Compound Bronchodilator Preparations

Compound bronchodilator preparations consist of combinations of bronchodilators and/or corticosteroids in one apparatus.

The recommendation is that patients requiring bronchodilators be given single-ingredient preparations so that doses can be up-titrated and individualised. However, combinations of bronchodilators may be used in cases where patients are stabilised on a certain dose. They may also help simplify regimens for certain patients e.g. patients with visual deficits and those with adherence issues. At present there is little evidence as to the benefit of compound preparations over single compound products.

However, there are mixed reactions amongst practitioners as to whether compound bronchodilator preparations should be used. Some feel that they lead to suboptimal therapy of asthma/COPD as up or down titration is difficult to perform. On the other hand they can improve patient adherence.

• Combivent®: salbutamol (100 mcg/metered inhalation) and ipratropium bromide (20 mcg/metered inhalation). Available as inhaler and nebuliser.
• Duovent®: fenoterol hydrobromide (1.25 mg/4 ml vial) and ipratropium bromide (500 mcg/4 ml vial) - only available as nebulised solution.
• Seretide® inhaler: e.g. the "50" inhaler (fluticasone 50 mcg and salmeterol 25 mcg per puff) and "500" Accuhaler® (fluticasone 500 mcg and salmeterol 50 mcg/blister).
• Symbicort® inhaler: budesonide and eformoterol available as 100/6 & 200/6 Turbohaler®.

The use of salbutamol and ipratropium combinations has increased compared to that of fenoterol combinations.¹

However, need to bear in mind that the regional drug and therapeutic centre did not find a difference between adherence and cost of steroid and long acting beta 2 agonist inhaler combinations.²

In asthma some trials have detected better morning peak flows with compound preparations rather than single inhalers alone.³ In COPD a cochrane database suggests that compound preparations may be associated with better quality of life but these effects need to be further researched.⁴

See each individual drug monographs. It should be noted that nebulised ipratropium bromide can be associated with acute angle glaucoma.

Patients should be monitored as for asthma and COPD, with regular peak flow measurements and lung function. If patients have exacerbations of their illness then it may be advisable to revert to single ingredient preparations. Once they are stabilised they could go back on compound bronchodilator preparations.