Note: If chronic obstructive pulmonary disease symptoms occur in the period between doses, an inhaled, short-acting beta-2 agonist (SABA) should be taken for immediate relief. For acute asthma exacerbations, budesonide/formoterol is preferred as a reliever; however, SABAs may be used. In patients presenting to primary care or acute care facility, SABAs are recommended for the acute management of exacerbations. For both Step 1 and Step 2 mild asthma, budesonide/formoterol may be used on an as-needed basis for control of asthma symptoms. Alternatively, a SABA as needed and daily use of low-dose inhaled glucocorticoid for Step 2 mild asthma may be used. Both options appear equally effective in reducing the frequency and severity of exacerbations in Step 2 mild asthma, but symptom control is somewhat better with daily inhaled glucocorticoids (Busse 2008; GINA 2020). The maximum dose is based on the formoterol component; to increase the dose of the inhaled glucocorticoid component, a separate inhaler with a higher budesonide dose per inhalation must be prescribed.
Asthma (controller/maintenance): Oral inhalation:
Starting dose is based on asthma severity.
Metered-dose inhaler:
Budesonide 80 mcg/formoterol 4.5 mcg: 2 inhalations once or twice daily (GINA 2020; Rabe 2006); if response is inadequate, may increase to higher dose combination after 1 to 2 weeks; maximum dose: Budesonide 160 mcg/formoterol 4.5 mcg: 2 inhalations twice daily.
Budesonide 160 mcg/formoterol 4.5 mcg: 2 inhalations twice daily (Patel 2013)
Dry powder inhaler [Canadian product]:
Moderate to severe asthma, inhaler used as maintenance therapy only: 
Symbicort 100 Turbuhaler, Symbicort 200 Turbuhaler: 1 to 2 inhalations once or twice daily until symptom control, then titrate to lowest effective dosage to maintain control. Maximum recommended maintenance dose: 4 inhalations/day. During periods of worsening asthma, the dose may temporarily be increased up to a maximum of 8 inhalations/day.
Symbicort Forte Turbuhaler: 1 inhalation once or twice daily until symptom control, then titrate to lowest effective dosage to maintain control. Maximum dose: 4 inhalations/day.
Moderate to severe asthma, maintenance therapy (as part of a combined maintenance/reliever protocol using the same inhaler): Symbicort 100 Turbuhaler or Symbicort 200 Turbuhaler: 1 to 2 inhalations twice daily or 2 inhalations once daily.
Asthma (reliever for acute exacerbations): Oral inhalation: Note: Based on asthma severity, this regimen can be reliever only or maintenance PLUS reliever.
Metered-dose inhaler (off-label use):
Budesonide 80 mcg/formoterol 4.5 mcg or budesonide 160 mcg/formoterol 4.5 mcg: 1 inhalation as needed; may repeat if no relief (Bateman 2018; Beasley 2019; GINA 2020; O’Byrne 2018; Patel 2013; Rabe 2006). Maximum: Up to 12 inhalations/day (GINA 2020; Rabe 2006).
Dry powder inhaler [Canadian products]:
Mild persistent asthma, inhaler used as reliever therapy only: Symbicort 200 Turbuhaler: 1 inhalation as needed; may repeat if no relief after a few minutes, up to 6 inhalations per single occasion. Maximum daily dose: 8 inhalations/day.
Moderate to severe asthma, reliever therapy (as part of a combined maintenance/reliever protocol using the same inhaler): Symbicort 100 Turbuhaler or Symbicort 200 Turbuhaler: 1 inhalation as needed, may repeat if no relief for up to 6 inhalations per single occasion (maximum: 8 inhalations/day including maintenance therapy).
Chronic obstructive pulmonary disease: Oral inhalation:
Budesonide 160 mcg/formoterol 4.5 mcg: Metered-dose inhaler: 2 inhalations twice daily (maximum: 2 inhalations twice daily).
Symbicort 200 Turbuhaler [Canadian product]: Dry powder inhaler: 2 inhalations twice daily (maximum: 2 inhalations twice daily).
Symbicort Forte Turbuhaler: [Canadian product]: Dry powder inhaler: 1 inhalation twice daily (maximum: 1 inhalation twice daily).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
 Detailed Budesonide/formoterol dosage information
Dosing: Geriatric
Refer to adult dosing.
Dosing: Pediatric
Asthma; maintenance treatment:
Symbicort: Metered-dose inhaler: Note: Do not administer more than 2 inhalations twice daily for maintenance treatment. The maximum maintenance dose is based on the formoterol component; to increase the dose of the inhaled glucocorticoid component, a separate inhaler with a higher budesonide dose per inhalation must be prescribed. If asthma symptoms occur in the period between doses, consider an inhaled, short-acting beta-2 agonist for immediate relief.
