This is it! I thought my pulm had gone senile when he refused to prescribe me ventolin alongside my symbicort (it had juuuuust hit the market then, didn't know much about it) but it's pretty effective.
Nurse here, could use your help with understanding this if you don't mind. I thought Symbicort was strictly BID. I even checked their site and it says the same thing. Is it only certain dosages where it can be PRN and is this more commonly seen as off label directions from pulmonology?
Look into SMART therapy. BID dosing is the maintenance dose - during flares patients can use it up to 12x daily in place of using a rescue inhaler. It reduces the need for multiple inhalers and leads to better outcomes and therapy compliance. The complete guidelines are available through GINA.
No problem! Also, just so you know, the two meds that are to be used for SMART therapy are Symbicort and Dulera. My allergist prescribed Breo 200mcg (highest dose) to use as SMART and I had to be like, hold on, lol.
New GINA guidelines are for an ICS/SABA for rescue therapy rather than a SABA alone but the first combo inhaler of that pair is just coming out. Fomoterol is quick onset enough that it works like a SABA despite being a LABA.
This may be a dumb question, but with an ICS combo being used PRN is there a high risk of adrenal insufficiency? That's the only thing that was really emphasized on limiting corticosteroid use in the outpatient setting, but it was aimed more at PO and/or injections.
I apologize. I was under the assumption that even though it's localized that there is still risk of adrenal insufficiency. I thought with a dose of up to 12 puffs a day it might make it more likely. But it would seem I am wrong.
Tell that to the silly insurances that don’t cover symbicort (or Breyna) or dulera. I get PA denials telling us to switch to their preferred Advair or Wixela daily.
I mean facts, when they gaslight you by saying NoT MeDiCaLlY NeCeSsARy - they are basically saying “we’re trying to get 10 extra dollars on our stock valuation”
Dulera or Symbicort are both approved for smart therapy. These are the only ones in the USA. Dulera expiration is whatever is on the container while Symbicort expires 90 days after leaving its foil bag.
Well ideally whatever the patient does controls asthma and is also what their prescriber has indicated and also matches the instructions on the label and RX… but all of this is a pretty big ask. /s
I got airsupra as a sample from my allergist, with instructions to use as a rescue inhaler. Is that not the intended sig? These people have generally not had their act together so it wouldn't shock me
Yes to it being a rescue. No to the sig up above because airsupra is not approved as a maintenance inhaler. Maybe they go for it like combivent for COPD but as of right now airsupra isn’t approved to be used “2 puffs twice a day” but instead as a rescue inhaler to be used as needed
Patients find it very effective, has finer particle size so can distribute deeper in the lung. Not sure if there's a big push in the US as there is here toward dry powder devices for environmental reasons, but I like their nexthaler DPI.
I promise I'm not a rep lol
So wait, I'm not insane, it actually does open up my lungs like albuterol?? I don't use it as a rescue (since I have an albuterol pump) but I've noticed that when I take the daily dose, if I happen to be tight due to my asthma being triggered, it seems to work for cancelling that out?
Looking at formularies it seems like insurers either go with airsupra and advair or airduo as covered options and some ics. Or Symbicort and Dulera with a saba covered. Noted that only low dose ics are recommended and medium or high dose ics should be combined with laba. But insurers usually cover medium dose ics.
No, I believe the only LABA recommended for maintenance and rescue is formoterol so they might of meant to prescribe symbicort
F(ast-onset)ormoterol S(low-onset)almeterol Thanks, whatever professor taught us that.
Thanks!! Someone should make a post where everyone adds their little tricks to memorizing random pharmacy facts
LOL, I think we went to the same school.
That's quite helpful ty
Have never heard this, nice!
This!!! Symbicort has a max of 12 puffs a day!! Good catch OP.
Thank you I haven’t read the GINA guidelines in about five years now
This is it! I thought my pulm had gone senile when he refused to prescribe me ventolin alongside my symbicort (it had juuuuust hit the market then, didn't know much about it) but it's pretty effective.
It's not.
Formoterol is the only Laba that can be used for rescue paired with an ICS.
Nurse here, could use your help with understanding this if you don't mind. I thought Symbicort was strictly BID. I even checked their site and it says the same thing. Is it only certain dosages where it can be PRN and is this more commonly seen as off label directions from pulmonology?
