‘The blue inhaler is a killer,’ says expert

asthma reliever puffer on its side

There is “mounting evidence” that it’s time to reduce reliance on short-acting beta2 agonists, say experts

A recent controlled trial published in the New England Journal of Medicine found treatment with short-acting beta2 agonists (SABA) alone was inferior to other approaches in terms of asthma attacks.

The same study showed as needed combined inhaled corticosteroids (ICS)/long-acting beta2 agonist (LABA) such as budesonide-formoterol was better than either SABA alone or low-dose ICS plus as-needed SABA at preventing severe attacks.

These results add to the “mounting evidence” that intermittent, as-needed budesonide-formoterol is more effective than conventional regimens, says Professor Andrew Bush, Department of Paediatric Respiratory Medicine at Royal Brompton Hospital, London.

Guidelines around the world suggest intermittent administration of SABA, progressing to ICS if SABA are being used more than an arbitrary number of times per week.

In Australia the guidelines suggest SABA as needed for adults with symptoms less than twice per month, or starting with regular ICS at a low dose plus SABA as needed for those with symptoms twice per month or more.

Professor Bush points out that overuse of SABA such as salbutamol is a risk factor for asthma deaths.

“The blue inhaler is a killer; numerous asthma deaths occur in those who are using SABA for relief in increasing quantities but not using ICS,” he writes in The Lancet Respiratory Medicine.

“Given the abundance of evidence for the as-needed budesonide-formoterol approach, what is the justification for retaining SABA alone, with their highly dubious safety profile, when we have something at least equally effective but without the safety concerns?

“If SABA on their own were not available, and these patients were thus compelled to use budesonide-formoterol for relief therapy, it seems highly likely that lives would be saved.”

While it may not be feasible to take SABA as a single agent off the market altogether, it should be considered “negligent” to prescribe it to adults, Professor Bush concludes—with exceptions for its use in non-atopic wheeze in children younger than five years, and chronic obstructive pulmonary disease.

Studies have reported that regular use of SABA is associated with increased airway hyper-responsiveness and poor asthma control, says Professor Mark Naunton, Head of Pharmacy at the University of Canberra.

“We know that SABA are overused – inappropriately – from our anecdotal interactions with patients and we also know this from population-based studies,” he tells AJP.

“We also know there is data showing underuse of inhaled corticosteroids, the backbone for most patients with asthma.”

Pharmacists should refer patients to their GP for review where appropriate, for example, those who have poor or worsening asthma control, he says.

“Pharmacists can ensure patients are well informed about their asthma and educate patients about personal action plans. These asthma action plans should be written, describing how patients may recognise a deterioration in their asthma and what steps they should take to re-establish control.

“Any education should be structured and encompass patient education monitoring, lifestyle and pharmacological management while addressing support needs,” says Professor Naunton.

“Pharmacists should also ensure patients know how to use their inhalers, as this is getting more complicated with a large number available on the market. Periodically, patients should have their inhaler technique reviewed.”

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