Opinions in Healthcare


Symbicort is a pressurized metered dose inhaler used in patients with moderate to severe asthma who are at least 6 years old, and for chronic obstructive pulmonary disorder (COPD) who are at least 12 years old. FDA approval was acquired for asthma in 2006 and for COPD in 2009. Symbicort includes a combination of budesonide, a corticosteroid, and formoterol fumarate dihydrate, a long-acting beta2 agonist.

Inhaled corticosteroids, like budesonide, are relatively safe and are considered first line in people who have moderate to severe asthma. The effect of glucocorticoids is that they bind to receptors and activate the response elements located in the nucleus of the cell to help reduce airway inflammation in the lungs. However, corticosteroid use does come with adverse effects like increasing risk of infections, hypertension, and may trigger the onset of diabetes, which patients need to be made aware of.

The long acting beta2 agonists, like formoterol, works with budesonide to help with the long-term control of the airways. The mechanism of formoterol is that it would relax the smooth muscles located in the airways by stimulating the beta2 receptors of the muscle and results in direct bronchodilation, reducing some symptoms. The use of formoterol alone is contraindicated in patients with asthma because formoterol may cause serious asthma-related breathing problems. There was a placebo-controlled study with another LABA, salmeterol, which increased hospitalizations and may also apply to formoterol. Using a combination of an inhaled corticosteroid and a long acting beta2 agonist, like Symbicort, is the preferred and safe combination indicated for asthma and COPD.

Symbicort, or budesonide/formoterol, comes in two different strengths, 80mcg/4.5mcg and 160mcg/4.5mcg. It is important that when prescribing Symbicort, they can only be given to patients who are not adequately controlled on other asthma controller medications or whose disease severity clearly warrants initiation of treatment with two maintenance therapies, as stated on the package insert. The usual dosage for the maintenance of asthma in patients who are >12 years old is; 2 inhalations twice daily of 80/4.5 or 160/4.5. The starting dose is based on the severity, and it may take 2 weeks to see the full effect. For the reliever therapy of asthma, the dosage is 1 to 2 inhalations as needed every 4 hours with a max of 12 inhalations/day including the maintenance therapy. The maintenance treatment of COPD is 2 inhalations of Symbicort 160/4.5 twice daily. Since Symbicort may increase the risk of oral thrush after every use, it is highly recommended that the patient should rinse the mouth and always spit out the water, never swallow.

In 2010, there was a critical appraisal released regarding the use of Symbicort for both maintenance and reliever therapy also known as SMART therapy. This is beneficial because instead of the patient having to deal with 2 different inhalers for different situations, which may cause confusion, the patient will only need Symbicort for both maintenance and reliever needs. The critical appraisal refers to a published double-blind trial proving that budesonide/formoterol therapy given as SMART therapy achieves better asthma control outcomes as compared to budesonide monotherapy.

Directions for preparing and using Symbicort from AstraZeneca:


  1. If you are using Symbicort for the first time, or haven’t used it in more than 7 days, shake Symbicort inhaler well for 5 seconds and then release a test spray.
  2. Shake it again for 5 seconds and release a second test spray.
  3. Now that it is ready to be used, remove the mouthpiece cover and check mouthpiece for any foreign objects.
  4. Breathe out fully, then place mouthpiece into your mouth and close your lips around it. Inhale deeply and slowly while pressing down on the top of the inhaler.
  5. Continue to breath in and hold breath for 10 seconds, or for as long as you can. Before you breathe out, release your finger from the top of the counter. Keep the inhaler upright and remove from mouth.
  6. For second puff, shake Symbicort inhaler again for 5 seconds and repeat steps 4 and 5.
  7. After use, make sure to close the mouthpiece cover and rinse your mouth with water. Make sure to spit out the water, never swallow.
  8. Make sure to never wash the inhaler, keep it dry. The mouthpiece should be cleaned every 7 days with a clean, dry cloth.

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Jennifer Litman, PharmD 2023 Candidate