‘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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  1. Jarrod McMaugh

    There is no doubt that the use of SABA without other treatments is a recipe for disaster, but knowing how human nature/behaviour affects health care utilisation, I worry that labeling SABAs as “dangerous” gives the wrong message.

    Treatment of asthma with nothing more than SABA is dangerous.
    Use of SABA should not be characterised as dangerous.

    The message that will get through to people who are not treating asthma effectively will be “blue puffers are dangerous, don’t use them” – the rest of the message will be missed, and there will be a portion of people who will not utilise any treatment at all. This is clearly not the outcome that should be sought.

    There has been discussions recently about replacing the schedule-3 listing of SABA low-dose ICS/eformoterol combinations as a schedule 3 option (I believe Debbie Rigby mentioned this recently, but apologies if I’m remembering this incorrectly).

    This would be a good option, but a move like this needs to be in place before health messaging demonises the use of SABA alone.

    This article also correctly notes that people with COPD have a need for SABA without ICS (ICS is associated with increased risk of pneumonia in people with COPD, and should be used only during relapsing symptoms as part of a COPDX plan).

    Overall, moving away from SABA alone – and availability as a schedule 3 – may be appropriate, but we need regulatory changes in access to low dose ICS/eformoterol before we use language that may scare people with asthma into taking the wrong actions….

    Lastly, can I implore pharmacists to please find a way to have discussions about SABA use when it is sold OTC. At every instance that SABA is supplied, you need to discuss at least one thing – anything relevant – to get through to people. YOU need to develop the comfort in raising these conversations. YOU need the practice points to discuss (inhaler technique, asthma plan, views on “severity”) that open a person up from saying ‘yeah I know this already’

    Asthma is a chronic, progressive condition that kills people. We need to be active EVERY TIME we supply SABA to ensure that the most important person (the person you are speaking to at that time) gets the best treatment/advice/referral needed to improve their life.

    • Debbie Rigby

      Symbicort® Turbuhaler® 200/6; Symbicort® Rapihaler® 100/3 as an Authority Required (STREAMLINED) listing for use as first-line treatment of mild asthma is included on the July 2019 PBAC agenda – see http://www.pbs.gov.au/info/industry/listing/elements/pbac-meetings/agenda/july-2019-pbac-meeting; so changes in the use of ICS/fast-acting LABA prn vs SABA prn for adults with mild asthma may occur soon.

      I agree with Jarrod on the critical need for pharmacists to talk with patients and parents of children with asthma on appropriate use of SABAs and check device technique at every opportunity. Need to find different ways of starting the conversation, apart from “Have you had this before?”

  2. william hau kin so

    The same argument can be applied to any pain killers. The over reliance of any thing by it’s very action is dangerous.
    Three litre of water a day is essential to health. But… try drinking thirty?

    Isn’t the first thing we ask patient is how often you use your Ventolin?

    • Debbie Rigby

      Sadly no. “Have you had this before?” is often the first thing a pharmacist or pharmacy assistant asks.

  3. Debbie Rigby

    A reminder of my article in Australian Pharmacist on overuse of relievers – https://www.australianpharmacist.com.au/too-much-asthma-reliever/

  4. Kingsley Coulthard

    Perhaps one of the key issues is how does the pharmacist inform the GP of patients who are over-using salbutamol? In my experience as a locum not all pharmacies record in the patient’s dispensing history such supply. Perhaps such supply should be S3 recordable? IF My Health record works appropriately then in theory the GP may have access to such over use?

    • PeterC

      Kingsley, Debbie, all S3s should be S3R in all States and no arguments entered into. Single ingredient ICSs should to be S3R as well, if we’re to be able to do our jobs properly. As a pharmacist you can do all the ‘right things’ mentioned here and still be on a hiding to nothing because you’re being denied the basic tools to do the job yourself and also indirectly copping the blame for prescribers who cannot/will not stop prescribing LABA combos, no matter how much you intervene, and who don’t have the right business models to pick up and deal with the at-risk patients in the first place. It is – once again – a bit like letting ourselves be challenged to a race around the block while having our legs tied together. Will things change? Of course not. Scheduling etc. is not so much about public benefit as maintaining the status quo w.r.t. (lack of) inter-professional collaboration and professional power relationships

    • Debbie Rigby

      Totally agree that S3 Ventolin/Asmol should be recorded in the pharmacy software and therefore in MHR.

  5. Unter Berg

    Isn’t SABA overuse a clear message that we are failing to educate patients and getting them on the right treatment? Other countries are doing this much better. Finland for example has tackled this effectively and reduced asthma deaths to a much lower level than we have in Australia.

    Let’s not forget that SABA use in an acute setting can save lives. I find the sensationalism in this article simply negligent. Someone needs to post a balanced view that does not put patients at risk.

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