuterol PRN, and can be scheduled twice a day for more control. Symbicort has been recommended by GINA as first line treatment for mild asthma.⁵

For COPD

A good starting choice for COPD is a LABA-LAMA. Studies have shown a LABA-LAMA is superior to either monotherapy.⁶ At the same time, it does not come with the increased risk of pneumonia with added ICS.