A better way to manage asthma; maintenance and reliever therapy

Asthma affects your airways in two ways:

1. Airway tightening, causes wheeze and can make it feel hard to breathe. This can be relieved by airway openers (or bronchodilators).
2. Airway swelling and inflammation. This is the fundamental problem in asthma, which makes you more prone to airway tightening, and can cause cough and mucus production. It is best treated with preventer inhalers (inhaled steroids). If you have untreated airway inflammation you are at risk of an asthma attack.

A major problem with the way we treat asthma in the UK (and many other countries), is that we focus too much on treating airway tightening with fast-acting airway openers (blue reliever sprays), and don’t treat the airway inflammation enough. People with uncontrolled airway inflammation suffer more symptoms, need more doses of their reliever inhaler, and are at greater risk of flare-ups and hospital admissions. People who need 3 or more blue inhalers a year are at greater risk, but we know about half of asthma patients in the UK fall into this category.

Conversely, we know that people who take regular controller therapies for their asthma are less likely to have flare-ups requiring hospital admissions. For good asthma control, it’s vital to treat both the inflammation and the airway tightening.

So how can we make sure we’re controlling airway inflammation at the same time as relieving symptoms caused by airway tightening? Quite simply by using a combination inhaler that contains a fast-acting airway opener as well as a steroid to control airway inflammation. This approach is now recommended first-line in international guidelines. It exists as an option in UK guidance (from NICE) but I think it’s an under-used strategy. It has the potential to simplify treatment, reduce the risk of severe exacerbations, reduce your overall exposure to steroids (as the amount of steroid in the inhaler is tiny compared to the amount in a tablet if you need a course of steroid tablets to treat a flare-up), and reduce carbon footprint as you’re no longer relying on the blue reliever inhaler.

Combination inhalers may be more expensive for the NHS, but because they can improve overall asthma control they are cost-effective. If you pay for your prescriptions, it could be cheaper for you.

There are various inhaler options licensed for using the MART approach, including several choices of great propellant-free inhalers.

For more detailed information look at the asthma UK website, or talk to your healthcare professional.

https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-spacers/mart/

References

Schatz M. et al. Validation of a beta-agonist long-term asthma control scale derived from computerized pharmacy data. J Allergy Clin Immunol. 2006 May;117(5):995-1000. doi: 10.1016/j.jaci.2006.01.053.

Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000 Aug 3;343(5):332-6. doi: 10.1056/NEJM200008033430504. PMID: 10922423.

Cusack RP, Satia I, O’Byrne PM. Asthma maintenance and reliever therapy: Should this be the standard of care? Ann Allergy Asthma Immunol. 2020 Aug;125(2):150-155. doi: 10.1016/j.anai.2020.04.009. Epub 2020 Apr 24. PMID: 32339657.

Wilkinson, A, Woodcock, A. The environmental impact of inhalers for asthma: A green challenge and a golden opportunity. Br J Clin Pharmacol. 2022; 88( 7): 3016– 3022. doi:10.1111/bcp.15135

Greenhouse gas emissions associated with asthma care in the UK: results from SABINA CARBON Alexander Wilkinson et al. European Respiratory Journal Sep 2021, 58 (suppl 65) OA76; DOI: 10.1183/13993003.congress-2021.OA76