Blue puffer isn’t enough, even in mild asthma: GINA

Around one in three people with asthma is receiving suboptimal care.

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No adults or teens with asthma should be treated with short-acting beta2 agonists (SABA) alone, say asthma experts – yet this is what is happening in a third of cases. 

Almost all patients over the age of six should take either daily or as-needed corticosteroid-containing inhaled therapy, the new Global Initiative for Asthma (GINA) Strategy 2021 stresses. 

One option for mild asthma is regular low dose inhaled corticosteroids (ICS), such as fluticasone propionate, budesonide or ciclesonide, said Professor Helen Reddel, chair of the GINA Science Committee.

But the guidelines have added a new treatment option for patients whose symptoms are infrequent: a low dose of a combination of inhaled corticosteroid with the LABA formoterol as needed for symptom relief. 

This can be used “used exactly as the patient would normally use their blue puffer”, Professor Reddel said. 

“It relieves asthma symptoms as quickly as a blue puffer. As well as a bronchodilator, it’s got a little bit of the anti-inflammatory treatment in it, and the combination together reduces the risk of severe attacks very substantially, even with a small amount of use.”

The advice is based on studies showing low-dose ICS reduces the risk of life-threatening asthma exacerbations by two-thirds even in people with mild or so-called intermittent asthma compared with SABA-only treatment. 

And, unlike treatments such as OCS, there are no significant adverse effects, the authors of the strategy summary paper assured. 

“Four studies (~10,000 patients) showed a similar or greater reduction in severe exacerbations compared with daily low-dose ICS, without clinically important differences in symptom control, lung function, or airway inflammation … over 12 months,” they said. 

Budesonide + formoterol fixed-dose combination (FDC) was added to the PBS General Schedule in June 2020 and changes were made to the Australian asthma guidelines in September.  

Professor Reddel told The Medical Republic that not many people with mild asthma were good at continuing to take their ICS to control their asthma, relying instead on using the SABA for intermittent symptoms. This left patients at higher risk of a severe exacerbation. 

“In the community, patients take on average about 25% to 35% of their prescribed dose of inhaled corticosteroid containing treatment. And what they tend to do is not take it at all, and then their asthma gets worse.” 

But infrequent or mild symptoms can make it difficult to justify the need for or remember to take regular medication. 

“Part of that is because people can just go and buy it over the counter in a pharmacy and so they think they can manage their asthma without necessarily talking to a doctor about it. But in addition, there’s not a huge awareness by GPs of the risks of treating asthma with short-acting beta agonists alone.”

This piece has been updated to reflect that formoterol is a LABA, not a SABA as previously stated.