Is Pulmicort Needed When Patient Is Already on Systemic Steroids?

At our hospital, it’s become standard practice for doctors to order Pulmicort and Formoterol—or Symbicort—for nearly every patient admitted with asthma, COPD, pneumonia, or even many with a wheeze due to heart failure. While I don’t have an issue with these medications in the right context, the problem arises when a patient is already receiving systemic corticosteroids and Duoneb, and the doctor still adds a combination of controller medications on top. This feels excessive.

There are times when I’m administering Duoneb, Formoterol, and Pulmicort, all while the patient is on systemic steroids. Now, we know that Formoterol and Pulmicort are useful once a patient’s breathing is stabilized. They prevent flare-ups and help maintain control over asthma and COPD. 

But when you pair Duoneb, which already contains a beta agonist, with Formoterol, another beta agonist, that feels redundant. I’ve raised this issue before, but it seems like the over-ordering is becoming more frequent. Are there studies out there suggesting that combining a LABA, SABA, inhaled steroids, and systemic steroids actually works better than just one of those treatments? Or do our doctors simply need to be educated? 

I’m no doctor, but from a respiratory therapy standpoint, it seems unnecessary to give both systemic steroids and controller medications when the patient is already receiving effective treatment. Are there studies backing up this approach that I haven’t seen?

As respiratory therapists, we’re committed to providing the best care for our patients, even when that means administering lengthy treatments.  If they help fine. But if they are merely redundant, why are we giving patients medicine they don't need? 

But when these orders become routine and feel excessive, they create additional work that can contribute to burnout. The hours add up, and we end up stretching ourselves thin. It’s worth considering whether all of these orders are necessary or if there’s a more streamlined, effective approach. 

If you are a hospital administrator, and are looking at ways of cutting costs, this would be a great area to look into. 

So, what’s the solution here? Are we overmedicating, or is there evidence that justifies these repeated orders? It's something worth discussing among ourselves.