The Breath of Science: Rationale for Inhaled Combination Therapy of LABA and ICS
With summer here, allergies and asthma may be rearing their heads. People with asthma may have increased symptoms, and inhaled corticosteroids (ICS) and long-acting B2 agonists (LABA) play a significant role in asthma maintenance.
ICS Inhalers
LABA Use
LABAs work to relax the smooth muscle in the airways by stimulating B2 adrenergic receptors. They also inhibit mast cell mediator release and may decrease sensory nerve activation. This may help reduce coughing, wheezing and shortness of breath. LABAs desensitize B2 receptors and ICS inhalers work to increase B2 receptors so the receptors are not fully saturated. This is important in case the patient has an exacerbation and needs immediate bronchodilation with a short acting B2 agonist (SABA). If all the B2 receptors are saturated, then the short-acting beta agonist may not work as effectively, and the risk of mortality greatly increases.
Best of Both
The different mechanisms of actions of these two classes of medication work in a complementary manner to better manage the various aspects of asthma. In order to assist patients with compliance, there are combination products which include: budesonide + formoterol (Symbicort), mometasone + formoterol (Dulera), fluticasone + salmeterol (Advair), and fluticasone + vilanterol (Breo).
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Pharmacist Action Steps:
- Monitor patients and use the “Rule of Twos” to assess if their asthma is controlled on their current treatment and assess inhaler technique.
- If patients are not well controlled, give them information about ICS/LABA combination inhalers and reach out to the prescriber to see if a change in therapy is appropriate.
- Cost may be a factor in medication adherence. If patients express concerns about the cost of their medication, consider counseling them on the available treatment alternatives.
- Counsel patients on the appropriate use of ICS/LABA inhalers, how to prime, use, and clean them.
- Counsel patients on the importance of using an ICS inhaler with their LABA inhaler or a combination product. Some patients may be hesitant to use a steroid inhaler so education can be given about inhaled corticosteroids and how they are different from oral steroids.
Written by Acacia MacCallum, PharmD Candidate with review by Rachael Zins, PharmD, AE-C
Heart Failure and Diabetes: What is New
Heart failure is a complication in both type 1 and type 2 diabetes, occurring in approximately 22% of people with diabetes.
Historically clinicians have focused on the common co-morbidities: neuropathy, nephropathy, retinopathy, and atherosclerotic cardiovascular disease (ASCVD).
Partially due to information revealed in the cardiovascular outcomes trials (CVOT) for new agents in the treatment of diabetes, heart failure has been identified as a unique cardiovascular risk factor independent of hypertension or ASCVD.
Results of population-based research, such as the Framingham Heart Study and others, have shown that having diabetes or prediabetes confers a two- to four-fold increase in the risk for heart failure in both men and women.
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American Diabetes Association Consensus Statement, June 2022
The American Diabetes Association (ADA) with representation from the American College of Cardiology (ACA) has released a consensus report, Heart Failure: An Underappreciated Complication of Diabetes. The purpose of this statement is to provide clear guidance for practitioners on the screening, diagnosis, and management of heart failure in people with type 1 or type 2 diabetes.
Stages of heart failure
- Stage A: Includes those with risk factors such as obesity, hypertension, dyslipidemia, or CKD who have not progressed to clinical heart failure and are asymptomatic. People with diabetes automatically fall into this category. In this stage prevention is possible with early intervention.
- Stage B (pre-HF): Includes those with structural heart abnormalities and or elevated natriuretic peptide or cardiac troponin levels. Many people with diabetes are in this category. People in Stage B are also asymptomatic.
- Stages C and D: Those with diagnosed symptomatic heart failure.
Recommended testing
People in Stage A and Stage B do not have symptoms of heart failure. Effective testing can identify at those at risk in the earliest stages and thus allow individualized treatment to prevent progression to overt heat failure. Biomarker testing with natriuretic peptides (BNP or NT-proBNP) or high sensitivity cardiac troponin is recommended on a yearly basis and more often if indicated.
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What can pharmacists do to prevent heart failure progression?
Heart failure in people with diabetes has been a subject of many studies and much conversation over the last decade. The conversation now turns to identifying at risk individuals early and intervening to prevent the onset of heart failure.
The 3-Minute extra Mile:
Take 3 minutes to:
- Speak to your diabetes patients, both type 1 and type 2, about getting tested for heart failure on an annual basis.
- Become familiar with asymptomatic stages of heart failure, Stages A and B, and work up some talking points to explain why prevention is so important.
- Look at the patient’s chart to see if they are taking medications that aggravate heart failure such as thiazolidinediones and sulfonylureas both of which cause weight gain and fluid retention. Insulin can cause weight gain and fluid retention, but its use may be unavoidable. Dipeptidyl peptidase 4 inhibitors (DPP-4 I) are not recommended.
- Help patients focus by talking to them about Life’s Essential 8
Next: pharmacologic interventions in Stage A and B
James Bennett BsPharm, CDCES, BCGP
Bozeman MT
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