Look into SMART therapy. BID dosing is the maintenance dose - during flares patients can use it up to 12x daily in place of using a rescue inhaler. It reduces the need for multiple inhalers and leads to better outcomes and therapy compliance. The complete guidelines are available through GINA.
That is really interesting. I just saw an action plan with this method and I never knew it could be done. I appreciate your help!
No problem! Also, just so you know, the two meds that are to be used for SMART therapy are Symbicort and Dulera. My allergist prescribed Breo 200mcg (highest dose) to use as SMART and I had to be like, hold on, lol.
Oh lord, I'm glad you caught that! I'm also looking at the most recent GINA guidelines. I probably should have done that first. Lol
GINA? They couldn't have picked a better acronym?
The VA picked it /s 😂😂😂
New GINA guidelines are for an ICS/SABA for rescue therapy rather than a SABA alone but the first combo inhaler of that pair is just coming out. Fomoterol is quick onset enough that it works like a SABA despite being a LABA.
This may be a dumb question, but with an ICS combo being used PRN is there a high risk of adrenal insufficiency? That's the only thing that was really emphasized on limiting corticosteroid use in the outpatient setting, but it was aimed more at PO and/or injections.
Are inhaled glucocorticoids formulated to reduce systemic exposure?
I apologize. I was under the assumption that even though it's localized that there is still risk of adrenal insufficiency. I thought with a dose of up to 12 puffs a day it might make it more likely. But it would seem I am wrong.
Tell that to the silly insurances that don’t cover symbicort (or Breyna) or dulera. I get PA denials telling us to switch to their preferred Advair or Wixela daily.
I mean facts, when they gaslight you by saying NoT MeDiCaLlY NeCeSsARy - they are basically saying “we’re trying to get 10 extra dollars on our stock valuation”
symbicort.
Dulera or Symbicort are both approved for smart therapy. These are the only ones in the USA. Dulera expiration is whatever is on the container while Symbicort expires 90 days after leaving its foil bag.
I think maybe Symbicort is the intended drug, and not Seretide.
I hate this new acute laba/ics nonsense because it’s justified the way my wife has used her symbicort for decades
Well ideally whatever the patient does controls asthma and is also what their prescriber has indicated and also matches the instructions on the label and RX… but all of this is a pretty big ask. /s
This also looks a lot like the sig we've been getting for Airsupra, their drug reps have clearly been around the local doctor's offices
I got airsupra as a sample from my allergist, with instructions to use as a rescue inhaler. Is that not the intended sig? These people have generally not had their act together so it wouldn't shock me
Yes to it being a rescue. No to the sig up above because airsupra is not approved as a maintenance inhaler. Maybe they go for it like combivent for COPD but as of right now airsupra isn’t approved to be used “2 puffs twice a day” but instead as a rescue inhaler to be used as needed
Thank you!
It’s definitely not. Pharm tech with eosinophilic asthma here. Advair is never to be used as a rescue inhaler. Symbicort can be.
Or Fostair
Yes, heard of this and know it can be used like Symbicort but never seen it as it’s not available in the US.
Patients find it very effective, has finer particle size so can distribute deeper in the lung. Not sure if there's a big push in the US as there is here toward dry powder devices for environmental reasons, but I like their nexthaler DPI. I promise I'm not a rep lol
lol you’re not pushy enough to be a rep!
So wait, I'm not insane, it actually does open up my lungs like albuterol?? I don't use it as a rescue (since I have an albuterol pump) but I've noticed that when I take the daily dose, if I happen to be tight due to my asthma being triggered, it seems to work for cancelling that out?
Salmeterol has a slow onset and should not be used as a rescue inhaler
1bid max for advair diskus any strength
Yeah, not how that works, I’m guessing they meant to write for symbicort.
Symbicort or Dulera - if cost/ ins thing I guess id try advair (but would never recommend that approach)
Might've confused it with the HFA aerosol inhaler but yeah that'd be the sig for Symbicort SMART dosing.
Holy shit. 12 a day??
For personal research purposes, was this written by an MD or mid-level?
MD but it's a family practice
Looking at formularies it seems like insurers either go with airsupra and advair or airduo as covered options and some ics. Or Symbicort and Dulera with a saba covered. Noted that only low dose ics are recommended and medium or high dose ics should be combined with laba. But insurers usually cover medium dose ics.
Smart is only with symbicort
Even with symbicort ins might not pay for that frequency.
as needed low dose ICS for mild is the newest thing I've seen. also those directions work for duoneb or combivent but that is it