Short-term outcomes after implementation of SABA-free asthma management with a maintenance and anti-inflammatory reliever regimen within primary care

Abstract

Aim: Short-acting β₂-agonist (SABA) overuse adversely affects asthma-related outcomes and the environment. The latest Global Initiative for Asthma (GINA) report no longer recommends SABA-only therapy. Since 2020, we have implemented an inhaled corticosteroid (ICS)-containing reliever strategy for our moderately severe asthmatics within our practice population. We only administered budesonide/formoterol (BUD/FORM) via a single device maintenance and reliever therapy (MART) across this cohort and eliminated the use of SABA therapy. Methods: Our asthma registry revealed 195 patients in the cohort. All patients were invited for assessment and 101 patients agreed to this new strategy [MART + simultaneous anti-inflammatory reliever (AIR)]. The remaining 94 patients continued with MART and SABA inhalers. Both groups were followed up for 24 months. Results: There were no deaths in either group. Asthma-related hospitalizations fell by 91.5% in the SABA-free group (p=0.003). Exacerbations requiring oral corticosteroids (OCS) fell by 82.1% in the SABA-free group over the 24-month period (p=0.041). At the end of 24 months, 97.5% of patients in the SABA-free group remained SABA-free, with an average of 4.9 cannisters of BUD/FORM prescribed per year, compared with 7.68 cannisters in the MART/SABA groups (p=0.00347). Conclusions: This data provides real world evidence that the use of MART/AIR with BUD/FORM simultaneously with the elimination of SABA is safe and effective for moderate asthmatics within primary care.

Keywords

Asthma / inhaled corticosteroid (ICS) / short-acting β2-agonist (SABA) / Ventolin / exacerbation

References

[1] 2022 GINA Report, Global Strategy for Asthma Management and Prevention [Internet]. Fontana: Global Initiative for Asthma - GINA; c2024 [cited 2024 Aug 26]. Available from: https://ginasthma.org/gina-reports/

[2] Vaswani A, Khaw HJ. Medicine in a minute. Branbury: Scion Publishing Ltd; 2018.

[3] Asthma Statistics [Internet]. British Lung Foundation; c2023 [cited 2024 Aug 26]. Available from: https://irp.cdn-website.com/672be0a6/files/uploaded/Asthma%20statistics%20_%20British%20Lung%20Foundation.html

[4] Asthma [Internet]. World Health Organization; c2024 [cited 2024 Aug 27]. Available from: https://www.who.int/news-room/fact-sheets/detail/asthma

[5] Castillo JR, Peters SP, Busse WW. Asthma Exacerbations: Pathogenesis, Prevention, and Treatment. J Allergy Clin Immunol Pract. 2017; 5: 918-27.

[6] Ebmeier S, Thayabaran D, Braithwaite I, Bénamara C, Weatherall M, Beasley R. Trends in international asthma mortality: analysis of data from the WHO Mortality Database from 46 countries (1993-2012). Lancet. 2017; 390: 935-45.

[7] Scenario: Newly-diagnosed asthma [Internet]. NICE; c2025 [cited 2024 Aug 31]. Available from: https://cks.nice.org.uk/topics/asthma/management/newly-diagnosed-asthma/

[8] Aldridge RE, Hancox RJ, Cowant JO, Frampton CM, Town GI, Taylor DR. Eosinophils and eosinophilic cationic protein in induced sputum and blood: effects of budesonide and terbutaline treatment. Ann Allergy Asthma Immunol. 2002; 89: 492-7.

[9] Swystun VA, Gordon JR, Davis EB, Zhang X, Cockcroft DW. Mast cell tryptase release and asthmatic responses to allergen increase with regular use of salbutamol. J Allergy Clin Immunol. 2000; 106: 57-64.

[10] Bulletin 295: Inhaler carbon footprint [Internet]. Leeds: PrescQIPP; c2018 [cited 2024 Sep 2]. Available from: https://www.prescqipp.info/our-resources/bulletins/bulletin-295-inhaler-carbon-footprint/

[11] WMA Declaration of Helsinki - Ethical Principals For Medical Research Involving Human Participants. World Medical Association ; c2024 [cited 2024 Sep 3]. Available from: https://www.wma.net/policies-post/wma-declaration-of-helsinki/

[12] Jorup C, Lythgoe D, Bisgaard H. Budesonide/formoterol maintenance and reliever therapy in adolescent patients with asthma. Eur Respir J. 2018; 51: 1701688.

[13] Rabe KF, Pizzichini E, Ställberg B, Romero S, Balanzat AM, Atienza T, et al. Budesonide/formoterol in a single inhaler for maintenance and relief in mild-to-moderate asthma: a randomized, double-blind trial. Chest. 2006; 129: 246-56.

[14] Kuna P, Peters MJ, Manjra AI, Jorup C, Naya IP, Martínez-Jimenez NE, et al. Effect of budesonide/formoterol maintenance and reliever therapy on asthma exacerbations. Int J Clin Pract. 2007; 61: 725-36.

[15] Nannini LJ, Neumayer NS, Brandan N, Fernández OM, Flores DM. Asthma-related hospitalizations after implementing SABA-free asthma management with a maintenance and anti-inflammatory reliever regimen. Eur Clin Respir J. 2022; 9: 2110706.

[16] Nwaru BI, Ekström M, Hasvold P, Wiklund F, Telg G, Janson C. 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: 1901872.

[17] Yorgancıoğlu A, Aksu K, Naycı SA, Ediger D, Mungan D, Gül U, et al. ; SABINA Turkey Study Group. Short-acting β₂-agonist prescription patterns in patients with asthma in Turkey: results from SABINA III . BMC Pulm Med. 2022; 22: 216.

[18] Montero-Arias F, Garcia JCH, Gallego MP, Antila MA, Schonffeldt P, Mattarucco WJ, et al. Over-prescription of short-acting β₂-agonists is associated with poor asthma outcomes: results from the Latin American cohort of the SABINA III study . J Asthma. 2023; 60: 574-87.