Overview ^{1, 2}

·       Asthma is a common chronic respiratory disease, impacting both children and adults and stands as the most common chronic illness in children.

·       Mostly caused by airway inflammation and muscle tightening, leading to breathing difficulties.

·       Common symptoms include Persistent cough (especially at night), wheezing, shortness of breath, chest tightness, which worsens during night.

·       Triggers such asdust, smoke, pollen, animal fur, strong odors, certain soaps, and perfumes might often lead to occasional flare-ups or exacerbations.

·       Asthma treatment mostly includes use of an inhaler, which delivers medication directly to the lungs.

Asthma Treatment

• Patient education
• Minimizing exposure to asthma triggers
• Monitoring for changes in symptoms or lung function
• Pharmacologic therapy

Pharmacological therapy: Includes two main types of medications ^1,4

·       Relievers - Quickly open the airways to relieve acute symptoms

·       Controllers -  Reduce lung inflammation to prevent long-term symptoms; Include corticosteroids, beta2-agonists, and leukotriene antagonists

Challenges and Considerations ^5-7

·     Low medication adherence especially among adolescents and children

·     Adherence difficulties may arise due to forgetfulness, lack of routine, social stigma, and insufficient family support

·     Avoiding use of inhaled corticosteroid controllers and relying more on short-acting beta-agonist (SABA) relievers, which can lead to overuse, increased prescriptions, and increased asthma exacerbations.

·       Adverse effects of SABA overuse ^8,9

o   More frequent asthma exacerbations, harming patient health.

o   Males, adolescents, older adults, sedative/hypnotic users, and those with multiple health conditions are more likely to overuse SABAs

o   Lowers patients' overall and mental health, increasing risks for cognitive and mobility issues

Real world evidences ^{9, 10}

Study 1:

Excessive SABA use negatively impacts patients' self-perception of overall and mental health, increasing the risk of cognitive and mobility limitations. Patient perceptions play a key role in asthma management. One study found that SABA overuse was tied to patients’ perceived symptom severity, despite a weak correlation between actual lung function and these perceived symptoms.

Study 2:

A study by Stanford et al. shows that using two or more SABA canisters within six months doubles the risk of an asthma exacerbation. Each additional SABA canister increases the risk by 14-18%.

Benefits of Combining ICS and SABA ^{11, 12}

·       Enhances Control to achieve better overall asthma control and reduce symptoms.

·       Reduces Exacerbations: Lowers the frequency and severity of asthma attacks, leading to fewer emergency visits.

·       Lowers Medication Dosage: Allows for the use of lower doses of individual medications while still maintaining effective control.

·       Improves Lung Function: Can lead to better lung function and overall respiratory health

·       Increases Treatment Adherence: Fewer medications to manage can simplify treatment regimens, improving patient adherence

Clinical Evidence Supporting ICS-SABA Use ^{13, 14}

• A study by Reynold et al. (2024) revealed that asthma guidelines in the US recommend using a short-acting β2-agonist (SABA) in conjunction with an inhaled corticosteroid (ICS) as an alternative reliever at step 2 of treatment. In line with this recommendation, the FDA has approved a pressurized metered-dose inhaler that combines albuterol and budesonide. This inhaler is designed for on-demand treatment and prevention of bronchoconstriction, while also reducing the risk of exacerbations in adults with asthma.

o   The study involved 80 children aged 6 to 12 with mild chronic asthma. They were divided into two groups: one received SABA treatment alone, and the other received SABA in combination with inhaled corticosteroids.

o   The SABA-only group was treated as needed, while the SABA plus ICS group received regular therapy for symptom relief and maintenance. Spirometry measurements showed lower baseline values for both groups, indicating reduced lung function.

o   The study found that combining SABA with ICS therapy improved lung function in children with mild chronic asthma, indicating that this combination can enhance symptom management and lung function in children.

Conclusion

·       Administering SABA-ICS as needed, especially at the onset of worsening symptoms, can reduce exacerbation risks by delivering both genomic and non-genomic anti-inflammatory effects.

·       Combination therapy improves patient adherence, simplifies dosing regimens, and enhances therapeutic outcomes.

·       Combination inhalers enable a personalized approach to asthma management and simplify treatment complexity.

References

1.     POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION: GINA; 20234 [cited 2024 25-Oct-24]. Available from: GINA Pocket Guide 2023 (ginasthma.org) …

2.     Asthma: WHO; 2024 [cited 2024 28-Oct-24]. Available from: https://www.who.int/news-room/fact-sheets/detail/asthma.

3.     An overview of asthma management in children and adults 2024 [cited 2024 28-Dec-24]. Available from: https://www.uptodate.com/contents/an-overview-of-asthma-management-in-children-and-adults#:~:text=The%20four%20essential%20components%20of%20asthma%20management%20are,in%20symptoms%20or%20lung%20function%2C%20and%20pharmacologic%20therapy.

4.     InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Asthma: Learn More – Medication for people with asthma. [Updated 2022 Jul 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279519/

5.     Cochrane M, Horne R, Chanez P. Compliance in asthma. Respiratory medicine. 1999;VOLUME 93, ISSUE 11, P763-769(16-May-24).

6.     Vrijens B, Dima AL, Van Ganse E, van Boven JF, Eakin MN, Foster JM, et al. What We Mean When We Talk About Adherence in Respiratory Medicine. The journal of allergy and clinical immunology In practice. 2016;4(5):802-12.

7.     Papi A, Blasi F, Canonica GW, Morandi L, Richeldi L, Rossi A. Treatment strategies for asthma: reshaping the concept of asthma management. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology. 2020;16:75.

8.     Nwaru BI, Ekström M, Hasvold P, Wiklund F, Telg G, Janson C. Overuse of short-acting β(2)-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. 2020;55(4).

9.     Canonica GW, Paggiaro P, Blasi F, Musarra A, Richeldi L, Rossi A, et al. Manifesto on the overuse of SABA in the management of asthma: new approaches and new strategies. Ther Adv Respir Dis. 2021;15:17534666211042534.

10.  Stanford RH, Shah MB, D'Souza AO, Dhamane AD, Schatz M. Short-acting β-agonist use and its ability to predict future asthma-related outcomes. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. 2012;109(6):403-7.

11.  Brunaugh AD, Sharma S, Smyth H. Inhaled fixed-dose combination powders for the treatment of respiratory infections. 2021;18(8):1101-15.

12.  Asthma, Management and Treatment: CDC; 2023 [cited 2024 4-Apr-24]. Available from: https://www.cdc.gov/asthma/management.html .

13.  Reynold A. Panettieri Jr. M, Bradley E. Chipps M, Neil Skolnik M, Maureen George R, PhD, Kevin Murphy M, Njira Lugogo M. The Use of Albuterol/Budesonide as Reliever Therapy to Reduce Asthma Exacerbations: Journal of Allergy and Clinical Immunology: In Practice; VOLUME 12, ISSUE 4, P882-888, APRIL 2024; 2024 [cited 2024]. Available from: https://www.jaci-inpractice.org/article/S2213-2198(24)00145-4/fulltext#%20.

14.  Muhammad Amir GSLMSRFHFSDK. Effects of Short-Acting Beta-Agonist (SABA) Alone and SABA with Inhaled Corticosteroids in the Management of Asthma among Children. Pakistan Journal of Medica.