Albuterol and ICS at School

Now that Asthma guidelines recommend ICS use to treat asthma flare-ups, are we to advise parents to deliver both albuterol AND ICS to school for use to treat flare up at school?

Patients on combination inhalers like Dulera or Symbicort with a LABA with immediate relief may be used as a rescue inhaler.  the ICS being added at the same time particularly with allergic patients may be of extra benefit.  If they do not have a combination inhaler, it is still fine to give albuterol per standard recommendations for rescue.

That is a great question.  At this point, the use of combination agents as needed is not clearly recocmmended in kids under 18.  Using combination meds as needed with patients who have moderate persistent asthma is recommended down to age 12 but is not yet FDA, payer, or pharma approved so pateints will run out of meds faster than they will be covered by insurance.  As such, for now, I do not think this will be something recommended in schools.

We generally recommend if they are needing >8puffs of the combination inhaler/24 hours that they may need additional urgent/emergency care or at least to contact our office for instructions.

The recommendation for prn ICS/LABA you are referencing is from the 2019-2020 GINA guidelines and were made for adolescents and adults but not for younger children.  GINA updates so far have recommended this in mild (intermittent/persistent) asthma.  They are not recommending this use in younger children yet although they reference 1 study in 6-11yo African American children where it was helpful.  The max dose of formoterol they cite to be given in 24 hours is 72mcg so up to 8puffs/24 hours with Symbicort or 7puffs/24hours with Dulera.  The GINA guidelines are not consistently used here nearly as much as the NHLBI EPR-3 guidelines with their updates which do not give a similar recommendation at this time.   The use of ICS/LABA is being assessed currently by our guideline creators..  For now, I would follow Dr. Federico's advice and use typical SABA therapy as indicated.  If you have an adolescent with mild asthma and only a combination inhaler available with instructions from a treating MD for prn use - you do have GINA (global) but not American guidelines to support you and you would not want to exceed published maximum doses.  Probably best to play it safe at this point.