This article is authored by
Having worked in the respiratory field for nearly 20 years, I am passionate about improving outcomes for asthma, which is a chronic, variable, inflammatory disease affecting as many as 339 million people worldwide.1 I am a Reader in Respiratory Epidemiology at the National Heart and Lung Institute at Imperial College London and Honorary Consultant in Respiratory Medicine based at The Royal Brompton Hospital, London, UK.
Over the last 25 years or so, global asthma mortality rates have plateaued2, and there is a significant burden from exacerbations, with 176 million asthma attacks occurring globally every year.3 Patients with asthma are at risk of exacerbations, regardless of adherence to treatment, age or severity.4-6
With asthma being an inflammatory disease, it is key that the management of asthma should be directed towards preventing and controlling the variable inflammatory disease process. The short-acting beta-2 agonist (SABA) reliever is currently one of the most commonly prescribed therapies for asthma.7,8 Research shows patients often rely on their SABA reliever in their desire to seek immediate relief of their asthma symptoms.7,8 And a worsening in symptoms and lung function can also drive patients to use their SABA reliever.8,9 However, use of SABA relievers can actually mask the deterioration of their disease over time10 as it does not treat the fluctuating nature of the underlying airway inflammation7, which means that patients remain at risk of potentially preventable exacerbations.
There are 176 million asthma attacks globally per year. Patients living with asthma are at risk of exacerbations, regardless of adherence to treatment, age or severity.[4-6]
Time for a change?
For a number of years, the respiratory community has been calling for a rethink in how asthma is treated. Current expert opinion is calling for a fundamental change in approach to the management of asthma, suggesting SABA monotherapy is no longer recommended as-needed in mild asthma patients due to safety reasons. In fact, research shows there is increased risk of serious attacks associated with the use of three or more SABA canisters per year.8,11
New research on potential consequences of reliance on SABA relievers
New data from the SABINA programme, presented at the European Respiratory Society (ERS) International Congress 2019, demonstrates the impact of patients’ use of SABA relievers on clinical outcomes.12,13,14,15
An analysis of data from the nationwide Swedish asthma cohort shows that across all severities of asthma, 30% of patients prescribed two medications, are using three or more SABA canisters a year. These patients have significantly higher rates of asthma exacerbations and are associated with an increased mortality risk, compared with patients who were not reliant on their SABA relievers.12,14
Additionally, an analysis of mild asthma patients from the UK Clinical Practice Research Datalink (CRPD), also presented at ERS, suggests that patients manage their asthma by changing their use of their SABA treatment rather than their use of an inhaled corticosteroid (ICS) in response to changes in asthma control.15
The way forward
This research adds to the increasing body of evidence highlighting the problem of SABA reliance. It is clear that the right treatment approach should aim to reduce the burden of asthma as well as increase patients’ quality of life.
Watch the video below of me talking about the problem of SABA reliance and improvements needed in current asthma management.
1. The Global Asthma Network. The Global Asthma Report 2018. [Online]. Available at: globalasthmanetwork.org/publications/Global_Asthma_Report_2018.pdf [last accessed: September 2019]
2. Ebmeier S, Thayabaran D, Braihwaite et al. Trends in international asthma mortality: analysis of data from the WHO Mortality Database from 46 countries (1993–2012). The Lancet. 2017 390:935-945.
3. AstraZeneca Pharmaceuticals. Data on file. Annual Rate of Exacerbations Globally (ID:SD-3010-ALL-0017).
4. Papi A, Ryan D, Soriano JB et al. Relationship of Inhaled Corticosteroid Adherence to Asthma Exacerbations in Patients with Moderate-to-Severe Asthma. J Allergy Clin Immunol Pract 2018; 6(6):1989-1998.e3.
5. Bloom CI, Nissen F, Douglas IJ et al. Exacerbation risk and characterisation of the UK's asthma population from infants to old age. Thorax 2018; 73(4):313–20.
6. Ding B, Small M. Disease Burden of Mild Asthma: Findings from a Cross-Sectional Real-World Survey. Adv Ther 2017; 34(5):1109–27.
7. O’Byrne P, Jenkins C, Bateman E. The paradoxes of asthma management: time for a new approach? Eur Respir J. 2017; 50 (3).
8. 2019 GINA Report, Global Strategy for Asthma Management and Prevention. Available from: https://ginasthma.org/gina-reports/. [last accessed: September 2019].
9. Partridge M, van der Molen T, Myrseth S-E et al. Attitudes and actions of asthma patients on regular maintenance therapy: The INSPIRE study. BMC Pulm Med. 2006; 6:13.
10. Keeley D, Baxter N. Conflicting asthma guidelines cause confusion in primary care. BMJ 2018; 360:k29
11. Schatz M, Zeiger R, Vollmer WM, et al. Validation of a beta-agonist long-term asthma control scale derived from computerized pharmacy data. J Allergy Clin Immunol. 2006; 117(5):995–1000.
12. Janson C, Nwaru B, Hasvold LP, Wicklund F, Telg G, Ekstrom M. SABA overuse and risk of mortality in a nationwide Swedish asthma cohort (HERA). Late Breaker abstract at the European Respiratory Society 2019 International Congress. [last accessed: September 2019].
13. Ekstrom M, Nwaru B, Hasvold LP, Wiklund F, Telg G, Janson C. Use of short-acting beta-2 agonists (SABA) and exacerbations in a nationwide Swedish asthma cohort (HERA). Abstract at the European Respiratory Society 2019 International Congress. [last accessed: September 2019].
14. Janson C, Nwaru B, Hasvold LP, Wicklund F, Telg G, Ekstrom M. Use of short-acting beta-2 agonists (SABA) and exacerbations in a nationwide Swedish asthma cohort (HERA). Abstract at the European Respiratory Society 2019 International Congress. [last accessed: September 2019].
15. Bloom CI, Quint JK, Cabrera C. SABA and ICS use among mild asthma patients in UK primary care. Abstract at the European Respiratory Society 2019 International Congress. [last accessed: September 2019].
Veeva ID: Z4-19462
Date of preparation: September 2019
Date of expiry: September 2021