Two-in-one inhalers slash asthma attacks among young children

Inhalers that combine providing immediate relief with a longer-term preventative effect are already recommended as the standard treatment for mild asthma among people aged 12 and above in the UK, US and some other countries. Now, a study of nearly 400 children in New Zealand has shown that these inhalers are more effective in younger children, too, nearly halving the number of asthma attacks.

It remains to be seen if national and international guidelines will be changed on the basis of these findings, says team member Andy Bush at Imperial College London, but the results are clear cut. “Certainly if it was my child with asthma, I would have them on the combination,” he says.

The standard treatment for mild asthma used to be inhalers containing salbutamol, also known as albuterol, which relaxes muscles in the airways for 3 or 4 hours after use. These “reliever” inhalers were used as needed.

If reliever inhalers alone were insufficient, people were given a second, separate inhaler containing a steroid that reduces the immune inflammation that causes asthma. It was thought that these “preventer” inhalers had to be used regularly to have a protective effect, says Bush. “The previous thing was you had to take your inhaled steroids twice daily or they will not work,” says Bush. “Now it’s clear that’s not necessarily the case.”

Large trials in teenagers and adults have shown that combination inhalers are more effective than this previous regime, even when used only as needed. The steroid in these combination inhalers is called budesonide and the reliever is formoterol, which works in the same way as salbutamol, but its effect lasts for 12 hours.

There has been concern about children using combination inhalers, in that the steroid component might affect their growth, but the latest study found no effect over the year of the trial. This involved 360 children randomly assigned to receive either budesonide-formoterol or salbutamol for on-demand symptom relief, with a step up to twice daily budesonide-formoterol or the steroid fluticasone, respectively, in the event of a severe asthma attack.

In other trials, the combination inhaler reduced the overall steroid intake, says Bush. That is because when people use them as needed, the dose of inhaled steroids they receive goes up and down in line with the severity of their symptoms. Reducing the number of attacks also lowers the number of people who need to be “stepped up” to twice daily use of the combination inhaler, or who require a course of steroid pills.