A frequent question from those who are taking more than one respiratory medication to manage their chronic lung disease is, “In which order should I take my inhalers?” This is an important question to ask as it can determine the effectiveness of your therapy.

Knowing your medications will help you to better manage your condition as well as give you some pertinent questions to ask your physician.

The first thing you need to know is the class of each inhaled medication you are taking. For the sake of simplicity, I’ll list the classes and give a few examples of each while also giving the sequence of use.

TAKE THESE FIRST: Long-Acting Beta Agonist (alone or combination) (LABA)-Bronchodilator

  • Advair (salmeterol & fluticasone)
  • AirDuo (salmeterol & fluticasone)
  • Breo (vilanterol & fluticasone)
  • Dulera (mometasone & formoterol)
  • Serevent (salmeterol)
  • Streverdi (olodaterol)
  • Symbicort (formoterol & budesonide)

TAKE THESE SECOND: Long-Acting Anticholinergic (LAMA)-Bronchodilator

  • Incruse (umeclidinium)
  • Spiriva (tiotropium bromide)
  • Tudorza (aclidinium bromide)

TAKE THESE LAST: Steroid 

  • Arnuity (fluticasone)
  • Flovent (fluticasone)
  • Pulmicort (budesonide)
  • QVAR (beclomethasone)

 Other inhaled medications can also be added to the equation:

  • Short-Acting Beta-Agonists (SABA)-Bronchodilator: Albuterol (Ventolin, Proventil, ProAir, Xopenex)
  • Short-Acting Muscarinic Antagonist (SAMA)-Bronchodilator: Ipratropium Bromide (Atrovent)
  • Combination Short-Acting Bronchodilators- SAMA and LAMA: Duoneb, Combivent

IMPORTANT NOTES TO CONSIDER:

  1. If you are also taking a short acting beta-agonist on a regular basis (albuterol) in addition to your daily controlling medications, take it after you have taken your long-acting beta-agonist and never less than 2 hours before. For example, if you regularly take albuterol first thing in the morning, wait at least 2 hours to take your Advair, Dulera or Breo. Refer to the list above for others. The reason for this is that when you take your short-acting medication first it saturates the B2 receptors, leaving no room for the 12-hour medication (LABA) to bind if taken shortly afterwards since the SABA is already there. In a few breaths, LABA is gone and it never had a chance to work. In 4-6 hours the “rescue med” will wear off and shortness of breath will return, leaving you wondering if the medicines are not working. This same rule holds true for the short-acting and long-acting muscarinic antagonist (SAMA and LAMA). Examples of these are atrovent (SAMA) and Spiriva (LAMA).
  2. Short-acting bronchodilators should only be taken when you have symptoms or as a “rescue” unless otherwise directed by your physician. This is especially true if you are already taking long-acting or “controller” medications. You should not be taking 2 medications from the same class so taking a short-acting medication and long-acting medication from the same class is not appropriate and, as mentioned above, may do more harm than good.
  3. While in the hospital you may be receiving more medication than is ordered upon discharge. This is common and appropriate. When you’re in the doctor’s office or the hospital due to an exacerbation, you will need to take more medication until you can get back to normal breathing status. If you are taking controlling medications at home and are ordered to take albuterol as well a few times every day upon discharge, make sure to ask your doctor when you can start to cut back on it.

Remember, knowledge is power. If you still are having trouble determining how to treat your lung disease, contact your doctor for clarification.

  Ref:   www.emphysema.net/inhaler_sequence.asp

          https://www.copdfoundation.org/COPD360social/Community/Questions-and-Answers/What-is-the-preferred-order-of-taking-your-daily-inhaled-medications-Does-it-matter.aspx