Published: 4 August 2020
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Key practice points:
- A short-acting beta2-agonist (SABA) reliever as the sole treatment without an inhaled corticosteroid (ICS) (i.e. SABA-only treatment) is no longer
recommended for the management of asthma in adolescents* or adults; patients taking SABA-only treatment need to switch to budesonide/formoterol or
be advised to take another ICS-containing inhaler every day
- In 2019, nationally:
- Nearly 75,000 people aged ≥ 12 years were dispensed a SABA as their sole asthma treatment†
- The rate of SABA-only treatment in people receiving inhaled asthma medicines was highest in those aged 12–18 years (27%); the rate decreased with age and was
lowest in those aged > 40 years (20%)
- The rate of SABA-only treatment was highest in Pacific peoples (26% of those receiving inhaled asthma medicines), followed by Asian peoples (24%) and Māori
(23%), and was lowest in European/Others (20%)
- Use of more SABA than ICS suggests that asthma control is not optimised and therefore these people are at increased risk of poor asthma outcomes.
Nationally, 47% of patients dispensed an ICS and SABA were dispensed more SABA than ICS. Māori and Pacific peoples were more likely to have more SABA
dispensed than ICS (55% and 52%, respectively) when compared to European/Others (44%) and Asian peoples (45%).
* People aged 12–17 years
† Defined as two or more SABA inhalers, and no ICS or other inhaled asthma or COPD medicines in 2019; this may include some older people being treated for mild COPD
For more than 50 years, people with asthma have been prescribed a short-acting beta2-agonist (SABA) as the first-line treatment for symptom relief.
However, the accumulated weight of evidence has shifted and regular use of a SABA without concurrent inhaled corticosteroid (ICS) is no longer recommended
for adolescents or adults. SABA-only treatment is associated with an increased risk of exacerbations due to increased inflammation, sensitivity to allergens
and tachyphylaxis. Dispensing of three or more SABA canisters per year (average ≥ 1.5 actuations per day) is associated with an increased risk of emergency
department visits or hospitalisation, independent of asthma severity. Dispensing of 12 or more canisters per year is associated with an increased risk of death.
All adolescent and adult patients who were previously prescribed a SABA only, including those with mild asthma or exercise-associated symptoms, are recommended to switch to
budesonide/formoterol (termed “anti-inflammatory reliever” [AIR] therapy*). Alternatively, if the patient wishes to continue using a SABA metered dose inhaler they should be
advised to also take an ICS-containing inhaler every day. Patients who are currently using an ICS with as needed SABA should also be encouraged to switch to AIR therapy with
budesonide/formoterol, especially if they do not have good asthma control. If they do remain taking an ICS with SABA, reiterate the importance of daily adherence to the ICS.
N.B. A SABA reliever used as needed without an ICS continues to be recommended in children aged < 12 years as there is currently insufficient evidence to recommend AIR therapy first-line.
* The term AIR includes both Single ICS/LABA Maintenance And Reliever Therapy (SMART), i.e. the use of budesonide/formoterol for both maintenance and reliever
treatment, and the use of budesonide/formoterol only for immediate symptom relief (as needed).
For further information on AIR therapy and the recommendations in the new Asthma and Respiratory Foundation NZ
guidelines, see: https://bpac.org.nz/2020/asthma.aspx
The recently released guidance from the Asthma and Respiratory Foundation NZ, including the recommendation against SABA-only treatment, provides an opportunity to
review all adolescent and adult patients with asthma and discuss how the changes in guidance, i.e. switching to AIR therapy, may help to optimise their asthma control.
Medicine use is one way of identifying people with asthma who are at high risk of poor control, exacerbations, hospitalisation and death. People who are well-controlled
on a regimen that includes an ICS will have reduced need for a reliever. The use of more SABA than ICS in patients who have been prescribed maintenance
ICS suggests that asthma control is not optimised, and the patient is at increased risk of poor asthma outcomes.
This report focuses on:
- Patients who are currently dispensed a SABA inhaler as their sole asthma treatment
- Patients who were dispensed more SABA inhalers than ICS inhalers
N.B. The dispensing data do not include patients who were prescribed medicines but did not present their prescription to be dispensed, but may include a small number
of patients who were dispensed medicines that they did not collect.
