Prescribing relievers for adults
Advise all patients with asthma to carry a reliever containing a rapid-onset inhaled beta2 agonist at all times and use it when they experience difficulty breathing.
Rapid-onset beta2 agonist relievers include:
- short-acting beta2 agonists (salbutamol, terbutaline)
- low-dose budesonide/formoterol (for people using budesonide/formoterol as both maintenance and reliever).
- Formoterol alone should not be prescribed as a reliever inhaler.
- For all inhalers: Train the patient how to use their inhaler correctly (including spacer, if used). A physical demonstration is essential.
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available).
Short-acting beta2 agonists should be used only on an as-needed basis for asthma symptoms (e.g. wheezing or breathlessness), and at the lowest dose and frequency required.
- that frequent use of short-acting beta2 agonists is a sign of poorly controlled asthma, and may indicate or increase risk of asthma flare-ups
- not to take their reliever when they do not have asthma symptoms (except before exercise, if indicated).
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):
Where more than one reliever option is appropriate, explain the options and take into consideration:
- the person’s preference
- the person’s ability to use the device
- potential adverse effects.
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available).
- Correct use of inhaler devices
High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,10, 11, 12, 13, 14 even among regular users.15 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.16
Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.10, 17, 15, 18, 19 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.15
Common errors and problems with inhaler technique
Common errors with manually actuated pressurised metered dose inhalers include:16
- failing to shake the inhaler before actuating
- holding the inhaler in wrong position
- failing to exhale fully before actuating the inhaler
- actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
- actuating the inhaler too late while inhaling
- actuating more than once while inhaling
- inhaling too rapidly (this can be especially difficult for chilren to overcome)
- multiple actuations without shaking between doses.
Common errors for dry powder inhalers include:16
- not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
- failing to exhale fully before inhaling
- failing to inhale completely
- inhaling too slowly and weakly
- exhaling into the device mouthpiece before or after inhaling
- failing to close the inhaler after use
- using past the expiry date or when empty.
Other common problems include:
- difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
- inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
- inability to generate adequate inspiratory flow for the inhaler type
- failure to use a spacer when appropriate
- use of incorrect size mask
- inappropriate use of a mask with a spacer in older children.
How to improve patients’ inhaler technique
Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.16 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.22, 10, 23, 24 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.23 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).8, 21
The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.Close
- Short-acting beta-2 agonist relievers for adults and adolescents
Short-acting beta2 agonists are used to:
- relieve asthma symptoms
- prevent exercise-induced bronchoconstriction
- relieve exercise-induced bronchoconstriction.
The duration of therapeutic effect is approximately 4 hours.
When using a pressurised metered-dose inhaler for salbutamol, the use of a large-volume spacer increases the proportion of drug delivered to the lung.25 For adults, it is not essential to use a spacer with salbutamol for day-to-day symptoms if adequate relief is obtained with a pressurised metered dose inhaler alone.
Patients with well-controlled asthma do not need to use their reliever on more than 2 days per week, not counting doses taken before exercise to prevent exercise-induced bronchoconstriction.
Note: Routine preventive doses of short-acting beta2 agonist taken before exercise are not counted when assessing recent asthma symptom control. However, persistent exercise-induced bronchoconstriction generally indicates inadequate asthma control.
Table. Definition of levels of recent asthma symptom control in adults and adolescents (regardless of current treatment regimen)
- Over-use of short-acting beta-2 agonists
- Data from population and case-control studies has led to concerns that the frequent use of short-acting beta2 agonists, including salbutamol, is associated with increased risk of asthma deaths.7 The risk of asthma deaths was greatest for fenoterol, which has since been withdrawn from use.4 For salbutamol, the risk is greatest for doses above 1000 mcg/day (10 puffs).
- Regular use of salbutamol 16 puffs/day (rather than as-needed use during symptoms) was associated with increased risk of asthma flare-ups requiring oral corticosteroids in a placebo-controlled clinical trial.6 Subsequent statistical modelling showed that the risk was associated with increased fluctuation in lung function.1
- Regular use of short-acting beta2 agonists leads to receptor tolerance (down-regulation) to their bronchoprotective and bronchodilator effects. Tolerance becomes more apparent with worsening bronchoconstriction. In severe asthma, this could result in a poor response to emergency treatment.3
When high doses of short-acting beta2 agonist are needed (e.g. dose repeated at intervals of less than 4 hours in a person with acute severe asthma), the patient should be under medical supervision and should usually also be receiving systemic corticosteroids.Close
- Combination budesonide/formoterol maintenance-and-reliever regimen in adults and adolescents: overview of efficacy
Low-dose budesonide/formoterol combination can be used as reliever for asthma symptoms (instead of using a short-acting beta2 agonist reliever), in addition to its use as regular long-term preventer treatment.27, 28, 29, 30, 31, 32 The following formulations can be used in maintenance-and-reliever regimens:
- dry-powder inhaler (Symbicort Turbuhaler) 100/6 mcg or 200/6 mcg
- pressurised metered-dose inhaler (Symbicort Rapihaler) 50/3 mcg or 100/3 mcg.
Neither the 400/12 mcg dry-powder inhaler nor the 200/6 mcg pressurised metered-dose inhaler should be used in this way.
Overall, clinical trials show that budesonide/formoterol combination as maintenance and reliever reduces the risk of flare-ups that require oral corticosteroids, compared with other current preventer regimens and compared with a fixed higher dose of inhaled corticosteroids.33
Pooled data from five randomised controlled trials assessing budesonide/formoterol maintenance-and-reliever regimens showed that similar or better levels of asthma control were achieved with budesonide/formoterol maintenance-and-reliever compared with the conventional maintenance regimen comparators:29
- higher-dose budesonide
- same dose budesonide/formoterol
- higher-dose inhaled corticosteroid/long-acting beta2 agonist (budesonide/formoterol or fluticasone propionate/salmeterol).
