BIRMINGHAM, UK — People with asthma should try to avoid frequent use of the blue inhaler containing the short-acting β2 adrenergic agonist (SABA) salbutamol to treat their symptoms. It is important to treat asthma appropriately and reduce the need for an emergency reliever, Steve Holmes, MMedSci, MB ChB, FRCGP, told Medscape News UK at the recent Primary Care Show. This is because overuse can actually worsen people’s symptoms rather than make them better.
“Be wary of [SABA] overuse. It is for when the patient has poor control of their symptoms, but should not be used for routine treatment,” said Holmes, a general practitioner (GP) partner at The Park Medical Partnership in Shepton Mallet, Somerset.
Holmes, who is also the integrated care lead for NHS Somerset Integrated Care Board, said that, if 100 people with or without asthma were to use a SABA twice a day, 2-3 days a week, for 1-2 months, most would develop asthma-like symptoms “because of the blue inhaler”. This is termed airway or bronchial hyperresponsiveness and has been well-described since the late 1990s.
“Give people asthma treatment and don’t rely on regular emergency relief treatment,” he urged. That should mean giving treatment with a low dose of an inhaled corticosteroid (ICS) to tackle the underlying inflammation with the possible addition of a long-acting β2 adrenergic (LABA) in a combined inhaler, while saving the SABA-containing blue inhaler for emergency relief when needed. There are also new options highlighted by the Global Initiative for Asthma (GINA) guidance that should be considered, he added.
Prevent Asthma Flare-Ups
According to GINA, asthma is a chronic condition in which there is inflammation of the airways. Even when there are no symptoms and the asthma appears mild, underlying inflammation puts people who are not on appropriate long-term medication at-risk for experiencing an asthma exacerbation or flare-up.
Over the years, treatment has evolved to try to prevent asthma from worsening. Regular use of low-dose ICS as a maintenance treatment was introduced in the late 1970s and early 80s. This was followed by combining it with a LABA as maintenance and reliever therapy (MART) in the late 1990s to 2000s. Now, treatment has moved to more of an as-required approach, which is often how patients take their medication in practice.
PRN Use of ICS/LABA?
The as-required approach is possible because of the availability of inhalers that can be used as both the maintenance and reliever medication. There are three combined ICS/LABA inhalers on the UK market, all of which combine varying doses of budesonide with formoterol.
Study data has shown a significant 60%-64% reduction in exacerbations with as-needed use of one of these – Symbicort Turbohaler – versus an as-needed use of a SABA, and comparable or lower reductions in exacerbations compared with maintenance low-dose ICS.
Post-Exacerbation Review
Do not forget to undertake a post-exacerbation review, Holmes advised. Components of this should include figuring out:
- Why did the exacerbation happen?
- Can any triggers or circumstances be identified?
- Is there anything that the patient has changed or learned from the recent experience?
“Do think about adherence and do definitely think about inhaler technique,” advised Holmes. Guidance on choosing an appropriate inhaler and then how to use it can be found on the NHS Right Breathe website, he said.
Primary Care Respiratory Society (PCRS) guidance on assessing asthma control also advises to check the diagnosis and smoking history.
The latter is important, said Holmes, because people who smoke may need higher doses of ICS to keep their asthma in check. They should ideally be given plenty of support and encouragement to quit smoking, he said.
“Don’t always believe the diagnosis, and don't be afraid to re-evaluate,” Holmes added. Studies have shown that the diagnosis can be wrong in almost a third of cases regardless of who made it: a generalist or a specialist, he observed.
Navigating the Asthma Care ‘Minefield’
In an on-demand webinar held by the PCRS that coincided with the Primary Care Show, Katherine Hickman, MRCP, who is a GP partner working in Bradford, said: “Asthma care really is about getting the basics right.”
Asthma care in the UK can be “an absolute minefield”, however, especially as there are two out-of-date guidelines, she said, referring to the British Thoracic Society (BTS) and Scottish Intercollegiate Network (SIGN) guidance published in 2019 and the National Institute for Health and Care Excellence (NICE) guidance that was last updated 3 years ago in 2021.
“We are still not getting asthma care right in the UK: three people are still dying of asthma every day, and every 3 minutes somebody is having a life-threatening asthma attack. We need to do better,” Hickman said.
New British Guidelines Forthcoming
New UK-wide guidelines have been drafted and should be finalised by the end of this year. This time, the BTS, SIGN, and NICE have worked together, so there will be a single guideline to help clinicians.
Holmes said an update on the progress of these guidelines was imminent. The draft guidance is expected to be published on the three organisations’ websites within a matter of weeks.
One of the expected changes is a new asthma pathway, which the BTS premiered at its annual winter meeting last November. Stand-alone guidelines for the management of acute and uncontrolled asthma are also being produced.
“I would expect there to be a very definite push away from using a [SABA] and there will be more talk about recent as-required treatment; options having a role in asthma care very much like the GINA guidance,” Holmes said.
“It is likely that we are going to have to think of ways to try to improve the quality of the diagnosis of asthma – and this is likely to entail better availability of fractional exhaled nitric oxide (FeNO) testing in the UK,” he added.
“It is important, however, to ensure the diagnosis is made based on clinical history, examination, and multiple test finding – which might include FeNO, peak expiratory flow rate, eosinophil count, or spirometry – but never on a single test.”
This article is based on an interview with and presentation by Holmes at The Primary Care Show 2024. Holmes disclosed receiving financial support for various activities form AstraZeneca, Boehringer Ingelheim, Chiesi, Pulmonx, Sanofi, Teva, Trudell Medical International, and Viatris. Hickman’s comment is taken from a webinar held by the PCRS on May 15 that was sponsored by AstraZeneca. Hickman is the respiratory lead for West Yorkshire ICB, primary care clinical lead for the National Respiratory Audit Programme (NRAP), and chair of the PCRS. The PCRS receives financial support from AstraZeneca UK Ltd, Chiesi Ltd, and Lupin Healthcare Ltd. Right Breathe is funded and maintained by the NHS London Procurement Partnership with support from AstraZeneca, Boehringer Ingelheim, Chiesi, Pfizer, Teva, and Napp.
Sara Freeman is a medical journalist and writer based in London, UK. She is a regular contributor to Medscape and other specialist healthcare media outlets.