The Woolcock Institute of Medical Research

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Study Paints Grim Picture of Puffer Use

Thursday, August 15, 2019

Australian asthmatics are overusing reliever medication, according to new research that strongly suggests many are failing to manage their condition.

A study from the Woolcock Institute of Medical Research and the University of Sydney reveals for the first-time details surrounding a hidden population of people who buy their reliever puffer over the counter, with concerning results. 

More than two thirds of those surveyed overused their reliever, while in contrast a similar number did not use a preventer puffer regularly. Alarmingly, almost 20 per cent of people who bought their reliever without a prescription reported that they had not been diagnosed with asthma. The study is published in the prestigious international journal BMJ Open.

“Results show our concerns about asthma management are real,” says Professor Sinthia Bosnic-Anticevich, senior author and head of the Woolcock’s Quality Use of Respiratory Medicines Group, which is an affiliate of the University of Sydney. The high proportion of reliever overuse and the low proportion of regular preventer use is in complete contrast to what we would hope to see.”

She adds: “It’s well established that one of the key signs of poor asthma symptom control is the need for frequent reliever use. This research indicates that this is common, yet patients don’t seem to be complaining.”

Two million Australians - about one in ten - have asthma, a chronic lung condition that inflames and narrows the airways, causing wheezing, shortness of breath, chest tightness and coughing. The causes are still not well understood, but triggers are known to include viral infections, exercise, and exposure to allergens and irritants. 

Adherence to medications is poor, with many patients failing to use their preventer inhalers regularly, instead relying on reliever medication, the “ambulance-at-the-bottom-of-the-cliff” solution. Global asthma experts recently moved to officially condemn reliever-only use as a practice associated with high risk.

Australia is one of the few countries to make asthma relievers available through pharmacies without a prescription, which provides us with a unique opportunity to understand how patients truly use their relievers, with more than 60 per cent of people getting the medication this way. Researchers from the Woolcock and University of Sydney investigated the real-life purchase of short-acting beta agonists (SABA) in NSW pharmacies. The team examined questionnaires completed by 412 people buying SABA over the counter. Results showed 70 per cent of participants reported so-called “overuse” of SABA, that is more than the recommended maximum of twice a week within the last four weeks. 

“SABA overuse is very high, while preventer medication use remains low, a habit which can lead to poor outcomes and likely explains why only a quarter of over-the-counter purchasers reported well-controlled asthma,” Professor Bosnic-Anticevich says. “When you consider that there are potentially tens of thousands of people using their medication like this, it suggests that a considerable proportion of Australians are experiencing wheezing, chest tightness and, worse still, asthma flare ups, due to uncontrolled disease.”

The Woolcock expert explains that SABA therapy should be carefully restricted to ‘as needed’ usage only. “We know that using your reliever too much is linked to poor asthma control, increased airway hyper-responsiveness, more asthma-related hospital admissions and, in extreme cases, death,” Professor Bosnic-Anticevich says. “What we really need to understand is why this is happening.” 

“We absolutely don’t want to ask patients to withhold using their SABA if they need it, but we do need to solve the problem of why they need it or feel they need it,” she says. “It is critical that we support patients and work with them and their doctors to ensure that asthma flare ups are prevented, and overuse of SABA is not the answer.” 

The researchers are calling for more work to explore ways in which community pharmacists can identify these uncontrolled asthma patients and refer them onto treatment plans that improve asthma outcomes.

The paper, entitled Understanding reliever overuse in patients purchasing over-the-counter short-acting beta2 agonists: An Australian community pharmacy- based survey, was a collaboration involving the Woolcock Institute of Medical Research, Sydney Local Health District and University of Aberdeen, United Kingdom. 

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