Countering the counter-productive: it’s time for an alternative to SABA only asthma treatment


Bradley E. Chipps, Past President of the American College of Allergy, Asthma & Immunology and Medical Director of Capital Allergy & Respiratory Disease Center in Sacramento, US

As time progresses, so does our understanding of how to optimise asthma care. Yet too often people with asthma are under-diagnosed1 and under-treated,2 with potentially serious consequences.3

Many patients with asthma use short-acting beta2-agonist (SABA) rescue inhalers to treat their disease. Though SABA provides fast symptom relief, it does not address the underlying inflammation that causes asthma attacks.4 Data from the SABA Use IN Asthma (SABINA) global programme provides recent evidence showing that the use of three or more SABA inhalers per year can be counter-productive, actually increasing the risk of asthma attacks.5,6

We must bring asthma management strategies in line with the latest science, addressing the underlying inflammation to optimise patient outcomes.

Significant unmet need among patients with asthma

Asthma is a chronic, inflammatory disease that affects around 339 million people globally.3 In the US alone, over 25 million patients are living with asthma,7 with more than 40% of these patients in the US experiencing one or more attacks a year.7 That amounts to over 10 million attacks per year.7 Sadly, from these attacks, around 3,500 people die each year in the US from asthma.7

Beyond the emotional and physical cost, poorly managed asthma carries a hefty economic and societal burden. When accounting for the amount spent annually on asthma-related medical or indirect costs such as lost school and workdays, this puts a significant strain on not only the people living with this disease and their families, but also healthcare systems.8

Current treatment approaches are leaving patients at risk of attacks

I often hear patients telling me how attached they feel to their SABA rescue inhaler, believing it is the best way to control their asthma. But SABA medication alone only addresses symptoms and regular use can mask disease progression and increase hyper-responsiveness in the airways, causing greater sensitivity to triggers.9 What’s more, a surprising 39% of patients see no need to take their preventative medicine10 (which is usually prescribed alongside their SABA inhaler) when they don’t feel unwell, thereby significantly underusing their maintenance inhaler.

Early reliance by patients on SABA is quickly established as it’s often the first medicine prescribed and because it provides immediate relief from the breathlessness symptoms they experience.4,11,12 This means that during symptom onset, many patients instinctively reach for their SABA inhaler. Paradoxically, use of SABA alone can leave patients at increased risk of attacks as the medicine does not treat the underlying inflammation, meaning patients may require oral corticosteroids (OCS).13,14 Repeated courses of OCS are associated with an increased risk of systemic side effects such as osteoporosis, pneumonia and type 2 diabetes.14,15 Country-specific data show US asthma patients may not be exempt from these risks with 15% of the asthmatic population overusing SABA16 and a quarter only using quick-relief medication, such as SABA, to manage their asthma.17

What needs to change in asthma management?

To reduce asthma attacks and potentially preventable deaths, global treatment and healthcare policies should provide clear guidelines for asthma management. Indeed, international recommendations from the Global Initiative for Asthma have been updated to no longer recommend SABA as the preferred rescue therapy.3

A combined approach focusing on inhaled combination medicines that provide symptom relief whilst also addressing underlying inflammation should be central to asthma management. This treatment intervention is especially important when asthma control is lost and symptoms increase, which could indicate the onset of a severe asthma attack. If such an approach were delivered early in the course of disease progression, patients would suffer fewer asthma attacks and live a life less burdened by their disease.

Strategies to achieve better outcomes for patients will also need to include education for healthcare providers around the risks of using SABA alone to manage this disease, given that even patients with mild asthma can have severe attacks.2


1. Kavanagh J, et al. Over-and under-diagnosis in asthma. Breathe. 2019; 15(1): e20-7.

2. Nolte H, et al. Unawareness and undertreatment of asthma and allergic rhinitis in a general population. Respir Med. 2006; 100(2): 354-62.

3. Global Initiative for Asthma. 2021 GINA Report, Global Strategy for Asthma Management and Prevention. [Online]. Available at:  [Last accessed: 26 August 2021].

4. O'Byrne PM, et al. The paradoxes of asthma management: time for a new approach?. Eur Respir J. 2017; 50(3).

5. Bloom CI, et al. Asthma-Related Health Outcomes Associated with Short-Acting β2-Agonist Inhaler Use: An Observational UK Study as Part of the SABINA Global Program. Adv Ther. 2020; 37: 4190–4208.

6. Nwaru BI, et al. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020; 55 (4): 1901872.

7. CDC. Most Recent National Asthma Data. [Online]. Available at: [Last accessed: 26 August 2021].

8. The Global Asthma Network. The Global Asthma Report 2018. [Online]. Available at: [Last accessed: 2 July 2021].

9. Beasley R, et al. The further paradoxes of asthma management: Time for a new approach across the spectrum of asthma severity. Eur Respir J. 2018; 52 :1800694

10. Partridge MR, et al. Attitudes and actions of asthma patients on regular maintenance therapy: the INSPIRE study. BMC Pulm Med. 2006; 6: 13.

11. Reddel HK, 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 (9): e016688-e.

12. Cole S, et al. ‘The blue one takes a battering’ why do young adults with asthma overuse bronchodilator inhalers? A qualitative study. BMJ Open. 2013; 3(2): e002247.

13. Kaplan A, et al. Effective asthma management: is it time to let the AIR out of SABA?. J Clin Med. 2020; 9(4): 921.

14. Price DB, et al. Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study. J Asthma Allergy. 2018; 11: 193–204.

15. Sullivan PW, et al. Oral corticosteroid exposure and adverse effects in asthmatic patients. J Allergy Clin Immunol. 2018; 141 (1): 110-116.e7.

16. Slejko JF, et al. Asthma control in the United States, 2008-2010: indicators of poor asthma control. J Allergy Clin Immunol. 2014; 133: 1579–87.

17. Murphy KR , et al. Asthma management and control in the United States: results of the 2009 asthma insight and management survey. Allergy Asthma Proc. 2012; 33: 54–64.

Veeva ID: Z4-36285
Date of Preparation: September 2021