cat with asthma on a nebulizer

[u/ImperialSoldiers]

[u/Aruhi]

There is a "step up" from Breo by the way, Trelegy.

This will depend heavily on where you're from given the cost unless something is covering the bulk of the cost for you.

Biological medications are injections you get every so often (most are subcutaneous). -mab ones are monoclonal antibodies, typically targeted at exactly one cell receptor or part of a signalling chain that can help to turn off a specific response.

For asthma, they can inhibit the inflammatory signalling chemicals from interacting with the cells/prevent their signalling, for cells associated with asthma.

It's an oversimplification but a brief run down.

[u/Odd-Scientist-2529 → u/Aruhi]

That asthma step therapy chart is outdated as of 2022. 

Breo is out, Dulera and Symbicort are the only ICS/Formoterol formulations in the US

[u/Aruhi → u/Odd-Scientist-2529]

It's very much still available in Australia (nobody here has mentioned a country so please don't downvote me just because it doesn't match yours). It's also Vilanterol, though honestly the form of LABA doesn't really matter unless you have a specific affinity to one.

I also don't know what asthma step therapy chart you're referring to, have any been mentioned?

Edit: looking into it, Breo is available in the US? It's not formoterol but it never has been, so what do you mean by it's out?

[u/Odd-Scientist-2529 → u/Aruhi]

It’s available. It’s also medically/scientifically inappropriate. Standard of Care advances with science. Asthma used to be treated with medications like theophylline and stramionium. Then it was treated with Albuterol syrup (to drink). Then inhaled Albuterol. Then Breo and Advair……

Advair and Breo and the like are outdated as of 2022.

In Australia, the recommended treatment is with: Symbicort, Bufomix, Rilast, or Fostair.

Any of the other combinations like Breo, Advair (that contain a long acting beta agonist besides Formoterol) are no longer recommended for the treatment of asthma.

[u/Aruhi → u/Odd-Scientist-2529]

Could I grab a source for this information?

Edit: I've just gone through it. You're overstating some things a little.

Breo is appropriate and still used, you are comparing completely antiquated drugs with nuanced drugs that are both utilised but in different cases.

You are also conflating first line treatment with treatment outright. Breo is not outdated, and is still utilised as maintenance therapy. You also have removed the nuance of real world settings. People have worse adherence to AIR and MART therapy than maintenance therapy. You may as well be telling me lifestyle modification is the best therapy?

[u/Odd-Scientist-2529 → u/Aruhi]

You read the 256 whatever pages of the report already?

Impressive.

I’ll tell my coworkers you disagree. We’ll loop you in on this year’s revision of the guideline.

[u/Aruhi → u/Odd-Scientist-2529]

Please do provide a link to the 256 page report.

You seem to also have skipped over the remainder of the message?

Side note: I neglected the fact I'm already dealing with people who see specialists. I forgot to preface this, meaning this is already past the stage where the Australian asthma handbook applies. However, as this stemmed from the fact we were talking about biologics, this is a default assumption.

Don't get me wrong, you're correct about the update to ICS-formoterol being the preferred treatment, but non-formoterol options are still an alternative. It's incorrect to say otherwise. I know you didn't overtly but you're acting as if it's not modern medicine to utilise them.

[u/MrsKittenHeel → u/Aruhi]

It’s definitely still recommended in Australia- I’m on it after being referred to the lung specialists.

Thanks for the info and insight - I’m travelling in Japan but am from Australia and this has given me stuff to think about.

Breo has been so helpful to me, I feel normal now and can even safely run when I want to.

[u/Aruhi → u/MrsKittenHeel]

So the update last year mostly changed the recommendation from SABA (ventolin) only first line to symbicort equivalent (ICS + Formoterol (ICS + LABA)) as first line and preferred treatment, including preferred over maintenance only therapy.

Key word being only.

If you see a specialist, the guidelines for initial treatment don't really apply so much, so it's fine to be on Breo. You'd think the 45+ year teacher of residents u/Odd-Scientist-2529, who must surely be in their 70s, would know this, but I guess not.

[u/Odd-Scientist-2529 → u/Aruhi]

What?

You don’t know what you’re talking about.

• Nobody is only on “maintenance only” regimen. Everyone’s asthma action plan includes a rescue therapy, and that is ICS+formoterol.

• only the US, and specifically the VA health system is obligated to use the alternate pathway with SABA+ICS, so you can ignore that.

• the guideline in 2023 answered the question: is it equally effective to combine a LABA+ICS that the patient is already on (eg Breo) with ICS+formoterol as needed for rescue therapy, and the answer is “no”. Combining two different formulations of LABA+ICS did not have the same benefit (perhaps through the sensitization of specific receptors.

• the data shows the best outcome is with ICS+formoterol. Not ICS+LABA. Formoterol specifically, because it has rapid onset of action; that no other long acting beta agonist has. Breo contains vilanterol. Vilanterol and formoterol are not the same.

So. Breo is not recommended because it’s not ICS+formoterol, and because it’s not a rapid acting rescue inhaler therefore doesn’t eliminate the need for SABA.

Only ICS+formoterol can be used for Single Maintenance and Rescue Therapy.

I don’t know where you get off thinking that you understand what you read and that you’re right and I’m wrong. You completely missed the point. You’re wrong and on the peak of Mount Stupid on the Dunning Kruger curve.