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#411 Bronchodilator with Benefits? Budesonide-formoterol rescue inhaler for asthma


CLINICAL QUESTION
QUESTION CLINIQUE
 What is the effectiveness of as-needed budesonide with beta-agonist as an asthma-reliever?

BOTTOM LINE
RÉSULTAT FINAL
 In adults, as-needed budesonide-formoterol likely reduces the proportion with severe exacerbations versus short-acting beta-agonists (SABA) (example in mild asthma: from ~12% with SABA to 5.6% at 1 year). It is likely comparable to maintenance inhaled corticosteroids (ICS). Evidence in children is limited.


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EVIDENCE
DONNÉES PROBANTES
  • Results statistically significant unless indicated.
  • Five systematic reviews of randomized controlled trials (RCTs).1-5 RCTs reported due to heterogeneous populations. Patients with uncontrolled mild asthma, and exacerbations defined as requiring oral steroids, unless indicated.
  • As-needed budesonide-beta agonist versus SABA.
    • 2554 adults, ~50% on maintenance ICS (stopped). Follow-up: 52 weeks.6
      • Proportion with ≥1 exacerbation: 5.6% (budesonide 200ug-formoterol) versus 12% (terbutaline), number needed to treat (NNT)=16.
      • Proportion with clinically meaningful improvement in asthma control: 42% versus 38% (terbutaline), NNT=22.
    • 2516 adults, ~25% on maintenance ICS (continued). Follow-up: 52 weeks:7
      • Proportion with first exacerbation: 3% (budesonide 160ug-salbutamol) versus 9.4% (salbutamol), NNT=25.
      • Asthma control: No difference.
    • 3132 adults, moderate-severe asthma, on maintenance ICS +/- long-acting beta-agonist (continued). Follow-up: 24 weeks.8
      • ≥1 exacerbation (emergency department visit): 4.8% (budesonide-320ug- salbutamol) versus 6.3% (salbutamol), not statistically different (PEER calculation). Annualized rate statistically significant.
      • Proportion with clinically meaningful improvement in asthma control: 67% versus 63% (salbutamol). NNT=25.
    • 360 children (mean age: 10). Follow-up: 52 weeks.9
      • ≥1 exacerbation: 9% (budesonide 100ug-formoterol) versus 16% (salbutamol), not statistically different.
      • Asthma control: No difference.
  • As-needed budesonide-formoterol versus maintenance ICS. Systematic review (4 RCTs, 8065 patients).1 Follow up: 52 weeks.
    • ≥1 exacerbation: No difference.
    • Asthma control (scale: 0-30, lower=fewer symptoms, minimally clinically important difference=0.5): 0.12 points worse with budesonide-formoterol.
    • Other systematic review: Similar.2
  • Adverse effects: Budesonide-formoterol.1
    • Versus SABA: 44% versus 49% (SABA), NNT=20.
    • Versus maintenance steroids: No difference.
  • Limitations: Most RCTs industry sponsored, few hospitalizations.
CONTEXT
CONTEXTE
  • Guidelines:10
    • ≥12years: Budesonide-formoterol 200/6mcg (single puff) preferred reliever.
    • Ongoing symptoms: Budesonide-formoterol maintenance (1 puff twice daily) and reliever. Maintenance: Up to 2 puffs twice daily.
  • Cost (90 days): $180 (budesonide-formoterol one puff/day), $25 (salbutamol four puffs/day), $90 (budesonide twice/day).11

Qanta Ayesha April 10, 2026

Good topic

Frank Foley April 13, 2026

more info to advise pts.

Patricia Barry April 13, 2026

Useful information; cost would probably be the deciding factor.

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Author(s)
Auteur(s)
  • Émélie Braschi MD PhD CCFP
  • Samantha S Moe PharmD ACPR

1. Crossingham I, Turner S, Ramakrishnan S, et al. Cochrane Database Syst Rev 2021;5: CD013518.

2. Tong X, Liu T, Li Z, et al Front Pharmacol 2021;12: 644629.

3. Hatter L, Brunce P, Braithwaite I, et al. ERJ Open Res 2021;7(1): 00701-2020.

4. Pornsuriyasak P, Sa-Nguansai S, Thadanipon K, et al. BMC Med 2025;23(1): 21.

5. Rayner DG, Ferri DM, Guyatt GH. JAMA 2025;333(2): 143-152.

6. O’Byrne PM, Mark Fitzgerald J, Bateman ED, et al. N Eng J Med. 2018;378: 1865-76.

7. LaForce C, Albers F, Danilewicz A, et al. N Engl J Med 2025;393(2): 113-124.

8. Papi A, Chipps B, Beasly R et al. N Engl J Med 2022;386: 2071-2083.

9. Hatter L, Holliday M, Oldfield K, et al. Lancet 2025;406: 1473-83.

10. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (2025 update). Available at: www.ginasthma.org. Accessed November 21, 2025.

11. Alberta College of Family Physicians. Pharmaceutic Pricing. Available at: https://pricingdoc.acfp.ca/pricing/. Accessed November 24, 2025.

Authors have no conflicts of interest to declare.