Asthma and COPD as-needed inhalers (SABD): where refills matter!

Authors

Kevin Liang MD (biography, no disclosures) and Philip Hui MD (biography, no disclosures)

What I did before

In a busy practice, I often prescribed multiple refills of patients’ long-term medications, so they do not run out before their next appointment. For patients with chronic obstructive pulmonary disease (COPD) or asthma, I would:

• give repeats of one or more rescue inhalers like salbutamol and/or ipratropium with each prescription
• automatically authorise pharmacy requests for refills of these rescue inhalers

Because of the health-care resource shortage, I worried that my patients would otherwise run out of their rescue inhalers when needed, causing a preventable exacerbation.

Figure 1. Helpful inhaler terminology used in the article

What changed my practice

New asthma and COPD guidelines are changing the way we provide respiratory care;^1,2,3 SABDs, such as salbutamol and ipratropium, are no longer the mainstay treatment for both conditions. Importantly, SABD overuse is a measure of poor disease control and suggests a need for treatment escalation.^4,5

Asthma:

SABA alone does not treat the airway inflammation underlying asthma pathophysiology. However, SABA overuse and monotherapy with salbutamol or terbutaline in asthma is common in Canada (defined as using >2 canisters a year).⁶ SABA overuse is thought to create tolerance to beta-agonist bronchoprotection, reduce bronchodilator response, and increase airway hyperresponsiveness.⁴ Longitudinal studies show that SABA overuse is also associated with increased risk of asthma exacerbations, hospital admissions, and even death.⁶ Hence, the Global Initiative for Asthma (GINA) guidelines no longer recommend SABAs as monotherapy for patients with asthma.⁴

The latest Canadian Thoracic Society (CTS) guideline also changed the criteria for well-controlled asthma, recommending only a maximum of 2 SABA doses per week.¹ The guideline suggests escalating patients on SABA PRN to daily ICS or PRN budesonide-formoterol (for patients ≥12 years of age) to achieve better asthma control and to decrease exacerbation risks.

COPD:

Recommended pharmacotherapy for COPD has changed from the latest CTS guideline.² For individuals with low symptom burden, minimal health status impairment, and mild lung function impairment, CTS recommends starting with a maintenance LABD rather than a short-acting inhaler. SABD should be reserved only for as-needed basis and high SABD use indicates disease deterioration and may require step-up to a different inhaler. While the pathophysiology remains unclear, there is also emerging evidence that excessive use of SABD in COPD is associated with an increased risk of exacerbations and mortality.⁵

Beyond clinical concerns, pressurised metered-dose inhalers (pMDIs), the predominant inhaler device type in Canada, pose serious environmental harms. pMDIs use hydrofluoroalkane propellants to deliver medications to the lungs; these propellants are potent greenhouse gases and account for up to 4% of healthcare’s climate emissions.⁷ Salbutamol alone accounts for 71% of total inhaler use in Canada.⁸

Overuse of inhalers also taxes the medical supply chain. Critical shortages of both salbutamol and ipratropium due to increased demand have occurred during the COVID-19 pandemic, wildfire smoke season, and peak respiratory seasons in Canada.^9,10

What I do now

I no longer classify rescue inhalers/SABD as “chronic” or maintenance medications and provide refills or repeats without careful reassessment. Unlike blood pressure medications or statins, patients with asthma should not be taking their rescue inhaler every day if they have no symptoms. In COPD, no patients should be maintained on SABDs. Given the associated harms from their SABD overuse, both to directly the patient, health care systems, and the environment — I use a stewardship lens when prescribing and refilling rescue inhalers.

For patients with asthma, I:

• Review the new asthma control guideline with the patient — whereby using over 2 doses/week of their SABA shows suboptimal asthma control.
  • For patients on salbutamol pMDI, two puffs (one dose) twice weekly equals 208 puffs a year, and each SABA pMDI canister has 200 puffs. Under optimal conditions, patients should be using fewer than two canisters of their salbutamol pMDI each year.
• Ensure that patients using ≥ 2 doses/week of their SABA medication, which indicates suboptimal asthma control, are also prescribed an ICS or budesonide-formoterol.
• Do not counsel patients on using their bronchodilator before using an ICS to “open up the airways”. There is no evidence to support the benefits of this practice and contributes to SABA overuse.¹¹

For patients with COPD, I:

• Confirm that they are on a long-acting maintenance controller (LAMA or LAMA/LABA) appropriate for their symptoms.
• Check that SABD therapy is prescribed only on an as-needed basis
• Simplify their rescue medications when possible — SAMA (e.g., ipratropium) is not recommended to be used with LAMAs due to additive anticholinergic side effects.¹² If there is indeed a therapeutic need for both SABA and SAMA, I try to prescribe the combination inhaler.

