Patient and physician factors contributing to excessive use of SABA monotherapy

Although no longer recommended as a preferred reliever in symptomatic patients, inhaled SABA has been the mainstay asthma therapy since the 1950s, providing rapid bronchodilation and quick relief from acute symptoms [16, 17]. The identification of the inflammatory component of asthma pathophysiology in the 1990s led to the recommendation of an ICS-long-acting beta-agonist (LABA) combination as maintenance therapy and prompted switching inhaled SABAs to an as-needed treatment modality in the early 2000s [16]. Despite the 2019 GINA paradigm-shifting recommendation discouraging the use of SABA-only relievers, persistent reliance on it continues in the Gulf Region due to multiple physician- and patient-related factors, posing a challenge in achieving optimal asthma control (see Table 1) [15, 17,18,19,20]. As a part of the international CARBON program, a study retrospectively assessing the carbon footprint of SABA and controller inhalers across various countries found that SABA utilization accounted for 70% of total inhaler use and SABA-related greenhouse gas (GHG) emissions constituted 78% of the total inhaler-related GHG emissions in the UAE [21].

Table 1 Patient and physician factors that lead to overreliance on SABA-only relievers

Asthma patients have become so accustomed to SABA relievers that they instinctively reach for them whenever symptoms arise, often without realizing that the underlying inflammation is not being addressed. Thus, to reduce patients’ excessive reliance on as-needed SABA relievers, GINA introduced the concept of the ‘anti-inflammatory reliever’ (AIR). The AIR involves the use of a reliever inhaler that includes a low-dose ICS and a fast-acting bronchodilator, i.e., ICS-formoterol for Track 1 patients or ICS-SABA for Track 2 patients. While the SABA-only reliever provides instant symptom relief, the rationale behind AIR use is to provide rapid symptom relief and reduce the risk of exacerbations in the future due to the inclusion of a small dose of ICS [5, 20].

Inadequate anti-inflammatory treatment can cause inflammation to go unchecked, decreasing lung function, worsening asthma control, increasing exacerbation risk, and causing airway remodeling [16, 22]. Regular SABA use can increase bronchial hyper-responsiveness, thereby making patients more sensitive to asthma triggers [23]. Overuse of SABA has been shown to increase the incidence of ED visits, hospitalizations, and the use of oral corticosteroids, and in an ED setting has also been associated with transient lactic acidosis, tachycardia, arrhythmias, QTc interval prolongation, hypokalemia, hypomagnesemia, muscle tremors and cramps, and anxiety [14, 24]. Additionally, overreliance on SABA relievers, which signals poor asthma control, has also been linked to an increased risk of death, prompting the Royal College of Physicians to recommend an urgent review of all patients prescribed > 12 short-acting relievers in the previous 12 months [25].

The US administrative claims data from IBM MarketScan research databases were analyzed to correlate the real-world prescription fill trends of SABA and maintenance medications with severe exacerbations in asthma patients (≥ 12 years old, N = 135,540). The results showed that 48.5% of the patients categorized as having well-controlled asthma (defined by 1 SABA fill per year) and reporting 53% adherence to maintenance medication also had at least one severe exacerbation per year. The findings indicate that there are gaps in the real-world SABA and maintenance therapy usage trends. The real-world use of SABA and maintenance therapy may not fully address the fluctuating nature of airway inflammation associated with asthma or eliminate the risk of asthma exacerbations, highlighting the importance of filling these gaps [26].

To reduce the risk of inappropriate use and overreliance on SABA-only therapy and to ensure inflammation is effectively targeted early on, experts from the Middle East and Africa (MEA) region and key opinion leaders (KOLs) from the Gulf Region have also advocated the adoption of SABA-alone-free clinical practice in both outpatient and ED settings and recommended the use of the ICS-SABA combination replacing SABA monotherapy in GINA Track 2 patients and facilitation of its availability in the region [14, 27]. The availability of both the ICS and SABA components in a single inhaler device can help reduce the risk of non-adherence associated with using 2 separate inhaler devices [27]. Additionally, the combination, which allows concomitant treatment of symptoms and inflammation, might ensure this ‘window of opportunity’ to reduce future exacerbation risk is not lost [28].

