Why patients don’t need salbutamol ‘just in case’

Daivd has a flare of his asthma. Tight chest, coughing, wheezy, he’s not at the nebuliser stage but he’s going to need some prednisolone to bring it under control. 

It’s disappointing this flare has happened. Only a few months ago at his annual asthma review you switched David from his traditional brown and blue inhaler combination, on which he’d had several asthma attacks over the years, to an anti-inflammatory reliever therapy regime using a combination inhaler with corticosteroid and formoterol. You were hoping for better. Where did it go wrong? This is where:

“Should I have a blue inhaler, just in case?”  You think, what if he was to get an asthma attack? We all know the treatment is lots of puffs of salbutamol via a spacer. How would you manage this with a combination inhaler?

So, you issued the salbutamol. And this is where it went wrong. David used his new combination inhaler most mornings and evenings. He keeps it by his bed so he doesn’t forget. He keeps his salbutamol in his rucksack so if he feels tight chested when he’s out and about, when he’s playing sport, when his asthma is getting worse, he can have some quick relief. Because of this, he’s missing the most important benefit of anti-inflammatory reliever therapy.

On the latest Hot Topics course we talk about the new asthma guidelines from the British Thoracic Society / SIGN / NICE. One of the key changes here is the drive to use anti-inflammatory reliever therapy (AIR) – combination ICS (inhaled corticosteroid) / LABA (long-acting beta agonist) inhalers – for all severities of asthma for relief of symptoms instead of salbutamol. 

The most common question we get asked by delegates is should we still prescribe a salbutamol inhaler alongside an ICS / LABA inhaler in case the patient has a severe flare, a ‘just in case’ inhaler. 

The short answer is: no. 

The new guideline recommends combination inhalers for prn use in mild asthma, and regular use with extra puffs for breakthrough symptoms in more severe asthma, for those aged 12 and over and for many aged 5 – 11 as well. The omission of ‘and also prescribe salbutamol’, is very deliberate.

For clinicians used to the idea of salbutamol as the bedrock of acute asthma management this leaves a very uncomfortable feeling, but understanding how formoterol compares to salbutamol and how patients should use combination inhalers in an asthma attack provides reassurance and confidence in leaving salbutamol behind.

Firstly, combination ICS / LABA inhalers are established as superior to regimes containing salbutamol either as monotherapy or when used for acute relief alongside regular ICS use. They reduce rates of severe exacerbations, provide equal symptom control and reduce total steroid burden compared to traditional regimes. The drip feed of extra steroid addresses the airways inflammation driving symptoms and risk. 

Secondly, in the context of worsening asthma symptoms or asthma attack data demonstrates the efficacy of formoterol. A very useful review paper on ICS/LABA inhalers for asthma published in 2023 in the Journal of Allergy and Clinical Immunology discusses data comparing formoterol and salbutamol. Most research on ICS/LABA has been conducted on inhalers containing 6mcg per dose, which is what the majority of UK licensed versions provide. The greater efficacy of formoterol means that 1 puff results in a similar degree of symptomatic relief as 2 puffs of salbutamol 100mcg, with a similar rate of onset. Formoterol is, of course, known to be long-acting with a durable effect lasting at least 12 hours in contrast to the shorter-acting salbutamol. 

There are two clinical consequences of this. First, with the longer duration of action, far fewer rescue puffs are likely to be needed compared to salbutamol. This alleviates the concern that in the UK most ICS / formoterol inhalers are only licensed for up to 8 puffs a day. It would be unusual that patients would require more even with a flare. Second, we will need to flag to patients previously using salbutamol that instead of taking 2 puffs  to relieve symptoms they will only require 1 puff with ICS / LABA.

But what if the patient has a full blown asthma attack? 

Thankfully with better asthma care and these new regimes, asthma attacks will be less frequent. Nevertheless, acute asthma can still occur and the Primary Care Respiratory Society produced a very useful resource on use of MART for practices which provides an asthma action plan template for patients with escalating symptoms and during an asthma attack. It recommends:

• When asthma is ‘not good’ continue taking the normal treatment daily and take 1 extra puff as needed, usually up to 8 puffs in total for a day. It suggests seeking medical advice if more than 8 puffs in 24 hours is required, even if the patient feels better.
• If the patient is having an asthma attack despite increased doses of inhaler (excessive coughing, tight chest, wheezy, unable to speak in full sentences) then seek emergency medical advice via calling 999. While waiting patients can take 1 puff, wait 1-3 minutes and if there is no improvement take another puff, repeating this up to a maximum of 6 puffs if necessary. 

Concerns around total number of doses for patients who have already used their inhaler that day are realistically outweighed by the potential for imminent death from their acute asthma. In fact, New Zealand national guidance recommends patients just keep going as needed until help arrives.

For practices, it still remains appropriate to keep salbutamol inhalers and nebulisers available to patients attending with acute asthma, but for patients at home, the PCRS asthma plan demonstrates how patients can respond to acute asthma without relying on salbutamol.

Back to David, if we had changed the conversation, explained how he can use his combination inhaler for rescue therapy for minor and more serious flares and given him a MART-specific personalised asthma action plan (as well as the PRCS, Asthma UK has downloadable and editable versions for MART and AIR/PRN regimes), then we could have avoided prescribing salbutamol. He would have had to carry his AIR inhaler with him and used this for relieving breakthrough symptoms, providing extra steroid to control his airways inflammation making it much less likely he would ever reach the stage of severe acute asthma, safe in the knowledge he can use more during an acute flare while seeking medical advice.

The best treatment for an asthma attack is the one that makes it never happen.