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Bronchodilator Pregnancy: C — inhaled ICS considered safe in pregnancy; formoterol limited data

Budesonide / Formoterol

Brand names: Symbicort, DuoResp Spiromax, Fobumix

Adult dose

Dose: MART (asthma): 200/6mcg 1 puff BD maintenance + PRN (max 8 puffs/day). COPD: 400/12mcg BD
Route: Inhaled
Frequency: Twice daily (maintenance); PRN (reliever in MART strategy)
Max: 8 puffs/day (MART strategy Symbicort 200/6)
Budesonide/formoterol MART: single inhaler used for both maintenance and reliever. NICE recommends MART for moderate-severe asthma. COPD: 400/12 BD as add-on to LAMA.

Paediatric dose

Route: Inhaled
Frequency: Twice daily
Max: 4 puffs/day
Age bands
  • 72–216m: 100/6mcg 1–2 puffs BD (children ≥6 years)

Clinical pearls

  • MART strategy (maintenance and reliever therapy): single Symbicort 200/6 inhaler for both maintenance (1 puff BD) and symptom relief (additional puffs up to 8/day total). Reduces asthma attacks vs traditional fixed-dose regimen.
  • Always prescribe with spacer if patient struggles with inhaler technique — equally effective to nebulised in acute moderate asthma.
  • ICS component reduces eosinophilic airway inflammation. Formoterol is fast-acting LABA (onset 1–3 min vs salmeterol 15 min) — enabling reliever use.
  • Rinse mouth and gargle after every dose — oral candidiasis prevention.

Contraindications

  • Not for acute bronchospasm (formoterol onset ~3 min, use salbutamol if urgent)
  • Hypersensitivity to budesonide or formoterol

Side effects

  • Oral candidiasis (ICS component — use spacer, rinse mouth after each dose)
  • Dysphonia / hoarseness (ICS component)
  • Tachycardia, tremor (formoterol component — lower than salbutamol)
  • HPA axis suppression (high-dose ICS — rare at licensed doses)
  • Hypokalaemia at high doses

Interactions

  • Beta-blockers: antagonise bronchodilator effect
  • QT-prolonging drugs: additive risk with formoterol (dose-related)
  • CYP3A4 inhibitors (ketoconazole): modestly increase budesonide levels

Monitoring

  • Peak flow / FEV₁
  • symptom diary
  • exacerbation frequency
  • inhaler technique
  • oral cavity

Reference: BNFc; BTS/SIGN Asthma 2023; NICE NG80 Asthma; NICE BNF 84. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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