Ask two simple questions about “reliever” use to assess asthma control

Short-acting beta-agonists (SABAs) are essential as reliever medications to treat acute symptoms of asthma and to prevent symptoms in response to known triggers (e.g., exercise, allergen exposure), but their overuse is a strong indicator of poor asthma control. Over-reliance on SABAs to treat acute symptoms can adversely impact quality of life, increase the risk of exacerbations and the risk of mortality. The Canadian Thoracic Society (CTS) 2021 update on the diagnosis and management of mild asthma, includes a new recommendation that a combination inhaled corticosteroid and long-acting beta-agonist, specifically budesonide/formoterol, may be used as-needed (prn) as an alternate reliever to a SABA in very mild asthma (for ages ≥ 12 years). The CTS 2021 update includes an algorithm that can be used as a guide to determining when prn budesonide/formoterol is appropriate as a reliever compared with a SABA prn. In an article recently published in Allergy, Asthma & Clinical Immunology, Canadian authors contend that while the CTS algorithm provides necessary and precise guidance, the requirements for determining control and exacerbation risk are somewhat complicated, which may leave some patients at risk of SABA over-reliance, particularly if the patient overestimates their asthma control or simply ignores worsening symptoms. Read: New TB guidelines from the Canadian Thoracic Society To simplify the reliever decision algorithm developed by the CTS for application in daily practice, the Canadian researchers recommend a 30-second evaluation using two simple questions related to reliever use to assess whether a patient’s asthma is controlled: How many SABA canisters do you use a year? How many times do you use SABA each week? If the patient indicates use of > 2 SABA canisters per year or > 2 administrations of SABA per week for any reason, including prevention of exercise-induced asthma or in anticipation of allergen-induced symptoms, the patient does not have controlled asthma and prn SABA is not an appropriate treatment regimen. Similarly, more than two administrations of prn budesonide/formoterol per week indicates the need for a clinical review and reevaluation of the patient’s asthma management, including augmentation using a regular controller therapy. Read: Iron for allergies? The authors note that two studies have demonstrated a decrease in the rate of severe exacerbations when low-dose budesonide/formoterol is used as a reliever medication compared with prn SABA alone. Therefore, prn budesonide/formoterol is a superior and safer option compared to prn SABA for most adults and adolescents using excessive SABA therapy, who have very mild to mild asthma, and who are not on a daily controller medication. The authors warn that stepping up to prn budesonide/formoterol from a prn SABA may still not be sufficient to provide adequate control. Patients using prn budesonide/formoterol should also be asked how many times they use this form of medication a week as a reliever. More than two administrations per week should dictate a clinical review, with verification of the asthma diagnosis and reevaluation of their asthma management strategy to include a regular controller therapy. The authors stress that very few patients will actually fit into the prn SABA-only category, whether this is determined by using the reliever decision algorithm developed by the CTS or the authors’ proposed two-question simplified approach. Education is essential to inform patients, caregivers and healthcare providers that overuse of any reliever (SABA or budesonide/formoterol) is not acceptable and is potentially harmful. Read: Obstructive sleep apnea behind drivers falling asleep at the wheel References 1. Ellis AK, Foran V, Kaplan A, et al. Clarifying SABA overuse: translating Canadian Thoracic Society guidelines into clinical practice. Allergy Asthma Clin Immunol 2022;18:48. (accessed June 23, 2022). 2. Yang CL, Hicks EA, Mitchell P, et al. 2021 Canadian Thoracic Society Guideline—a focused update on the management of very mild and mild asthma. Can J Respir Crit Care Sleep Med 2021;5:205-45. (accessed June 23, 2022)

Ask two simple questions about “reliever” use to assess asthma control

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