1 September 2020
This article is authored by
Dr Alan Kaplan, Honorary Professor of Primary Care in Respiratory Medicine and Chairperson of the Family Physician Airways Group of Canada based in the York Region, Ontario, Canada
When asthma patients are over-reliant on their short-acting beta-agonist (SABA) reliever inhaler they are at an increased risk of asthma attacks,1,2 hospitalisation3,4 and, in some cases, early mortality.3,4 It is vital that we as respiratory physicians address this major public health challenge and act now to break this cycle of SABA over-reliance.
The problem with SABA over-reliance
Around 339 million people around the world have asthma5 and many of these patients are struggling to properly manage their condition.6-9 Asthma experts believe that a significant factor in this is the “asthma paradox”, where reliance on a short-acting reliever inhaler, usually a blue inhaler which contains the SABA rescue medication, is perceived by the patient to be controlling the disease, but due to lack of treatment of the underlying inflammation, is actually putting patients at greater risk of a potentially life-threatening attack.10
Recommendations from around the world, including the Global Initiative for Asthma (GINA), suggest that if a patient is using a short-acting reliever inhaler more than three times a week, this is a strong warning sign of poor asthma control and a predictor of future asthma attacks.1,2
Patients prescribed three or more SABA canisters per year are more likely to have an asthma attack and even die prematurely.3,4 Yet the SABA inhaler remains first-line treatment when a patient presents with asthma and, as they use it to successfully relieve their symptoms, this forges a relationship of reliance for life.10-12
SABA inhalers have no inherent anti-inflammatory pharmacological properties and therefore do not control the underlying airway inflammation that causes asthma.10 In fact, overuse of SABA inhalers can mask the progression of the disease and increase hyper-responsiveness in the airways, leading to greater sensitivity to triggers.13 As such, the patient is not getting the correct treatment for their asthma right from the beginning.
It also presents a problem for doctors because patients tend to over-estimate their control of their condition.6,14 Subsequently, when a clinician recognises overuse of a SABA inhaler, it can be hard to get patients to understand the value of using a maintenance, anti-inflammatory inhaler,14 and still rely on the symptom relief provided by the SABA. Most patients want immediate relief from symptoms, and many don’t realise they need to take maintenance medication, even when they feel well.14,15
We also should not underestimate the public health challenge this ingrained behaviour poses, as there has been no improvement in asthma mortality over the last 25 years.16 This issue does not just cost lives, as evidenced by two studies in Brazil and British Colombia, Canada that showed uncontrolled asthma can result in a more than two-fold increase in direct health costs.17,18 Poorly controlled asthma is also associated with reduced productivity and increased healthcare utilisation caused by increased days off work and school, doctor visits and hospitalisations.19
Time for action
It is vital that the respiratory community takes action now to break this cycle of over-reliance on SABA inhalers.20 Updated recommendations from GINA recommend against the use of SABA reliever therapy alone,1 yet despite the evidence, SABA over-reliance continues.21 We know that changing behaviour is challenging, but it is up to us as respiratory physicians to ensure that our patients don’t continue to manage an inflammatory disease with a treatment that doesn’t address this inflammation.21
To achieve better asthma outcomes, patients must be encouraged to attend regular reviews. In the UK, almost two thirds (65%) of people with asthma do not receive a yearly review, despite recommendations by The National Institute for Health and Care Excellence (NICE) that they should.22,23 These reviews are important to ensure that a patient’s asthma is controlled, they are using their inhaler properly and they have a clear written asthma action plan to follow.24 We need to make sure these reviews take place to educate patients about how to control their asthma and make them aware of the range of treatments available. We must also push for clearer policies around the treatment of this disease to avoid preventable deaths from uncontrolled asthma. At each review, there should be an assessment of comorbidities, inhaler adherence, inhaler technique, lung function and patient goals.
Poor adherence to regular controller therapy has long been an issue that prevents optimal asthma control. The GINA recommendations clearly say that optimal treatment of asthma for adults and adolescents is with inhaled corticosteroids (ICS)-containing controller treatment.1 This can be either as regular maintenance with an ICS alone, or in combination with a long-acting beta agonist (LABA) and, in mild asthma, as ICS-formoterol used as the preferred reliever instead of a SABA due to its anti-inflammatory properties.1 This allows ICS use to align with many patients’ innate desire to have control over their condition and take medication when needed, rather than regularly.21
Rethinking asthma treatment
The respiratory community is seeking a rethink in the way asthma is treated.21 The Break Over-Reliance public health campaign is being launched by AstraZeneca around the world to inform, educate and encourage action among patients, HCPs and policymakers to question deeply rooted behaviours, perceptions and policies related to asthma treatment and the risks of SABA over-reliance.
An integral part of this initiative is to encourage patients to take the Reliever Reliance Test, a new patient-friendly digital tool designed to identify whether a patient might be over-reliant on their SABA inhaler.25
The five questions are based on a validated SABA Reliance Questionnaire26 and will help clinicians understand the depth of the relationship an individual patient has with their SABA to allow patients with asthma to work with their doctor to understand whether they might be relying too heavily on SABA use alone. Encouraging patients to take the Reliever Reliance Test can help initiate conversations between doctors and their patients about the choice of asthma treatments available.*
The Break Over-Reliance campaign aims to help patients with asthma and the healthcare professionals that support them understand that over-reliance on the use of SABA inhalers to control asthma symptoms increases their risk of asthma attacks. This could be an important first step towards better controlled asthma, fewer hospitalisations and the avoidance of preventable deaths. And it has the potential to deliver significant benefits to asthma patients, their doctors and healthcare systems around the world.
