Still Using the Same Rescue Inhaler for Asthma? You Might Have Better Options

Asthma treatment has evolved in recent years, and for many people, especially those who rely heavily on their rescue inhaler, there may be a more effective—and simpler—approach.

Whereas many people with asthma relied on both a daily controller inhaler containing corticosteroids, plus an as-needed rescue inhaler, Yale Medicine pulmonologists now say that combination therapies can be effective for both prevention and quick relief.

Asthma is a chronic lung disease in which the airways are inflamed and prone to narrowing. Symptoms can include wheezing, coughing, chest tightness, and shortness of breath. For decades, management typically involved two inhalers: a daily inhaled corticosteroid to prevent symptoms and a separate “rescue” inhaler containing albuterol, a medication that quickly relaxes airway muscles during flareups.

Today, many experts recommend a single inhaler that combines both prevention and fast relief. Despite strong evidence supporting this approach, it is not yet widely used, says Sandra Zaeh, MD, MS, a Yale Medicine pulmonologist who specializes in asthma.

“There’s often a disconnect between the scientific evidence that we have and the practice that we do,” Dr. Zaeh says. “There are various barriers that come up in the actual implementation of guidelines. For example, physicians may not be aware of updated guidelines, there may be insurance hurdles, or patients may prefer their old way of managing their asthma.”

Dr. Zaeh and fellow Yale Medicine pulmonologist and asthma specialist Lauren Cohn, MD, encourage people with asthma—especially those whose symptoms are not well controlled under current treatment—to talk to their provider about new treatment approaches.

“Some patients may not hear about these therapies unless they ask,” Dr. Cohn says. “For people who aren’t on a daily inhaled corticosteroid for their asthma, we encourage them to talk to their providers about these options.”

Major updates from the Global Initiative for Asthma (GINA), an international expert group that issues annual asthma guidance, marked the most significant shift in asthma treatment in more than 30 years.

Previously, people with mild asthma were often advised to use albuterol alone as needed. But albuterol treats airway tightening (bronchospasm) without addressing the underlying problem in asthma: airway inflammation.

Even when someone feels fine, low-level inflammation is often still present. The newer approach emphasizes treating inflammation whenever symptoms occur.

For people who have mild asthma, GINA now recommends what’s called anti-inflammatory reliever (AIR) therapy. This approach uses a single inhaler that combines an inhaled corticosteroid (such as budesonide) to reduce inflammation and formoterol, a fast-acting bronchodilator that opens the airways.

The other option is to use an inhaled corticosteroid combined with albuterol as needed for symptoms. For example, budesonide-albuterol, sold under the brand name AirSupra, is one that many asthma physicians now prescribe, Dr. Zaeh says.

Instead of reaching for albuterol alone when symptoms start, people can use these types of combination inhalers as needed. That way, they’re treating both the immediate airway tightening and the underlying inflammation at the same time.

It’s a subtle shift—but an important one.

For people with moderate to severe asthma, guidelines recommend a related strategy called maintenance and reliever therapy (MART). With MART, the same combination inhaler is used every day, to control inflammation, and as needed, when symptoms flare.

This replaces the traditional two-inhaler system with one device for both purposes.

Common brand-name inhalers used in MART approaches include Symbicort, Breyna, and Dulera. These contain a corticosteroid plus formoterol.

Large clinical trials conducted over more than a decade have shown that this combined strategy reduces severe asthma attacks, emergency department visits, and the need for oral steroids compared with using just albuterol as a rescue inhaler.

Clinicians may recommend an alternate strategy for moderate to severe asthma patients who choose not to use MART; this involves staying on their traditional asthma controller while switching to AirSupra as their reliever.

When asthma symptoms act up, it’s called a “flare or exacerbation,” notes Dr. Cohn.

“We’ve known for years that inflammation underlies asthma. Even when people with asthma are not flaring, they have airway inflammation,” she says. “Of course, it gets worse when they flare and they have bronchospasm, but the point is that the inflammation never goes away. With these new therapy approaches, the inhaled corticosteroid addresses the inflammation and keeps the airways calm, while the formoterol works really fast and keeps the airways open.”

Reducing inflammation early can also help prevent the need for oral steroids like prednisone. That’s important because repeated courses of prednisone are associated with long-term risks such as osteoporosis, diabetes, and high blood pressure.

“It’s not uncommon for patients to need prednisone a couple of times in, say, five years when they get very sick from flu, for example,” Dr. Cohn says. “But if they are taking an inhaled corticosteroid as soon as symptoms start, they may be able to avoid going to the hospital and avoid taking steroids.”

Not necessarily. Albuterol remains an effective medication and continues to play a role in asthma care. If your asthma is well controlled, your current plan may still be appropriate.

“If someone has grown up using albuterol as their reliever and it works for them, they might be less eager to make a transition to something different. And if their asthma is really well controlled, there’s less of a push to make that change,” Dr. Zaeh says. “But with these updated asthma management guidelines, we should consider if a change is appropriate.”

It may be worth asking your provider whether AIR or MART is right for you if you:

• Use your rescue inhaler frequently
• Have asthma flareups, even if just one a year
• Require repeated courses of oral steroids
• Visit urgent care or the emergency department for asthma treatment
• Have difficulty taking your prescribed inhaled corticosteroid daily

There isn’t a single reason. Some clinicians follow GINA guidelines, while others rely on recommendations from the National Asthma Education and Prevention Program (NAEPP), part of the National Institutes of Health. Although NAEPP has incorporated aspects of the newer approach, practice patterns vary.

Insurance coverage can also influence which inhalers are prescribed. And for patients who feel stable on their current regimen, change may not feel urgent, Dr. Zaeh says.

Still, asthma is a chronic condition, and treatment plans can—and often should—evolve over time.

If your asthma feels well controlled, continue reviewing your treatment plan regularly with your clinician.

But if you rely heavily on your rescue inhaler or are experiencing frequent flareups, it may be worth starting a conversation about whether a combination inhaler could reduce inflammation more consistently and lower your risk of severe attacks, Dr. Cohn adds.

A brief discussion with your provider can help determine the safest and most effective strategy for you—and whether newer approaches might make asthma management simpler and more effective.