Usual dosing of anti-inflammatory reliever (AIR) therapy

Drug name(s)	Preparation(s)	Dose
Inhaled corticosteroid and short-acting beta-agonist (ICS-SABA)
Albuterol-budesonide MDI^* (Brand name [United States]: Airsupra)	MDI: Albuterol 90 mcg and budesonide 80 mcg/actuation	Usual dose: 2 inhalations as needed up to a maximum of 12 inhalations per day Acute exacerbation at home: 2 inhalations; may repeat every 20 minutes for a total of 6 inhalations, then as directed^¶
ICS and formoterol combinations^Δ◊
Budesonide-formoterol MDI (Brand names [United States]: Symbicort, Breyna)	MDI: Budesonide 80 mcg and formoterol 4.5 mcg/actuation MDI: Budesonide 160 mcg and formoterol 4.5 mcg/actuation	Usual dose: 80 mcg/4.5 mcg: 1 to 2 inhalations as needed; some experts use 2 inhalations unless infrequent rescue inhaler use; maximum dose: 12 inhalations per day 160 mcg/4.5 mcg: 1 inhalation as needed; if symptoms persist after a few minutes, may repeat; maximum dose: 12 inhalations per day Acute exacerbation at home: 1 to 2 inhalations as needed; wait for a few minutes between doses and use second dose if symptoms persist; may repeat 1 to 2 inhalations every 20 minutes for up to 6 inhalations in 1 hour, then as directed^¶
Budesonide-formoterol DPI^§ (Brand name [Canada]: Symbicort Forte)	DPI: Budesonide 100 mcg and formoterol 6 mcg/actuation DPI: Budesonide 200 mcg and formoterol 6 mcg/actuation	Usual dose: 100 mcg/6 mcg: 1 to 2 inhalations as needed; some experts use 2 inhalations unless infrequent rescue inhaler use; maximum dose: 12 inhalations per day 200 mcg/6 mcg: 1 inhalation as needed; if symptoms persist after a few minutes, may repeat; maximum dose: 12 inhalations per day Acute exacerbation at home: 1 to 2 inhalations as needed; wait for a few minutes between doses and use second dose if symptoms persist; may repeat 1 to 2 inhalations every 20 minutes for up to 6 inhalations in 1 hour, then as directed^¶
Mometasone-formoterol MDI (Brand names: Dulera [United States], Zenhale [Canada])	MDI: Mometasone 100 mcg and formoterol 5 mcg/actuation MDI: Mometasone 200 mcg and formoterol 5 mcg/actuation	Usual dose: 1 inhalation as needed; if insufficient relief, may administer a second dose a few minutes later; maximum dose: 12 inhalations per day Acute exacerbation at home: 1 to 2 inhalations as needed; wait for a few minutes between doses and use second dose if symptoms persist; may repeat 1 to 2 inhalations every 20 minutes for up to 6 inhalations in 1 hour, then as directed^¶
Beclomethasone [beclometasone]-formoterol DPI^§ or MDI (Not available in United States or Canada, but available elsewhere [sample brand names: Formodual, Fostair, Foster])	DPI or MDI: Beclomethasone 100 mcg and formoterol 6 mcg/actuation DPI or MDI: Beclomethasone 200 mcg and formoterol 6 mcg/actuation	Usual dose: 1 inhalation as needed; if insufficient relief, may administer a second dose a few minutes later; maximum dose: 12 inhalations per day Acute exacerbation at home: 1 to 2 inhalations as needed; wait for a few minutes between doses and use second dose if symptoms persist; may repeat 1 to 2 inhalations every 20 minutes for up to 6 inhalations in 1 hour, then as directed^¶
Fluticasone propionate-formoterol MDI (Not available in United States or Canada, but available elsewhere [sample brand name: Flutiform])	MDI: Fluticasone 50 mcg and formoterol 5 mcg/actuation MDI: Fluticasone 125 mcg and formoterol 5 mcg/actuation MDI: Fluticasone 250 mcg and formoterol 5 mcg/actuation	Usual dose: 50 mcg/5 mcg: 1 to 2 inhalations as needed; some experts use 2 inhalations unless infrequent rescue inhaler use; maximum dose: 12 inhalations per day 125 mcg/5 mcg or 250 mcg/5 mcg: 1 inhalation as needed; if symptoms persist after a few minutes, may repeat; maximum dose: 12 inhalations per day Acute exacerbation at home: 1 to 2 inhalations as needed; wait for a few minutes between doses and use second dose if symptoms persist; may repeat 1 to 2 inhalations every 20 minutes for up to 6 inhalations in 1 hour, then as directed^¶

Dose per actuation is according to United States prescribing information, unless otherwise noted, which may differ from how strengths are described in other countries. Consult local product information. Use of AIR on a daily or more frequent basis over a four-week period suggests poor asthma control and should prompt provider evaluation.

AIR: anti-inflammatory reliever; DPI: dry powder inhaler; MDI: metered-dose inhaler.

* Not approved for use in patients <18 years old.

¶ Over the course of the first hour, the patient can determine (based on action plan or clinician guidance) whether to continue self-care at home or seek additional medical attention. When administering an MDI for acute asthma exacerbation, use of a valved holding chamber (for compatible MDIs) and careful attention to technique are recommended.

Δ Do not exceed the maximum number of inhalations per day due to the risk of toxicity from an excess dose of formoterol. Guidelines published by the Global Initiative for Asthma (GINA) recommend a maximum dose of 12 inhalations per day; however, in some countries, prescribing information includes a maximum dose of 8 inhalations per day.

◊ Evidence for AIR-only therapy is with budesonide-formoterol 200 mcg/6 mcg DPI inhalers. Other strengths or formulations may be used based on local product availability or as part of maintenance and reliever therapy (MART). Refer to related table for more detail on MART dosing.

§ DPIs contain lactose which may have small amounts of milk protein.

References:

National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Revised August 2007 (NIH publication no. 07-4051). Available at: https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma (Accessed November 3, 2023).
National Heart, Lung, and Blood Institute. 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. December 2020 (NIH publication no. 20-HL-8140). Available at: https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates (Accessed November 3, 2023).
Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention, 2023. Updated July 2023. Available at: https://ginasthma.org/2023-gina-main-report/ (Accessed November 8, 2023).
Symbicort Forte Turbuhaler. Health Canada-approved product monograph. Revised February 8, 2021. Health Canada. https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=72555 (Accessed November 8, 2023).

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Usual dosing of anti-inflammatory reliever (AIR) therapy