How the data sets were defined
SABA-only: To be included in this data set, people must have met the following criteria in 2019:
- Age ≥ 12 years; SABA without an ICS is still recommended for younger children
- ≥ 2 SABA inhalers; people who had one inhaler only are likely to have been prescribed this for an upper respiratory tract infection or allergy
- No other inhaled respiratory medicine; the focus of this section is people who are only using SABA to control their asthma
Data are expressed as a percentage of all people who received inhaled asthma medicines in 2019, i.e. two or more SABA inhalers, an ICS or ICS/LABA.
SABA:ICS ratio: To be included in this data set, people must have met the following criteria in 2019:
- Age ≥ 12 years
- ≥ 2 SABA inhalers
- Dispensed an ICS or ICS/LABA; the focus of this section is SABA use relative to ICS
Data are expressed as a percentage of all people who received an ICS and two or more SABA inhalers in 2019.
N.B. a small number of people may have received SABA treatment for COPD, but these patients should also be reviewed as a short-acting
muscarinic antagonist (SAMA) or a combination medicine may be more appropriate for them.
A link to a clinical audit to help identify patients using SABA-only treatment is available at the end of this report.
For further information on the pharmacological treatment of COPD, see: www.bpac.org.nz/2020/copd.aspx
In 2019, 74,796 people in New Zealand aged ≥ 12 years were dispensed two or more SABA inhalers and no ICS, representing
approximately one-fifth of people dispensed inhaled asthma medicines.
Who in the patient population are receiving SABA-only treatment?
This section describes the characteristics of the patient population aged ≥ 12 years
who were dispensed SABA as their sole asthma treatment (i.e. SABA-only) in 2019 in terms of their age (Figure 1) and ethnicity (Figure 2).
N.B. As the guidelines have only been recently released, the purpose of this section is to show the number of patients who may benefit
from the change in treatment recommendations.
SABA-only dispensing by age
Nationally, the dispensing rate of SABA-only treatment was highest in people aged 12–18 years (27% of those receiving inhaled asthma medicines). The dispensing rate
decreased with age and was lowest in people aged > 40 years (20% of those receiving inhaled asthma medicines).
Figure 1. Percentage of patients aged ≥ 12 years receiving inhaled asthma medicines in 2019 who were dispensed two or more
SABA inhalers without an ICS from community pharmacies, by age.
SABA-only dispensing by ethnicity
SABA-only dispensing was highest in Pacific peoples (26% of people aged ≥ 12 years receiving inhaled asthma medicines), followed by Asian peoples (24%)
and Māori (23%), and was lowest in European/Others (20%). Māori and Pacific peoples have a higher prevalence of asthma than people of other ethnicities
and are more likely to be severely affected by it. Now that the guidelines provide clarity around initiating ICS and it is a standard recommendation that
everyone gets ICS regardless of asthma severity, inequities in asthma outcomes should be reduced.
Figure 2. Percentage of patients aged ≥ 12 years receiving inhaled asthma medicines in 2019 who were dispensed
two or more SABA inhalers without an ICS from community pharmacies, by ethnicity.
Consider the data and reflect on whether there are any differences in terms of age or ethnicity in the
number of patients who were dispensed SABA-only treatment.
Use of more SABA than ICS suggests that asthma control is not optimised, and the patient is at increased risk for poor asthma outcomes.
This section shows data of SABA dispensing relative to ICS dispensing in patients aged ≥ 12 who received both an ICS and SABA in 2019.
Nationally, nearly 50% of patients who were dispensed both an ICS and SABA were dispensed more SABA than ICS. While this likely
includes people who are adherent to their daily ICS regimen but are dispensed extra SABA, e.g. to keep at work, in the car or in their
sports bag, it also suggests there may be a number of people who do not have their asthma control optimised (Figure 3).
Figure 3. Percentage of patients aged ≥ 12 years receiving both an ICS and SABA who were dispensed
more SABA than ICS, more ICS than SABA and equal ICS and SABA from community pharmacies in 2019.
Māori and Pacific peoples were more likely to have more SABA dispensed than ICS (55% and 52%, respectively) when compared to
European/Others (44%) and Asian peoples (45%) (Figure 4). Switching adolescents and adults who are not regularly taking an ICS to a
combination medicine, i.e. budesonide/formoterol, is likely to improve symptoms and reduce the risk of exacerbations, and help to reduce inequities in asthma outcomes.
Figure 4. Percentage of patients in New Zealand aged ≥ 12 years receiving both an ICS and SABA who were dispensed more
SABA than ICS, more ICS than SABA and equal ICS and SABA from community pharmacies in 2019, by ethnicity.