*The SABA Reliance Questionnaire (SRQ): a novel screening tool to identify patients’ beliefs underpinning over-reliance on short-acting beta2 agonists in the management of asthma study was supported by Spoonful of Sugar Ltd, a UCL Business spin-out company, in collaboration with IPCRG and Asthma Right Care, with funding from AstraZeneca. AstraZeneca had no part in the design, data collection, analysis, or interpretation of the study data.
1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2020 Update.
2. Asthma UK: Reducing prescribing errors in asthma care. Available at:
3. Stanford RH, Shah MB, D’Souza AO, et al. Short-acting β-agonist use and its ability to predict future asthma-related outcomes. Annals of Allergy, Asthma & Immunology. 2012; 109: 403-407
4. Nwaru BI, Ekström M, Hasvold P, et al. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020;55(4):1901872.
5. The Global Asthma Network. The Global Asthma Report 2018. Available at:
6. Ding B, Small M. Disease Burden of Mild Asthma: Findings from a Cross-Sectional Real-World Survey. Adv Ther 2017; 34 (5): 1109–27.
7. Nathan RA, Thompson PJ, Price D, et al. Taking aim at asthma around the world: global results of the Asthma Insight and Management Survey in the Asia-Pacific Region, Latin America, Europe, Canada, and the United States. J Allergy Clin Immunol Pract 2015; 3: 734–742 e735.
8. Price D, Fletcher M, van der Molen T. Asthma control and management in 8,000 European patients: the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey. NPJ Prim Care Respir Med 2014; 24: 14009.
9. Demoly P, Annunziata K, Gubba E, et al. Repeated cross-sectional survey of patient-reported asthma control in Europe in the past 5 years. Eur Respir Rev 2012; 21: 66–74
10. O'Byrne PM, Jenkins C, Bateman ED. The paradoxes of asthma management: time for a new approach? Eur Respir J. 2017; 50 (3): 1701103.
11. Reddel HK, Ampon RD, Sawyer SM, Peters MJ. Risks associated with managing asthma without a preventer: urgent healthcare, poor asthma control and over-the-counter reliever use in a cross-sectional population survey. BMJ Open. 2017; 7 (9): e016688-e.
12. Cole S, Seale C, Griffiths C. ‘The blue one takes a battering’ why do young adults with asthma overuse bronchodilator inhalers? A qualitative study. BMJ Open. 2013;3(2): e002247.
13. Beasley R., Bird G., Harper J., Weatherall M. The further paradoxes of asthma management: Time for a new approach across the spectrum of asthma severity. Eur Respir J. 2018; 52 :1800694 doi: 10.1183/13993003.00694-2018
14. Bidad N, Barnes N, Griffiths C, Horne R. Understanding patients' perceptions of asthma control: a qualitative study. Eur Respir J. 2018;51(6):1701346.
15. Partridge MR, van der Molen T, Myrseth S-E, et al. Attitudes and actions of asthma patients on regular maintenance therapy: The INSPIRE study. BMC Pulm Med 2006; 6:13
16. Ebmeier S, Thayabaran D, Braithwaite I, et al. Trends in international asthma mortality: analysis of data from the WHO Mortality Database from 46 countries (1993-2012). Lancet. 2017; 390 (10098): 935-945.
17. Santos LA, Oliveira MA, Faresin SM, et al. Direct costs of asthma in Brazil: a comparison between controlled and uncontrolled asthmatic patients. Brazilian Journal of Medical and Biological Research 2007; 40 (7): 943-948
18. Sadatsafavi, M L Lynd, C Marra, et al. Direct health care costs associated with asthma in British Columbia. Can Respir J 2010; 17 (2): 74-80
19. Nunes C, Pereira AM, Morais-Almeida M. Asthma costs and social impact. Asthma Res Pract. 2017; 3: 1.
20. Kaplan A. SABA over-reliance; time for a change. J Lung Pulm Respir Res. 2019;6(4):101‒102
21. Kaplan A, Mitchell PD, Cave AJ, et al. Effective Asthma Management: Is It Time to Let the AIR out of SABA? J Clin Med. 2020; 9 (4): 921.
22. Pharmaceutical Services Negotiating Committee -- Essential facts, stats and quotes relating to asthma. Available at:
23. National Institute for Health and Care Excellence -- Asthma scenario follow-up [ONLINE] Available at: https://cks.nice.org.uk/asthma#!scenario:1 [Last accessed: July 2020]
24. Pinnock H. Supported self-management for asthma. Breathe (Sheff). 2015; 11 (2): 98-109.
25. International Primary Care Respiratory Group. Blue Reliever Reliance Test. Available at:
26. Chan AHY, Katzer C, Kaplan A, et al. SABA Reliance Questionnaire (SRQ): identifying patient beliefs underpinning reliever over-reliance in asthma [published online ahead of print, 2020 Jul 20]. J Allergy Clin Immunol Pract. 2020; S2213-2198(20)30722-4. : doi:10.1016/j.jaip.2020.07.014.
You have selected a link that will take you to a site maintained by a third party who is solely responsible for its contents.
Click ‘cancel’ to return to AstraZeneca’s site or ‘continue’ to proceed.