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60 CPD ACTIVITY FROM PAGE 59 be used as both maintenance and reliever therapy or as needed without a regular daily maintenance preventer. Budesonide/formoterol is registered as an anti-inflammatory reliever as needed for symptoms and with extra doses if symptoms increase, according to the maximum recommended doses (Table 1). Ongoing frequent use of as- needed budesonide/formoterol should prompt a review of treatment. SABA over-reliance The over-reliance of SABA reliever medications sourced over the counter is very common.3 A recent Australian survey of 412 participants aged 16 years and older showed more than 70 per cent overused SABAs obtained from a community pharmacy.8 Overuse is defined as use for symptom relief more than twice a week in the previous four weeks. Overall, 31 per cent of participants used 5-12 puffs per day and a staggering six per cent used more than 12 puffs per day. Nearly three- quarters (73.6 per cent) of participants reported not using a preventer daily and about one in four patients (25.9 per cent) used their preventer on an as-needed basis.8 A significantly higher proportion of SABA overusers had uncontrolled asthma compared with SABA non-overusers (Figure 1) and were more likely to use oral corticosteroids to manage worsening asthma symptoms.8 It is well recognised that excessive use of SABA alone to manage asthma increases adverse events from asthma. Trust and reliance on SABAs for symptom control is often established as a child. Paradoxes in current asthma management have been described, highlighting the need for a new approach: 9,10 1. SABA is the first medication prescribed to almost all patients, but SABA does not have anti-inflammatory effects. 2. Conflicting message between as- needed SABA as initial treatment and fixed-dose approach at higher steps. 3. Adherence to ICS preventers is low because the patient does not perceive an immediate beneficial effect as with SABA. 4. Different safety message that SABA alone is safe and LABA alone is not safe. 5. Dislocation between patient’s understanding of asthma control and the frequency, impact and severity of symptoms. Asthma symptom control in SABA overuse 6% 59% 35% Well Controlled Partly Controlled Uncontrolled Asthma symptom control in SABA non-overuse 15% 37% Well Controlled Partly Controlled Uncontrolled Figure 1. Asthma symptom control of participants in community pharmacy survey.8. 48% Regular exposure to relatively large doses of SABA medications in the absence of adequate preventer therapy paradoxically increases airway hyper- responsiveness and worsening of symptoms.11 This increase in airway hyper-responsiveness can eventually result in life-threatening exacerbations or flare-ups.12 Dispensing of 12 or more SABA inhalers in a year is associated with an increased risk of asthma-related death.12 Regular SABA monotherapy has also been associated with a near-doubling of sputum eosinophil counts,13 an indication of airway inflammation and disease, and an increase in allergen-induced airway hyper- responsiveness.14 Overuse of SABAs may also mask the true asthma severity and result in undertreatment.15 Guidelines The Global Initiative for Asthma (GINA) strategy no longer recommends treating asthma in adults and adolescents with short-acting bronchodilators alone. Instead, they should receive a symptom-driven (in mild asthma) or daily corticosteroid- containing inhaler, to reduce the risk of severe exacerbations.16 For patients with mild asthma, GINA recommends as- needed low-dose inhaled corticosteroid (ICS)/formoterol as the preferred option to prevent exacerbations and control symptoms, including for patients with symptoms less than twice a month.17 Alternatively, low-dose ICS should be taken whenever a SABA is used (ie, separate ICS and SABA inhalers) or daily low-dose ICS.17 The Australian Asthma Handbook differs from the GINA 2020 strategy, recommending as-needed SABA alone for the few adults and adolescents with symptoms less than twice a month and no risk factors for flare-ups.18 This means only with: • Daytime asthma symptoms less than twice a month. • No waking due to asthma while using as-needed SABA alone. • No history of severe exacerbations in previous 12 months. • No risk factors for severe exacerbations. To date, no studies have been designed to address treatment for patients presenting with symptoms less than twice a month with no risk factors for exacerbations. For most adults and adolescents with well-controlled asthma, as-needed low- dose budesonide/formoterol can be considered as an alternative to long-term treatment with regular daily low-dose inhaled corticosteroids plus a SABA reliever as needed.18 Ongoing frequent use of as-needed budesonide/formoterol should prompt review of treatment. Every patient should have a personalised written asthma action plan that clearly explains what to do if they need to take their anti-inflammatory reliever many times on one occasion, over one day, or over several days. Use of multiple different SYGMA 2 BUD + SABA prn 350 300 250 200 150 100 50 0 SYGMA 1 BUD + SABA prn 83% reduction BUD/FOR prn 75% reduction BUD/FOR prn 340 267.6 57 65.9 RETAIL PHARMACY • AUG 2020 Figure 2. Median daily dose of inhaled corticosteroid.