In randomised clinical trials in patients with a history of asthma flare-up within the previous 12 months (and therefore at greater risk of flare-up in the next 12 months), the use of formoterol/budesonide as maintenance-and-reliever regimen reduced the risk of asthma flare-ups that required treatment with oral corticosteroids, compared with the use of any of the following (plus a short-acting beta2 agonist reliever as needed):29, 34, 35
- the same combination as maintenance treatment only
- higher-dose combination as maintenance treatment only
- higher-dose inhaled corticosteroids.
Meta-analysis of six randomised controlled trials found that maintenance-and-reliever treatment with budesonide/formoterol reduced the risk of severe asthma flare-ups (use of oral corticosteroids for 3 days or more, hospitalisation or emergency department visits), compared with higher-dose inhaled corticosteroid alone, or in combination with a long-acting beta2 agonist.36
In open-label studies in which patients were not selected for a previous history of flare-ups, there was no overall difference in time to first flare-up between budesonide/formoterol as maintenance-and-reliever regimen and conventional maintenance regimens (including inhaled corticosteroid or inhaled corticosteroid/long-acting beta2 agonist combinations, leukotriene receptor antagonists, xanthines or any other asthma medicines) with rapid-onset beta2 agonist reliever (selected according to clinician’s choice).37 However, the inhaled corticosteroid dose was higher with conventional maintenance regimens.
Note: The fluticasone propionate/formoterol combination is approved by the Therapeutic Goods Administration only for regular maintenance therapy.Close
- Ipratropium for adults
Regular ipratropium bromide in addition to as-needed short-acting beta2 agonist does not appear to provide clinically significant benefit over as-needed short-acting beta2 agonists alone.38
Note: Ipratropium bromide may be used in the management of severe acute asthma.Close
- Technical notes: pressurised metered-dose inhalers with spacers
Manufacturers of most delivery devices recommend shaking the device before actuating. The physical characteristics of each formulation, including the effects of shaking, differ widely,39 but for simplicity it is best always to recommend shaking.
Pressurised metered-dose inhalers (except for those that are breath-actuated) can be used with a spacer. When a spacer is used with a pressurised metered-dose inhaler, delivery of the medicine to the patient’s airways is maximised when the patient takes a slow, deep breath from the spacer after each actuation.40, 41 Multiple actuations of a pressurised metered-dose inhaler into a spacer can reduce the amount of respirable medicine available because aerosol particles can agglomerate into larger particles or become attached to the spacer walls.40
Therefore, the ideal way to deliver inhaled medicines via pressurised metered-dose inhaler and spacer is to shake the device, ask the person to breathe out all the way into the spacer, fire a single actuation into the spacer, and have the person immediately take a slow deep breath from the spacer, then hold their breath for 5 seconds. This process should be repeated until the total intended number of actuations is taken. Patients should be trained to follow these instructions when using their inhalers. Inhaling slowly with a single breath maximises delivery of the medicine to the lungs and minimises deposition in the upper airways when using a manually actuated pressurised metered-dose inhaler with or without a spacer, or when using a breath-actuated pressurised metered-dose inhaler.42 However, slow breathing may not be possible for patients with acute asthma. Tidal breathing through the spacer (e.g. four breaths in and out without removing the spacer) is used in acute asthma and for very young children. First aid instructions should include how to use inhaler and spacer.
In practice, optimal delivery of inhaled medicines involves a balance between maximising the proportion of respirable medicine and maximising efficiency of inhalation by the patient within real-world constraints. The optimal delivery of salbutamol in real-world circumstances is not well defined. For day-to-day use of salbutamol, most adults gain sufficient relief from symptoms when using a pressurised metered-dose inhaler on its own. A spacer may only be needed during a flare-up. By contrast, the use of a spacer is always recommended for inhaled corticosteroids delivered by manually actuated pressurised metered-dose inhalers, to reduce the risk of local adverse effects and increase delivery to the airways.
Many available in vitro studies of aerosol particle deposition in the airways were performed using older CFC-propelled formulations, which are now obsolete. Similar studies have not been performed for current non-CFC pressurised metered-dose inhalers.Close
- Frey U, Brodbeck T, Majumdar A, et al. Risk of severe asthma episodes predicted from fluctuation analysis of airway function. Nature. 2005; 438: 667-670. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16319891
- Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org
- Hancox RJ. Concluding remarks: can we explain the association of beta-agonists with asthma mortality? A hypothesis. Clin Rev Allergy Immunol. 2006; 31: 279-88. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17085800
- Suissa S, Blais L, Ernst P. Patterns of increasing beta-agonist use and the risk of fatal or near-fatal asthma. Eur Respir J. 1994; 7: 1602-1609. Available from: http://erj.ersjournals.com/content/7/9/1602.abstract
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- Taylor DR, Town GI, Herbison GP, et al. Asthma control during long-term treatment with regular inhaled salbutamol and salmeterol. Thorax. 1998; 53: 744-752. Available from: http://thorax.bmj.com/content/53/9/744.full
- Walters EH, Walters JA, Gibson PG, Jones P. Inhaled short acting beta2-agonist use in chronic asthma: regular versus as needed treatment. Cochrane Database Syst Rev. 2003; Issue 1: CD001285. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001285/full
- Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
- Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
- Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
- Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
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- National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
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