Why not use solely Short-Acting Beta-Agonists (SABA) for asthmatic patients?

From the Guidelines

Relying solely on SABAs for asthmatic patients is not recommended due to the lack of control over underlying inflammation, which can lead to increased morbidity, mortality, and decreased quality of life. The use of SABAs alone only provides temporary symptom relief without addressing the chronic inflammation that causes airway hyperresponsiveness and remodeling. According to a study published in the Journal of Allergy and Clinical Immunology in 2020 1, the working group recommends concomitant ICS and SABA for adult patients at step 2 as an alternative to continuous daily ICS, highlighting the importance of combining SABAs with controller medications.

Some key points to consider when managing asthma include:

• The importance of controlling inflammation to prevent long-term airway damage and reduce exacerbation risk
• The recommendation to use controller medications, such as ICS, daily as prescribed, and reserve SABAs for breakthrough symptoms or before exercise when needed
• The potential risks associated with overreliance on SABAs, including poorer asthma control, more frequent exacerbations, and increased mortality risk
• The consideration of patient concerns about ICS side effects and the potential benefits of an as-needed ICS/SABA strategy, although this approach may be inferior to routine daily ICS in terms of asthma control as reflected by symptoms, as noted in the study 1.

In terms of specific treatment approaches, the guidelines suggest the following:

• For patients at step 2, concomitant ICS and SABA may be used as an alternative to continuous daily ICS
• For patients at step 3 and above, combination therapy with ICS and LABA may be considered
• The use of separate inhalers for ICS and SABA may be necessary due to the lack of commercially available combined ICS/SABA preparations.

From the Research

Reasons for Not Using Solely SABA for Asthmatic Patients

• SABA overuse is associated with poor asthma control and negative health outcomes, as it does not treat underlying inflammation 2.
• The use of SABA as monotherapy is no longer recommended due to significant safety concerns and poor outcomes 3.
• Patients who overuse SABA have a higher risk of severe exacerbations, as shown in a longitudinal study in Canada 2.
• The Global Initiative for Asthma and other guidelines recommend the use of a combined inhaled corticosteroid-fast acting beta agonist as a reliever instead of SABA alone 3, 4.

Alternative Treatment Approaches

• The use of as-needed inhaled corticosteroid (ICS)/formoterol is recommended as the preferred rescue medication in mild asthma as monotherapy and also in moderate to severe asthma when the maintenance and reliever therapy (MART) strategy is used 4.
• ICS-based maintenance treatment with SABA used as-needed as a reliever is considered an effective and safe treatment for patients with asthma, with no scientific evidence of a causal link between SABA use as a reliever and mortality or serious adverse events 5.

Challenges and Solutions

• Patient adherence to regular ICS-based anti-inflammatory maintenance therapy is frequently poor, leading to SABA overuse for symptom relief and associated poor outcomes 6.
• Identifying patients at risk of misusing their SABA relievers and managing issues of inhaler technique and treatment adherence are crucial to ensure appropriate use of SABA 5.