Short-Acting Beta Agonist Overuse a Global Public Health Issue

About one third of asthma patients have high use of short-acting beta agonists (SABAs) in Europe across all severity levels, said Santiago Quirce, MD, PhD, with Hospital Universitario in Madrid, Spain.

High use — defined as three or more canisters dispensed per year — “is a global public health issue,” and is associated with increased risk of asthma exacerbations and death, he said, along with increased healthcare costs.

Asthma patients tend to rely too heavily on SABAs and too little on inhaled corticosteroids (ICS), he said Saturday at the European Academy of Allergy and Clinical Immunology (EAACI) Hybrid Congress 2021, adding that SABA use continues to increase globally.

Quirce is a co-author on the SABINA study, the largest real-world study on SABA use. It included 1 million people with asthma across five European countries. Among the findings were that overuse varied greatly by country.

Overuse was 9% in Italy; 16% in Germany; 29% in Spain; 30% in Sweden; and 38% in the United Kingdom. In the UK, SABA overuse was greater for people with moderate-to-severe asthma compared with those who had mild asthma (58% vs 27%, respectively.)

Quirce also pointed to a 2012 study in the Annals of Allergy, Asthma & Immunology of more than 33,000 patients that identified values of SABA that predicted exacerbations in children in adults.

For adults, “use of 2 or more SABA canisters was found as the critical value with shorter optimal assessment periods of 3 and 6 months,” the 2012 study found. “Each additional SABA canister resulted in an 8% to 14%” increase in the risk for asthma-related exacerbation in children and “a 14% to 18%” increase in that risk in adults.

Patients become overreliant on the SABA inhalers, which have been in use for more than 50 years, for many reasons, Quirce said, despite the increased risk of exacerbations.

He noted that it’s difficult to increase awareness of the risks for SABA overuse among both patients and healthcare workers, partly because the inhalers offer fast relief, are easy to use, and are inexpensive.

However, the 2019 Global Initiative for Asthma (GINA) guidelines no longer recommend SABAs alone to treat asthma in adolescents and adults.

“[SABA overreliance] is one of the biggest problems we have in asthma management,” he said.

Quirce said that a better shared understanding of SABA overuse is needed, “so that specialists and GPs are totally aware of the problem.” Communicating that to patients is also important, he said.

Gaps in Understanding of Overuse are Wide

Researchers conducting a study published in NPJ Primary Care Respiratory Medicine interviewed asthma experts from hospital and primary care backgrounds to identify how SABA use is defined and perceived. They found providers’ definition of “acceptable SABA use” ranged from 0.5 SABA inhalers (100 doses per year) to 12 SABA inhalers (2400 doses/year). 

Quirce suggests a “warning or red flag” from community pharmacists and efforts by scientific organizations to highlight the problem.

Additionally, restrictions on use vary widely worldwide.

Session moderator Stefano Del Giacco, MD, associate professor of allergy and clinical immunology at University of Cagliari, Cagliari, Italy, said, “In Italy we can take (SABA) without a prescription because it is considered an emergency medication. If you rush to the pharmacy and you ask for it, they will give it to you immediately.”

Lack of prescriptions, and thus lack of prescription data, may also help explain why overuse numbers in Italy are lower than in other European countries, Quirce said.

Del Giacco said he agreed that “red flags” at the pharmacy level should be instituted.

Stanley Szefler, MD, director of the Pediatric Asthma Research Program and research medical director in the Breathing Institute at Children’s Hospital Colorado in Denver, told Medscape Medical News he suspects dependence on SABAs is similar in the US and Europe. He said it is also likely patients are driving the decisions to use SABA based on rapid relief and low cost.

“That is where close monitoring of prescription on a population basis could be helpful in identifying those patients and seeing what is going on,” he said.

He noted that, in the US, insurance provider Kaiser Permanente has set up a “SABA/ICS ration system” to detect patients who are overreliant on SABAs.

Quirce receives honoraria, serves on the speakers bureau, or is a consultant for ALK, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Regeneron, Sanofi, and Teva. Szefler and Del Giacco have disclosed no relevant financial relationships.

European Academy of Allergy and Clinical Immunology (EAACI) Hybrid Congress 2021: Plenary Session: New Frontiers in Asthma / Landscape of Short-Acting Beta Agonists in Europe. Presented July 10, 2021.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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