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“Tossing a coin:” defining the excessive use of short-acting beta2-agonists in asthma – the views of general practitioners and asthma experts in primary and secondary care

Shauna McKibben, Andy Bush, Mike Thomas, et al.
NPJ Prim Care Respir Med 2018;28:26
doi: 10.1038/s41533-018-0096-4

The majority of UK asthma deaths are potentially preventable, a point made most recently in the National Report on Asthma Deaths (NRAD) ‘Why asthma still kills’, which identified high prescribing of short-acting beta-agonists (SABAs) as a contributing factor in over 40% of asthma deaths. NRAD recommended that prescribing more than one SABA per month should trigger an asthma review. Mortality and morbidity have been found to rise progressively with increasing numbers of SABAs dispensed per year, and the risk of hospital admissions is associated with the prescription of more than three SABAs per year.

McKibben and colleagues set out to identify how SABA overuse is defined and perceived by general practitioners (8), asthma experts in general practice (8) and asthma experts in hospital-based care (5).

They discovered disparity in how acceptable SABA use is defined (ranging from 100–2400 doses per year), and complacency in overuse being a marker for risk of asthma death. Some experts questioned the risk of morbidity and mortality with high SABA use, and were of the opinion that factors including low inhaled corticosteroid use, and markers of asthma attacks such as oral steroid use, hospital admissions and emergency department attendances were necessary to prompt clinical intervention. Asthma guidance was perceived not to reflect the real world, and to range from ‘silly’ to ‘stringent’.

They concluded that a more nuanced approach to managing those at risk of asthma attack is required, that there was shocking complacency about SABA overuse and that it will be difficult to reduce the number of asthma deaths unless attitudes are challenged and changed.

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