How can you persuade this patient to give up their salbutamol inhaler?

Specialist respiratory nurse in primary care Marieke Strange advises on how to educate patients with asthma about why it is so important they swap their ‘blue’ salbutamol inhaler for a new combination inhaler

The dilemma: You are reviewing an adult female patient in their early 20s who was previously diagnosed with mild asthma and is currently prescribed a salbutamol inhaler. In line with updated NICE guidelines, you explain that she should now be switched to a different, combination inhaler, to improve her asthma management. However, she is reluctant to give up her blue inhaler – she says it definitely helps her breathe and it makes her feel safe being able to use it on the odd occasions she needs to. How can you convince her she would be better to switch to a combination?

Answer: This is a very common scenario and presents an interesting challenge.

Following the recent update to the NICE asthma guidelines, any patient newly diagnosed with mild asthma, or previously diagnosed and prescribed a short-acting beta agonist (SABA) inhaler on its own for symptom relief, as in this case, should now be prescribed anti-inflammatory reliever (AIR) therapy with a combination inhaler instead of a SABA.

Hence this patient with mild asthma should have her salbutamol inhaler prescription switched to a combination inhaler including the long-acting beta agonist (LABA) formoterol and an inhaled corticosteroid (ICS).

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This switch to a combination inhaler is sometimes easier said than done, however.

Patients can become reliant on their SABA inhaler as it provides immediate symptom relief, and may fear not being able to reach for their blue inhaler when feeling breathless. Their symptoms may not (yet) have been serious enough to make them think about the need for any preventive treatment.

The change to a breath-actuated, dry powder inhaler (DPI) from a pressurised metered-dose inhaler (pMDI) can also put patients off using it. Most salbutamol inhalers are pMDIs and not used with a spacer (even though they should be), meaning patients get an instant ‘hit’ at the back of their throat. They will not get this from a dry powder inhaler (DPI) which is commonly used for AIR regimens so it feels different to what they are used to.

Some patients also fear the use of steroids – often described as ‘steroid phobia’ – and so are averse to using a steroid inhaler regularly.

In addition, many of these patients have previously been prescribed an inhaled corticosteroid (ICS) as well as their SABA before being stepped down, so have been educated on how important it is to use two separate inhalers, one preventer and one reliever.

Note all these challenges can also arise with patients with for mild-to-moderate asthma who, due to poor control, need to be switched to a single combined inhaler. Under the new asthma guidelines, anyone newly diagnosed with mild-to-moderate symptoms should now also be prescribed a single combination inhaler containing formoterol and an ICS, for maintenance and reliever therapy (MART), instead of separate ICS and SABA inhalers. In addition, existing asthma patients with poorly controlled asthma on an ICS and SABA should be switched to a MART combination inhaler.

In practice, we often find patients on both an ICS and SABA are over-using their reliever inhaler (commonly while also underusing their ICS) even when they are not really aware their symptoms are not controlled. Use of three or more SABA inhalers in a year is known to be associated with increased morbidity and mortality. It is therefore important at asthma reviews to not only thoroughly discuss patients’ symptoms but also check in their records how many prescriptions of SABA inhaler they have received in the past year.

How can this problem be overcome?

Patient education is the key to addressing these challenges.

Patients will be used to getting the instant relief from their salbutamol inhaler and may feel it’s convenient and works for them, so why should they change?

It is vital to explain that the old SABA inhaler is not only failing to treat the cause of their symptoms, but also potentially masking progression of their underlying disease.

Reassure them that the longer acting bronchodilator formoterol within the combination inhaler will work rapidly to relieve symptoms, as fast as salbutamol (3-5 minutes), while at the same time addressing the cause of the symptoms by delivering the steroid and reducing the underlying inflammation. That means they are less likely to experience exacerbations, or asthma attacks, in future.

It can help to frame the new inhaler prescription as an ‘upgrade’, rather than a change, to reassure them.

Patients may take time to adjust to a DPI for the reasons described above. As ever it’s vital to demonstrate how to use the new inhaler properly. In addition, take time to explain that it may feel quite different to their old SABA inhaler but that doesn’t mean it’s not working – and in fact when used correctly the medication is being delivered more effectively.

To address ‘steroid phobia’ it is important to explain that potential side effects with this type of treatment are relatively mild, and that the dose is always kept to the lowest level required to control symptoms. Any side effects can also be minimised by ensuring they follow the correct inhaler technique, always using a spacer with a pMDI and by gargling and rinsing the mouth.

Some other points to help convince patients include:

The patient will only need one inhaler instead of two, which should save them some money as they only they have only the one prescription charge.
There is also only one inhaler technique to be mastered and this means whenever they take the inhaler, they will be getting more effective relief as well as prevention, by better treating the symptoms and the underlying inflammation.
If patients are very resistant, I do sometimes go in with the hard facts and these are that the UK is performing the worse in Western Europe with the highest rate of asthma hospital admissions and child asthma deaths and, unfortunately, a lot of them are preventable. The National Review of Asthma Deaths (NRAD) report by the Royal College of Physicians in 2014 showed that many preventable asthma deaths in the UK are due to overreliance on salbutamol inhalers: out of 195 people who died from asthma, over three-quarters had been prescribed more than three SABA inhalers and over half more than six SABA inhalers in the previous year; some had been issued as many as 12. A subsequent review of NRAD in 2022 found that the number of asthma deaths had actually increased, from 1,281 in 2014 to 1,465 to 2022. The move away from SABA inhalers in the new asthma guidelines is an important part of implementing safer asthma care. Sometimes the ‘shock factor’ of such information helps to shift people’s understanding.
It may help to highlight that this is now part of official Government drug safety advice to prevent SABA overuse, and that SABA use is associated with adverse airway changes such as increased inflammation and reduced bronchodilation response.

Practical pointers

Always provide patient leaflets and signpost to online resources to support patients with using their new inhaler.
When changing patients’ inhalers it’s vital to schedule a follow-up appointment 4-6 weeks later, either a phone call or face to face appointment, to discuss how they are getting on with a new inhaler.
It is also essential to ensure the new inhaler prescription is put onto their repeat template, and the old one taken off (which can be missed, so the patient by default reverts to the old regimen).
It goes without saying that good inhaler technique must be shown and checked and the inhaler prescribed as per guidelines. An asthma action plan should always be part of your review, especially if the treatment has been changed.
To assist with supporting patients to make the switch to AIR or MART in a timely way, ask your IT department to help you with a search for patients who are still being prescribed a SABA only, so you can address this with them at the next earliest opportunity.
In addition, you can run searches for patients who have been prescribed more than three SABA inhalers in the past year. The list may be long, so this can be flagged for actioning at the patients next review/annual review.

Marieke Strange is a specialist respiratory nurse in primary care

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