Children 5 to <12 years (limited data available for <6 years): Budesonide 80 mcg/formoterol 4.5 mcg: Oral inhalation: 2 inhalations twice daily (NAEPP 2007).
Children ≥12 years and Adolescents: Note: Initial dose prescribed should be based upon asthma severity and risk of exacerbation:
Budesonide 80 mcg/formoterol 4.5 mcg: 2 inhalations twice daily. If adequate response is not seen after 1 to 2 weeks, consider the higher dose combination.
Budesonide 160 mcg/formoterol 4.5 mcg: 2 inhalations twice daily.
Symbicort 100 Turbuhaler, Symbicort 200 Turbuhaler [Canadian products]: Children ≥12 years and Adolescents: Dry powder inhaler: Oral inhalation:
Maintenance therapy:
Initial: 1 to 2 inhalations twice daily until symptom control, then titrate to lowest effective dosage to maintain control.
Maintenance: 1 to 2 inhalations once or twice daily; may increase to 4 inhalations twice daily as temporary treatment in periods of worsening asthma; maximum daily dose: 8 inhalations/day.
Symbicort Maintenance and Reliever Therapy (Symbicort SMART) [Canadian product]:
Maintenance: 1 to 2 inhalations twice daily or 2 inhalations once daily.
Reliever therapy: 1 additional inhalation as needed, may repeat if no relief for up to 6 inhalations total; maximum daily dose: 8 inhalations/day.
Asthma, acute exacerbation: Note: Based on asthma severity, this regimen is for use when patient is on budesonide/formoterol as maintenance to allow for a single inhaler for both maintenance PLUS reliever; the benefit seems to be greatest with very early signs of exacerbation (GINA 2018). GINA guideline and study dosing is based on the dry powder inhaler product (Turbuhaler); dry powder inhaler not available in US. Limited data available:
Children 4 to 11 years: Budesonide 80 mcg/formoterol 4.5 mcg: Dry powder inhaler: Oral inhalation:
Maintenance: 1 inhalation once daily at bedtime (Bisgaard 2006; O'Byrne 2005).
Reliever therapy: 1 inhalation as needed; may repeat if no relief; maximum daily dose: 8 inhalations/day (including maintenance dose) (Bisgaard 2006; O'Byrne 2005).
Children ≥12 years and Adolescents: Budesonide 80 mcg/formoterol 4.5 mcg: Dry powder inhaler: Oral inhalation:
Maintenance: 1 inhalation twice daily or 2 inhalations once daily at bedtime (O'Byrne 2005; Rabe 2006).
Reliever therapy: 1 inhalation as needed; may repeat if no relief; maximum daily dose: 11 inhalations/day (including maintenance dose) (O'Byrne 2018; Rabe 2006).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Administration
Metered-dose inhaler: For oral inhalation only administered every morning and evening, approximately 12 hours apart. Prior to first use, inhaler must be primed by releasing 2 test sprays into the air; shake well for 5 seconds before each spray. Inhaler must be reprimed if not used for >7 days or if it has been dropped. Shake well for 5 seconds before each use. Discard inhaler after the labeled number of inhalations have been used or within 3 months after removal from foil pouch. Rinse mouth with water (spit out without swallowing) after each use. Do not wash inhaler with water; clean mouthpiece using a dry wipe every 7 days.
Delivery of dose: Instruct patient to place mouthpiece gently between teeth, closing lips around inhaler. Instruct patient to inhale deeply, press the top counter, and hold breath for up to 10 seconds or as long as they comfortably can. Remove mouthpiece from mouth prior to exhalation. Patient should not breathe out through the mouthpiece. Wait ≥30 seconds prior to the second inhalation dose.
Dry powder inhaler: Symbicort Turbuhaler [Canadian product]:
To “load” inhaler: Turn red grip on inhaler as far as it will move in one direction, then turn in opposite direction as far as it will go (inhaler is “loaded” with a dose, indicated by a “click”). Prior to first use, this procedure should be done twice, it does not need to be repeated with subsequent uses even when not used regularly.
Delivery of dose: Instruct patient to place mouthpiece gently between teeth, closing lips around inhaler. Instruct patient to inhale deeply and hold breath for as long as they comfortably can. Remove mouthpiece prior to exhalation. Patient should not breathe out through the mouthpiece. Dose is lost if patient drops, shakes, or exhales into inhaler after a dose has been loaded. After use of the inhaler, patient should rinse mouth/oropharynx with water and spit out rinse solution. Do not wash inhaler with water; clean mouthpiece using a dry wipe every 7 days.
