28 August 2023
OTC SABAs undermine good asthma care
Spirometry has dropped since the pandemic, adherence to medication guidelines is woeful and SABAs are readily available.
The Australian Institute of Health and Welfare (AIHW) released its latest report on asthma in Australia on 30 June, but it hasn’t received much attention.
Asthma deaths have continued to decline along with hospitalisations, with a very sharp drop in hospitalisations in 2020-21. Asthma deaths are thankfully rare events and the reduction in hospitalisations, mostly in children under six years, is also part of a longer trend.
But this is where the good news ends.
The reason for the sudden drop in hospitalisations in 2020-21 is a phenomenon of the pandemic lockdowns, evident across the world, and we can’t claim this as a success(1). If we fast forward to 2022-23, with covid and the resurgence of influenza and other viruses, it is unlikely that this will be repeated. And in fact, there is cause for concern.
Firstly, a lot of Australians have asthma. The Australian Bureau of Statistics reports asthma prevalence at 11% of the whole population, only exceeded by mental health disorders, back problems and arthritis.
Secondly, asthma is not an acute disease, it is a chronic disease, and measuring the acute aspect of asthma only gives part of the story. The AIHW report shows that people with asthma experience a worsened quality of life and the burden of disease in terms of healthy years lost has risen on average at 0.4% per year since 2003.
This impact is not proportionate, with the worst outcomes in terms of burden of illness seen in remote communities and those in the lowest socioeconomic groups. This includes Indigenous Australians, in whom asthma is 1.5 times more prevalent and who experience the greatest long-term burden of illness.
We demonstrated a similar finding in those with more severe asthma, across Australia, that those who lived in remote communities or socially disadvantaged ones, were more likely to have difficult asthma and suffered more frequent exacerbations requiring oral corticosteroids(2).
Does this mean our treatments are only able to prevent acute asthma outcomes?
We know this is not the case and have known it for more than 25 years. In people with asthma, low to medium dose inhaled corticosteroids reduce mortality, reduce asthma exacerbations, improve symptoms and quality of life over six years(3).
For this reason, Australian and international guidelines recommend inhaled corticosteroids should be used regularly or as needed, together with a fast-acting bronchodilator, for nearly all (in excess of 90%) people with asthma over the age of six years.
The reality though is that these recommendations are not being implemented.
The AIHW reports that preventers were used in only a third of people with asthma, 25% of those aged 15-24 years and – at best – only 41% of those aged 45-50 years.
Furthermore, less than 1% had an asthma cycle of care and only a third a written asthma action plan. It is hard to think of a worse adherence to the guidelines or best practice. Why is this the case?
The majority of people with asthma have so-called mild disease, best treated by low dose inhaled corticosteroids. But the perception people with asthma have, and one that the medical profession has fostered, is that their disease is intermittent. This implies they only need to treat when they are symptomatic, reinforced by terms like “seasonal asthma” or “viral induced asthma”.
There is no evidence that these are entities that should guide treatment, these are asthma triggers and there is no evidence that treatment should be different based on these definitions, as opposed to what is recognised as treatment for asthma.
Asthma is a chronic disease, that needs to be diagnosed by demonstrating reversible airflow obstruction on spirometry, and when this is the case people respond well to inhaled corticosteroids. The reality though is that spirometry is not performed, and the diagnosis remains uncertain, contributing to a failure to commit to long term treatments by patients and health providers. The use of spirometry has declined to alarmingly low levels since the pandemic, despite the increase in reimbursement.
There is no easy solution here, but a serious conversation needs to be had to improve asthma diagnosis so appropriate treatment is initiated and maintained(4).
The perception that asthma is intermittent fosters the idea that relief of symptoms with short acting beta agonists (SABA) is sufficient and safe. In Australia we allow over-the-counter supply of these “lifesaving” medications. This is undermining good asthma care.
SABAs are the cheapest form of treatment; they are readily available and do not even require a medical review. The powerful price signal is a disincentive against the use of preventers (even if they are efficacious and cost-effective), as well as the time and cost of seeing a doctor and having a medical review. This impacts most on the financially disadvantaged and there is no surprise then that they have the worst asthma outcomes.
