Source: Ducharme FM, Ni Chroinin M, Greenstone I, Lasserson TJ. Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma. Cochrane Database of Systematic Reviews 2010, Issue 4.

Efficacy Endpoints: Asthma attack prevention

Harm Endpoints: Increased asthma attacks, death

Narrative: Long-acting beta-agonists (LABAs) are designed to keep smooth muscle in the airways constantly relaxed, and they are the novel ingredient in the combination inhalers Advair® and Symbicort®. Unfortunately, these LABA medicines are proven to increase severe asthma attacks and asthma-related deaths and thus fell out of favor, most markedly after the 'SMART trial' published in 2006.1 Despite this, it is still felt by some that if the LABAs could be combined with steroids this might reduce any danger by providing steroid protection. This could theoretically allow the two medicines to work side-by-side to improve asthma control safely. While no one has suggested this as a first line therapy (inhaled steroids are first line), it has been suggested as a therapy when a first attempt to use inhaled steroids is inadequate.

Surprisingly, the authors were able to find only three trials in children to include in this review. The results of these trials did not suggest a benefit and actually hinted at a potential harm (increased asthma attacks requiring pill treatment).

Caveats: The strong evidence of harm that is associated with LABA medicines2, 3 is a reason to be very cautious in their use, and the pediatric data here offer no optimism. Children under 12 years of age were tested in these studies, and there is little to no review data for children under 4 years of age. Clearly, more trials of high quality are needed to evaluate whether this therapy is safe and effective as an option for children with asthma whose current regimen of inhaled steroids is inadequate.

Author: David Newman, MD

Published/Updated: May 16, 2011