The 'blue one' controls my asthma.
Overuse of short-acting beta₂ agonists (SABA)
Many people often treat their asthma as a short-term or acute condition, rather than a chronic condition, relying on short-acting beta₂ agonists (SABA) to relieve symptoms instead of managing the underlying characteristics of asthma.[i]
An Australian study[ii] surveyed almost 2700 people with asthma and found 39% only used a SABA, treating their symptoms but not the cause and 23% had urgent treatment for their condition in the past year, with just over 70% of these people suffering symptoms consistent with poorly-controlled asthma.
This vulnerable group of SABA only users were more likely to be younger and male.ii People who overuse SABA may have fundamentally different perceptions of asthma. It has been suggested that over-users are more likely to focus on the mechanical effects of bronchoconstriction and the quick relief provided by SABA rather than on the underlying inflammatory process and the prevention provided by preventer medication.[iii]
Frequent use of SABA is a sign of poorly controlled asthma, and indicates an increased risk of asthma flare-ups.[iv]
For almost half of people with asthma, there is a gap between the potential control of their asthma symptoms and the level currently experienced, with poor symptom control in 45% of people with asthma.[v]
People with well-controlled asthma do not need to use their reliever on more than 2 days per week (not including before exercise).
Impact on asthma management and lung health
Short-acting beta₂ agonists are life-saving in acute severe asthma, however, regular long-term use of SABA leads to receptor tolerance (down-regulation) to their bronchoprotective and bronchodilator effects.[vi]
Over use of SABA is associated with:
More frequent symptoms
Increased risk of asthma flare-ups
Increased healthcare utilisation
Lower mental and physical functioning iv,[vii],[viii]
That frequent use of their reliever is a sign of poorly controlled asthma, and may indicate an increased risk of asthma flare-ups
Not to take their reliever when they do not have asthma symptoms (except before exercise, if indicated).
Use of 3 or more reliever canisters in 12 months is associated with increased risk of flare-ups.[ix]
Most patients with asthma should be taking a regular ICS-containing preventer, to minimise their symptoms and markedly reduce their risk of flare-ups.iv Current Australian guideline recommendations to initiate ICS preventer treatment for adults with asthma include:
symptoms twice or more during the past month,
waking due to asthma symptoms once or more during the past month
Use of even a low dose of ICS, if taken regularly, reduces the risk of asthma-related death by 50–85%.[x]
Recommendations for General Practitioners
Assess level of asthma control using the Asthma Control Test™ (ACT)[xi],[xii] or Primary care Asthma Control Screening tool (PACS)[xiii]
Undertake or arrange spirometry - if the patient has poor symptom control and frequent SABA use but normal lung function, consider SABA overuse or a diagnosis other than asthma).
Review treatment – consider preventer, address adherence and potential barriers if prescribed.
Demonstrate and check delivery device technique for asthma medications
Discuss and provide an Asthma Action Plan
Set review appointment:
If treatment changed – review in 2-3 months, advise patient to come back sooner if they have not seen any benefit
No change in treatment - review at least once a year for patients with mild asthma and at least twice a year for patient with more severe asthma or complex comorbidities
Refer your patients with asthma to The COACH Program® - Asthma module*. Visit asthmaaustralia.org.au/coach
For resources to support your patients call the 1800 ASTHMA Helpline (1800 278 462) or visit asthmaaustralia.org.au/2daysin7
* The COACH Program® supports your patients in following their asthma management plans to improve their level of asthma control and overall health. The service is delivered via telephone and offers up to 5 free coaching sessions each supported by a letter summarising the interaction to both the patient and their doctor.
[i] AIHW: Correll PK, Poulos L, Ampon R et al. Respiratory medication use in Australia 2003–2013: treatment of asthma and COPD. Canberra: AIHW, 2015.
[ii] Reddel HK, Ampon RD, Sawyer SM, et al. Risks associated with managing asthma without a preventer: urgent healthcare, poor asthma control and over-the-counter reliever use in a cross-sectional population survey. BMJ Open 2017;7:e016688. doi:10.1136/ bmjopen-2017-016688
[iii] Cole S, Seale C, Griffiths C. The blue one takes a battering why do young adults with asthma overuse bronchodilator inhalers? A qualitative study. BMJ open 2013;3.
[iv] National Asthma Council Australia. Australian Asthma Handbook, Version 1.2. National Asthma Council Australia, Melbourne, 2016. Website. Available from: http://www.asthmahandbook.org.au
[v] Reddel HK, Sawyer SM, Everett PW, Peters MJ. Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population. Med J Aust 2015; 202: 492–7.
[vi] Hancox RJ. Concluding remarks: can we explain the association of beta-agonists with asthma mortality? A hypothesis. Clin Rev Allergy Immunol. 2006; 31: 279-88. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17085800
[vii] Cole S, Seale C, Griffiths C. The blue one takes a battering why do young adults with asthma overuse bronchodilator inhalers? A qualitative study. BMJ open 2013;3.
[viii] Gerald JK, Carr TF, Wei CY, Holbrook JT, Gerald LB. Albuterol Overuse: A Marker of Psychological Distress? The journal of allergy and clinical immunology In practice 2015;3:957-62.
[ix] Stanford et al. Short-acting β-agonist use and its ability to predict future asthma-related outcomes. Annals of Allergy, Asthma & Immunology 2012;109:403-407.
[x] Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med 2000;343:332-336.
[xi] Development of the Asthma Control Test: A survey for assessing asthma control; Nathan RA et al, J Allergy Clin Immunol 2004;113:59-65. 2.
[xii] The Asthma Control Test™ (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey; Thomas M et al, Prim Care Resp J 2009; 18(1): 41-49.
[xiii] LeMay KS, Armour CL, Reddel HK. Performance of a brief asthma control screening tool in community pharmacy: a cross-sectional and prospective longitudinal analysis. Prim Care Respir J; 2014. Available from: http://dx.doi.org/10.4104/pcrj.2014.00011