Patient behavior that tends to downplay the need for daily maintenance treatment and prioritize quick relief with a SABA inhaler represents a significant barrier to achieving optimal asthma control. The International Asthma Patient Insight Research (INSPIRE) study evaluated the attitudes towards asthma management of 3415 patients (≥ 16 years) from 11 countries with physician-confirmed asthma diagnoses and who were prescribed regular maintenance ICS therapy (with or without LABA). The study showed that 74% of these patients relied on at least one inhalation of SABA daily. Also, the level of control perceived by the patients varied from that assessed by the Asthma Control Questionnaire (ACQ). The study found that 87% of patients evaluated by the ACQ as having ‘not well-controlled’ asthma perceived their asthma control as ‘relatively good.’ Moreover, 55% of those with ‘uncontrolled asthma’ also thought their asthma control was ‘relatively good.’ Additionally, 54% of the patients felt concerned about taking medications during symptom-free periods, 39% believed there was no need to take daily treatment when they felt well, and 90% preferred treatments providing instant relief [29]. Patient misconceptions about the importance of maintenance treatment and overreliance on SABA increase the risk of non-adherence to prescribed treatments and underscore the pivotal role of patient education in overcoming this barrier.

The role of ED physicians in asthma care

We believe patients presenting to the ED with exacerbations represent a cohort with poorly controlled asthma, providing the ED physicians in the UAE hospitals with a unique opportunity to intervene favorably to optimize the disease course proactively. The role of ED physicians must extend beyond treating the acute symptoms to ensuring that patients are discharged on the best-suited, evidence-based asthma treatment plans. The ED physicians should be encouraged to identify the causes of exacerbations and take steps to help reduce the exacerbation frequency and, consequently, future ED visits. They can help patients identify and avoid triggers while emphasizing the importance of treatment adherence and guiding them on using the inhaler correctly, including with spacers when necessary. Educating patients on identifying triggers and warning signs of an impending exacerbation can allow them to seek early intervention. ED physicians can train patients to use peak flow meters and encourage them to maintain a diary with readings. Additionally, they can encourage patients to follow up with their primary care physicians for mild cases and with specialist pulmonologists for moderate-to-severe cases, who can evaluate the use of advanced therapies such as immunotherapy.

Collectively, these steps can help optimize long-term asthma control, reduce the burden on the UAE healthcare system, and contribute to a more efficient and sustainable healthcare framework.

Beyond the ED: optimizing a standardized discharge plan for adult asthma patients

The ESEM-ETS experts’ joint task force proposes establishing a structured, straightforward, and easy-to-follow discharge plan comprising a post-discharge asthma management strategy that can be integrated seamlessly into the UAE National Algorithm for the Management of Adult Asthma in the ED (see Fig. 2). This discharge plan aligns with the most recent GINA guidelines and can be used across all the hospitals in the UAE. The benefits of such a discharge plan encompassing a post-discharge management strategy will be two-fold — (1) It will allow all ED physicians to consistently adhere to GINA guidelines and practice evidence-based care, and (2) It will also help patients receive guidance to manage their symptoms optimally after getting discharged from a hospital. The availability of a discharge plan can streamline the discharge process without putting additional undue burden on busy ED physicians. The goals of implementing this discharge plan are shown in Table 2.

Fig. 2

Discharge plan integrated into the National algorithm for the management of adult asthma in the ED

Table 2 Goals of implementing a standardized discharge plan in the UAE hospitals

The joint task force also proposes implementing specific Key Performance Indicators (KPIs) that could be used to objectively evaluate treatment outcomes following patients’ index exacerbation (see Table 3). These KPIs would provide insights into the effectiveness of ED physicians’ prescribed interventions and help identify areas for further optimizing post-discharge patient care.

Table 3 Proposed key performance indicators (KPIs) during the measurement year post-index exacerbation