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Alarming overuse of asthma inhalers in South Africa hinders effective treatment, study finds

Asthma is an inflammatory condition of the airways affecting more than 339 million. people globally. Picture:Supplied

Asthma is an inflammatory condition of the airways affecting more than 339 million. people globally. Picture:Supplied

Published Sep 12, 2023


Asthma affects millions of people worldwide, and inhalers are essential tools for managing its symptoms.

However, there is a growing concern about the overuse of these devices, which can inadvertently put individuals at risk and compromise their long-term health.

Asthma inhalers, commonly known as asthma pumps, provide quick relief during attacks and help control symptoms daily.

One of the dangers of overusing asthma inhalers is that it can mask the severity of an asthma attack or exacerbation.

Additionally, frequent or unnecessary use of inhalers can reduce their effectiveness over time. This can lead to diminished symptom control and the need for higher doses of medication, further exacerbating potential side effects. ( This phenomenon is known as “tachyphylaxis” or “tolerance”.

It occurs when the body becomes less responsive to the medication due to overexposure.)

In the case of asthma inhalers, the most common type of medication used is a bronchodilator, such as a short-acting beta-agonist (SABA).

These medications work by relaxing the muscles in the airways, opening them up and making it easier to breathe during an asthma attack or during times of increased symptoms.

Insufficient understanding of asthma management, triggers, and proper inhaler usage can lead to misuse or overuse of inhalers. Without adequate knowledge, individuals may attempt to manage their condition without proper guidance.

In South Africa, asthma affects more than 20% of children and 10-15% of adults, with an alarming number of deaths occurring each year.

Research, such as the recently published SABINA III study, highlights the issue of over-prescription and over-the-counter purchase of reliever pumps, despite new treatment guidelines.

Professor Ismail Kalla, a Pulmonologist and Head of the Department - of Internal Medicine at the University of Witwatersrand, points out that asthmatic patients have been overusing their blue SABA symptom-reliever inhalers for decades.

This overuse stems from the mistaken belief that it is the best way to control symptoms.

In line with new global and locally endorsed asthma treatment guidelines, a low-dose inhaled corticosteroid (ICS) formoterol therapy is now recommended as needed, regardless of asthma severity.

This combination inhaler contains an anti-inflammatory agent that reduces airway inflammation and provides controlled relief.

Asthma is an inflammatory condition of the airways affecting more than 339 million people globally. In South Africa, more than 20% of children and 10-15% of adults have asthma.

For those living with the illness, it can reduce quality of life in varying degrees and it’s not uncommon to be hospitalised during an attack.

Despite changes in the approach to treatment and evidenced-based medications to manage the condition, an alarming number of South Africans still die from asthma every year.

Treating asthma has evolved, but the SABINA III study reveals a slow adoption of new guidelines. The results show that nearly 75% of patients used more than three SABA canisters in the past year, and over 55% were prescribed more than 10 canisters.

These figures are alarming because evidence suggests that overusing SABA inhalers, especially using more than three canisters per year, increases the risk of asthma attacks, hospitalisations, and even death.

The importance of patients who fall into this category speaking with their doctors to reassess and revise their asthma treatment plans.

Chronic asthma control relies on anti-inflammatory maintenance, regardless of the severity of the illness. Professor Kalla explained that the approach to treating and managing asthma is almost the same for all patients, with reducing inflammation being the key focus.

The SABINA III study found that over 50% of patients with mild asthma had uncontrolled symptoms. The risk remains high regardless of severity, treatment adherence, or level of control.

Poor adherence to maintenance medication is believed to be the main reason for this continued lack of control.

The findings of the SABINA III study underscore the importance of following asthma treatment guidelines. Patients, regardless of asthma severity, should work closely with their healthcare providers to develop personalised treatment plans that prioritise anti-inflammatory maintenance.

By doing so, individuals can better manage their symptoms, reduce the risk of asthma attacks, and improve their overall quality of life.

“While there’s no cure for asthma it can be controlled and it’s important that asthmatics partner with their doctor to develop a solid asthma treatment plan that prioritises reducing inflammation safely,” said Professor Kalla.

“To illustrate how dangerous this inflammation can be for those who live with asthma, a global study reports that excessive inflammation causes 176 million asthma attacks annually. These attacks can be frightening, dangerous, and can be costly for the patients.”

To educate people living with asthma, and to help them reduce their risk of attacks, AstraZeneca is running the Break Over-Reliance campaign. Asthma patients can assess their levels of over-reliance through a digital assessment tool, known as the Reliever Reliance Test.

This evidence-based questionnaire empowers patients to assess their over-reliance on their blue reliever inhaler, SABA, by answering five short questions.

Professor Kalla added, “I strongly urge that everyone living with asthma take the test – it’s easy to navigate and will help them understand whether they are relying too heavily on their SABA.

“If the results indicate over-reliance, then that information can facilitate conversations with their healthcare professional about their asthma management.

“Recognising that the use of a SABA blue inhaler to control asthma symptoms actually masks symptoms and increases the risk of asthma attacks – action to correct asthmatic compliance has never been more important.

“When you consider that South Africa’s prevalence of asthma is among the highest in the world, the case for better control is urgently needed,” advised Professor Kallla.