SABA use alone is not safe. Australians with “mild asthma” who don’t use a preventer, excessively self-medicate with over-the-counter SABAs. More than two in three have poor symptom control on objective testing, but underperceive these symptoms and 25% have to seek urgent medical care, exposing them additionally to the use of oral corticosteroids (5).
Excessive SABA use directly increases asthma mortality (6). Over-the-counter availability of these medications is part of the problem.
People with mild asthma find it hard to conceive they need to take a regular treatment and our continual insistence that this has to be the case is probably counterproductive (7). An alternative approach is the use of as-needed inhaled corticosteroid and fast-acting bronchodilators that has been shown to be overwhelmingly more effective and safer, compared to SABAs alone, reducing exacerbations, achieving good day-to-day control of symptoms and is readily adopted by people with mild asthma (8-10). It is also recommended by the guidelines and available under the Pharmaceutical Benefits Scheme.
All is not well with asthma in Australia.
We need to implement asthma best practice. This includes health practitioners, people with asthma and government. Asthma needs to be correctly diagnosed and treated. Inhaled corticosteroids are the centre piece of treatment, there needs to be greater implementation of more flexible regimes for their use considered in those with mild disease.
Government needs to support best practice by enabling diagnosis and access to care, and incentivising the use of inhaled corticosteroids.
Over-the-counter salbutamol is not a lifesaving medication, it is a dangerous unregulated drug that undermines our best efforts in asthma care.
Professor Peter Wark is a respiratory physician and director of National Asthma Council Australia.
1. Davies GA, Alsallakh MA, Sivakumaran S, Vasileiou E, Lyons RA, Robertson C, et al. Impact of COVID-19 lockdown on emergency asthma admissions and deaths: national interrupted time series analyses for Scotland and Wales. Thorax. 2021;76(9):867-73.
2. Wark PAB, Hew M, Xu Y, Ghisla C, Nguyen T-M, Erdemli B, et al. Regional variation in prevalence of difficult-to-treat asthma and oral corticosteroid use for patients in Australia: heat map analysis. Journal of Asthma. 2023;60(4):727-36.
3. Barnes P. Efficacy of inhaled corticosteroids in asthma????. Journal of Allergy and Clinical Immunology. 1998;102(4):531-8.
4. Gibson PG. Spirometry, you have an image problem! Respirology. 2023;28(6):577-.
5. Reddel HK, Ampon RD, Sawyer SM, Peters MJ. 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.
6. Bateman ED, Price DB, Wang H-C, Khattab A, Schonffeldt P, Catanzariti A, et al. Short-acting ?<sub>2</sub>-agonist prescriptions are associated with poor clinical outcomes of asthma: the multi-country, cross-sectional SABINA III study. European Respiratory Journal. 2022;59(5):2101402.
7. O’Byrne PM, Jenkins C, Bateman ED. The paradoxes of asthma management: time for a new approach? Eur Respir J. 2017;50(3).
8. Bateman ED, Reddel HK, O’Byrne PM, Barnes PJ, Zhong N, Keen C, et al. As-Needed Budesonide–Formoterol versus Maintenance Budesonide in Mild Asthma. New England Journal of Medicine. 2018;378(20):1877-87.
9. Hardy J, Baggott C, Fingleton J, Reddel HK, Hancox RJ, Harwood M, et al. Budesonide-formoterol reliever therapy versus maintenance budesonide plus terbutaline reliever therapy in adults with mild to moderate asthma (PRACTICAL): a 52-week, open-label, multicentre, superiority, randomised controlled trial. Lancet. 2019;394(10202):919-28.
10. Foster J, Beasley R, Braithwaite I, Harrison T, Holliday M, Pavord I, et al. Perspectives of mild asthma patients on maintenance versus as-needed preventer treatment regimens: a qualitative study. BMJ Open. 2022;12(1):e048537.