When it comes to asthma, albuterol is not enough!

It isn’t a secret that new things are slow to come to Shreveport. When this occurs for restaurants or shopping, the inconvenience is relatively minor. When this happens in medical management, people’s health, well-being and even lives can be at risk. Asthma management is one of those things I notice to be more out of date than VHS players.

The old affliction, asthma, is one of the most important diseases I treat as a specialist in allergy, asthma and immunology. It has an ancient pedigree going back to the days of Hippocrates in classical Greece. Seneca, tutor to Emperor Nero and a Roman senator, suffered from asthma and wrote the first autobiographical account of asthma attacks almost 2,000 years ago.

Over a thousand years later, Jewish philosopher and physician Maimonides wrote the first treatise on asthma, which was written in Arabic in 1198 AD. It was later translated into Hebrew and Latin and was extremely influential across the Christian, Jewish and Islamic worlds. One of his predecessors, Islamic physician Rhazes, noticed the link between hay fever (allergic rhinitis) and asthma and pollen’s role in triggering asthma attacks.

I recently read “Asthma: The Biography” by Professor Mark Jackson to see how far asthma diagnosis and treatment has come since the days of Seneca, Rhazes and Maimonides. This disease has many new high-tech biologic treatments invented in the 21st century that are bringing great success to our severe asthma patients. However, I notice time and time again many or even most adult and pediatric patients with mild and moderate disease are not even getting basic inhaler treatments recommended at least 30 years ago and in existence for over 50 years.

Albuterol inhalers (which reduce lung tightening in asthma for a few hours) came out in 1969 as Ventolin. In 1972, steroid inhalers (which reduce lung inflammation) came out in the form of beclomethasone. More than 20 years ago, a combination inhaler with a long-acting albuterol and steroids came out in the form of Advair. Nowadays, there are many different asthma inhalers, but the essential groups are still short-acting bronchodilators like albuterol, steroid inhalers (ICS) and combination inhalers with steroids and long-acting bronchodilators (LABAs).

In 1991, the National Institutes of Health (NIH) issued the first guideline for diagnosis and treatment of asthma. This guideline was updated many times, most recently in 2020. It classified asthma by severity (mild, moderate, severe) and frequency (persistent or intermittent).

For years, the guideline recommended albuterol only for mild, intermittent asthma for emergency only. Everyone else needed a daily steroid (ICS) inhaler usually with a spacer to reduce lung inflammation. Those with moderate or severe asthma may need a combination inhaler (ICS-LABA) to reduce inflammation and relax the lungs for longer periods of time.

Albuterol, which only lasts for a few hours, was to be used only for rescue and not as a daily medication no matter the severity of asthma. Excessive use of albuterol was a sign of uncontrolled asthma that needed stepped up treatment.

What changed in the 2020 edition? The NIH now recommends for most patients, the best rescue inhaler for emergencies should contain not albuterol but formoterol (an LABA). A combination steroid-formoterol inhaler has been found in multiple studies and in thousands of patients to be a better rescue inhaler than plain old albuterol. Inhalers containing formoterol include Dulera and Symbicort. They also recommended using ICS-formoterol for both maintenance and emergency treatment and forgetting about albuterol completely. This single inhaler therapy is called SMART therapy, for single maintenance and reliever therapy. That means you can take Symbicort or Dulera for your daily inhaler, and if you need an extra puff when short of breath or wheezy, take a puff of Symbicort or Dulera instead of albuterol.

SMART therapy has also been shown to work better than albuterol only as a rescue. There are some exceptions, but the general trend in medicine internationally is to move away from albuterol-only inhalers.

Meanwhile in Shreveport, I am not seeing many patients get even the 1991 recommendations, much less the 2020 recommendations. Many patients are undiagnosed or undertreated, even with family histories of asthma. Most are coming in with albuterol alone and without a steroid inhaler to reduce lung inflammation. Spacers are needed in most types of inhalers to work effectively, and this is infrequently prescribed by doctors or emphasized to patients. Asthma is one of the most common diseases, and basic management should be known by all physicians, not just allergists and pulmonologists.

Just because asthma is an ancient disease does not mean we need to treat it with ancient remedies. It is time for patients and doctors to get up to date on asthma. It’s not SMART to use only albuterol for asthma.

Anand K. Bhat, M.D., M.Sc. (allergy/asthma & clinical immunology) is in practice at Highland Clinic, 1455 E. Bert Kouns Industrial Loop, Shreveport, La.