It is time to drop use of the blue inhaler in adults and children over 12, a group of influential asthma experts have urged.
There is now enough compelling evidence to use combined ICS–formoterol reliever therapy as an alternative to salbutamol inhalers, the clinicians from New Zealand and the UK write in a letter in The Lancet Respiratory Medicine.
Speaking with the limbic, lead author Professor Andrew Bush, Professor of Paediatrics and Paediatric Respirology at the National Heart and Lung Institute, UK, said there have been a number of good trials which have shown the combination reliever therapy to significantly reduce asthma attacks.
Most notably, evidence from two papers published in 2018 and 2019 in the New England Journal of Medicine showed that as-needed budesonide–formoterol provided superior asthma-symptom control in patients with mild asthma.
“The national review of asthma deaths shows that a major predictor of death risk is overuse of short acting β2 agonists,” Prof Bush said. “It’s a marker of poor control. We seem happy to let people have just short-acting β2 agonists for mild asthma and it makes no logical sense.”
He added that for young children the evidence is not there, but in 6-to-12 year olds, there is some evidence to support the notion that the use of combined ICS–formoterol inhalers will also be beneficial in some children.
In the letter, the researchers conclude: “Regulatory bodies should mandate SABA alone as off-label in this age group, and replace it with ICS–formoterol alone as reliever therapy, a regimen which results in a greater than 50% reduction in severe attack risk in people aged 12 years and older.”
They also called for urgent evidence to support decision making in those under the age of 12.
In 2019, the Global Initiative for Asthma (GINA) was the first guideline group to make the shift to no longer recommending treating adults and adolescents with short-acting β2 agonists alone.
Professor Bush stressed this was about outpatient care and not management of acute exacerbations in hospital.
“It is a complete shift in the way we think about how we treat asthma but there is a substantial body of evidence that we can deliver better outcomes,” he said.
“We have the guidelines, now what we need is the British Thoracic Society and SIGN to update their guidelines in light of the new evidence.
“The thing that comes out time and time again is the overuse of salbutamol and the underuse of inhaled corticosteroids.”
The recently updated Australian Asthma Handbook still recommends the use of as-needed short-acting beta2 agonists as reliever therapy, but only for patients with very infrequent symptoms and no risk factors for flare-ups.
Version 2.1 of the Handbook, released in 2020, also includes the Level 2 treatment option of as-needed low dose budesonide-formoterol for relief of symptoms in adults and adolescents over 12 years with mild asthma.
Chair of the Guidelines Committee Professor Amanda Barnard said short-acting relievers such as salbutamol remained an essential rescue medicine for acute asthma.
“They still provide safe relief of symptoms when used with a regular daily inhaled corticosteroid preventer,” she said.