For both patient groups, I:

• Review techniques on how to use their inhalers. For patients using pMDI, I make sure they use a spacer to maximise the therapeutic benefit of each puff.
• Counsel the need to track the dose on their pMDIs, many of which lack a dose counter, to ensure that they are not using an empty inhaler or disposing of a non-empty inhaler.
• Consider a switch to a non-pMDI medication in a shared decision-making process, because of both its environmental benefits and the dose counter from dry-powder or soft-mist inhalers to allow patients to monitor their SABD use.
• Warn patients on symptoms of SABA and SAMA overuse including tremor, tachycardia, feelings of anxiety, or other anticholinergic effects. Patients can associate these symptoms with exacerbation of their respiratory disease, rather than from their inhalers, potentially leading to increased SABD use.

In summary, high SABD use is a marker of more severe respiratory disease. By carefully reviewing the need for a refill we take advantage of the opportunity to re-assess a patient’s asthma or COPD control and adjust their therapy to ensure adequate and appropriate disease management — ultimately preventing medication side effects and future exacerbations.

Resources for patients

1. Asthma action plan. Asthma Canada. Accessed November 28, 2023. (View on asthma.ca)
2. COPD action plan. Canadian Thoracic Society. Accessed November 28, 2023. (View PDF)
3. How to use your inhaler. The Canadian Lung Association. Accessed November 28, 2023. (View on lung.ca)

Resources for health-care providers

1. Global Initiative for Asthma (GINA). 2023 GINA main report. Updated July 10, 2023. Accessed November 28, 2023. (View on ginasthma.org)
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2023 GOLD Report. Accessed November 28, 2023. (View on goldcopd.org)
3. A guide to green inhalers in British Columbia, Canada. BC Inhalers. Updated November 2023. Accessed November 28, 2023. (View inhalers.ca)
4. Child Health BC. Child health BC provincial asthma guideline appendix b: pediatric asthma education checklist. Updated September 30, 2021. Accessed November 28, 2023. (View PDF)
5. Jones P W. COPD assessment test (CAT). MD+ Calc. Accessed November 28, 2023. (View on mdcalc.com)
6. MRC Dyspnea Scale. Pathways BC. Accessed November 28, 2023. (View PDF)

References

1. Yang CL, Hicks EA, Mitchell P, et al. Canadian thoracic society 2021 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can J Respir Crit Care Sleep Med. 2021;5(4):348-361. Published online 2021 Aug 19. doi: 10.1080/24745332.2021.1945887 (View)
2. Bourbeau J, Bhutani M, Hernandez P, et al. 2023 Canadian thoracic society guideline on pharmacotherapy in patients with stable COPD. Chest. 2023;164(5):1159-1183. doi:10.1016/j.chest.2023.08.014 (Request with CPSBC or view with UBC)
3. British Columbia Ministry of Health. Asthma diagnosis, education and management. Updated July 26, 2023. Accessed December 12, 2023. (View)
4. Reddel HK, FitzGerald JM, Bateman ED, et al. GINA 2019: a fundamental change in asthma management: Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. Eur Respir J. 2019;53(6):1901046. Published 2019 Jun 27. doi:10.1183/13993003.01046-2019 (View)
5. Fan VS, Gylys-Colwell I, Locke E, et al. Overuse of short-acting beta-agonist bronchodilators in COPD during periods of clinical stability. Respir Med. 2016;116:100-106. doi:10.1016/j.rmed.2016.05.011 (View)
6. Noorduyn SG, Qian C, Johnston KM, et al. SABA use as an indicator for asthma exacerbation risk: an observational cohort study (SABINA Canada). ERJ Open Res. 2022;8(3):00140-2022. doi:10.1183/23120541.00140-2022 (View)
7. Stoynova V, Culley C. Mitigating the climate impact of asthma therapy. This Changed My Practice. June 28, 2022. Accessed September 1, 2023. (View)
8. Janson C, Maslova E, Wilkinson A, et al. The carbon footprint of respiratory treatments in Europe and Canada: an observational study from the CARBON programme. Eur Respir J. 2022;60(2):2102760. doi:10.1183/13993003.02760-2021 (View)
9. Britneff B. Health Canada warns of shortage in full supply of salbutamol inhalers due to COVID-19 demand. Global News. April 17, 2020. Accessed October 4, 2023. (View)
10. Understanding the albuterol shortage and its impacts on lung health. American Lung Association. March 13, 2023. Updated August 25, 2023. Accessed October 4, 2023. (View)
11. Global strategy for asthma management and prevention, 2023. Global Initiative for Asthma (GINA). Updated July 2023. Accessed December 12, 2023. (View)
12. Ferguson GT, Make B. Stable COPD: initial pharmacologic management. UpToDate. Updated Nov 06, 2023. Accessed September 30, 2023. (View)

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Asthma and COPD as-needed inhalers (SABD): where refills matter

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