An estimated million people with asthma in the UK could be teetering on the edge of a life-threatening asthma attack because they’re relying on their reliever inhaler rather than using a preventer inhaler which addresses the cause of their symptoms, according to new research by Asthma + Lung UK1.
There are two types of inhaler – a preventer which should be used every day to keep down inflammation and swelling in the airways and prevent someone having an asthma attack if they come into contact with something that triggers their asthma like dust, pollen, pollution, smoke or animal hair. A reliever inhaler (usually blue) should be used when someone has asthma symptoms like coughing and wheezing. But a new survey from Asthma + Lung UK of more than 8,000 people with asthma suggests 1 in 5 people with the condition are using their reliever inhaler too often, blitzing through six or more every year – triple the amount experts suggest. When applied to the general population of people with asthma this equates to more than one million people.
Overusing a reliever inhaler puts people more at risk of an asthma attack, hospitalisation and even death, because their asthma is less likely to be under control. Currently, 75,000 people are hospitalised for asthma every year and four people die every day from an asthma attack2.
The reasons for people using so many reliever inhalers are complex. They may not have been prescribed a preventer inhaler, because guidelines from the National Institute for Health and Care Excellence (NICE) around preventer prescription are outdated. Current NICE guidelines still recommend a reliever inhaler as the first line treatment for people who don’t have regular asthma symptoms and do not reflect evidence showing how important it is to prescribe a preventer inhaler alongside reliever inhalers.
Other reasons people may be overusing their inhalers include that asthma is very frightening and people can feel dependent on their reliever inhaler. Another reason is that a person may have a more serious form of asthma called severe asthma, which doesn’t respond to usual treatments and may mean they need more specialist care.
There’s a lack of education and understanding about how serious asthma can be, what the signs and symptoms are and how to manage them. Good asthma care can really help people get a handle on their condition, yet basic care rates are dismal. Last year in the UK, according to our survey 70% of people with asthma missed out on getting the three elements of basic asthma care from their GP or asthma nurse: an inhaler technique check, a written asthma plan and an annual review. This equates to around 3.8 million people with asthma not getting even the most basic elements of care.
Asthma + Lung UK is calling for a joined up approach to tackle the overuse of reliever inhalers.
Healthcare professionals need to have the time and resources available to understand each asthma patient to ensure they get the basic care they need and understand what their inhalers are for and how to use them. NICE needs to update guidelines to ensure more patients have preventer inhalers and don’t rely on their reliever inhalers. The charity also wants everyone with asthma to be aware of how to manage their condition well including what inhalers to use and how to use them by checking out the advice on its website and to speak to their GP, asthma nurse or pharmacist if they are using their reliever inhaler more than three times every week – a sign their asthma is not under control and they are at a greater risk of an asthma attack.
These changes, along with an increased awareness of the seriousness of lung conditions, would be a ‘vital stepping stone’ in tackling the dismal state of asthma care in the UK. We have one of the worst asthma death rates in Europe3 and Asthma + Lung UK, which funds research into lung conditions, campaigns for better diagnosis and access to treatment and campaigns for clean air, is urging government, the NHS and research funders to help cut deaths from lung conditions by 20% by 20274.
The charity is supportive of NHS England’s recently introduced measures to reduce the use of reliever inhalers and increase the use of preventer inhalers, as well as an education programme aimed at increasing awareness of this issue among healthcare professionals.
Paul Wilson, 47, from Beith near Glasgow, has asthma and says that during periods of poor asthma management he was “overmedicating” on his reliever inhaler, using up around one a month. Paul ended up in hospital 48 times because of his asthma and had to be resuscitated on 25 occasions. He says:
“I fell into bad habits with my reliever inhaler. My asthma was just so out of control that I felt myself reaching for my reliever inhaler every day, thinking it was the only thing that would help my symptoms. Looking back, I was just taking a puff and hoping for the best. While my reliever inhaler did help in the moment it was only a temporary fix, and I wasn’t giving too much thought to how to manage my asthma in the longer term.”
Paul missed out on vital inhaler technique checks and a review of his medication with his GP because he missed his yearly asthma reviews. Paul’s son being born was the wake-up call he needed to get his asthma under control.
“I couldn’t even push my son in his pram without getting out of breath. My attitude changed almost overnight and I realised I needed help. I booked an appointment with my asthma nurse for a medication review. They said the way I was using my inhaler meant that only 10-20% of the medicine was getting into my lungs. They showed me the correct inhaler technique and gave me a spacer to use, and the difference it has made to my asthma is incredible – I’ve even run marathons which would’ve been unthinkable just a few years ago.”
After using his reliever inhaler almost daily for years, Paul, who is now training to be a nurse inspired by the care he received, is now managing his asthma effectively by taking his preventer inhaler regularly and hasn’t had to take his reliever inhaler this year so far.
Dr Andy Whittamore, Clinical Lead at Asthma + Lung UK and a practising GP, says:
"“It’s vital that people with asthma have access to a preventer inhaler and take it every day, as this keeps the inflammation down in your airways and prevents symptoms. You should still take your reliever inhaler when symptoms come on. But if you are needing it three times a week or more, this is a sign of untreated inflammation in your airways and it’s really important you make an appointment with your GP, nurse or pharmacist to discuss your treatment options. You can also give the Asthma + Lung UK helpline a call on 0300 222 5800 or get information from our website at asthma.org.uk/advice/inhalers-medicines-treatments/ We also have some helpful inhaler technique videos to help people learn how to use their inhalers properly asthma.org.uk/advice/inhaler-videos/."
Sarah Woolnough, CEO of Asthma + Lung UK, says:
“People with asthma are being let down by dismal rates of basic care caused by pressures on the NHS and outdated treatment guidelines. Four people still die of an asthma attack every day but deaths from asthma are often preventable. We don’t want to see any more lives needlessly cut short. We are urging NICE to update its guidelines for healthcare professionals so that relievers are no longer prescribed without preventative treatment and we need to see an urgent increase in basic care such as yearly asthma reviews and inhaler technique checks so people are better equipped to manage their symptoms and use their inhalers effectively.”
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What is a preventer inhaler?
A preventer inhaler is the main way to treat asthma. It contains a low dose of steroid to keep down swelling in the airways. Preventer medication should be taken every day at the same time. By taking preventer medication every day, you should notice you’re less sensitive to your asthma triggers and don’t need your reliever inhaler as much. Examples include Symbicort, Seretide and Fostair.
What is a reliever inhaler?
A reliever inhaler provides quick relief when asthma attack symptoms come on. They work by relaxing the muscles in the airways so you can breathe more easily. Examples include Airomir, Salamol and Ventolin.
Both preventer and reliever medicine can come in different types of inhaler devices, such as:
- Metered dose inhalers, which give the medicine as an aerosol.
- Breath actuated inhalers, which automatically release a spray of medicine when you begin to inhale.
- Dry powder inhalers, which give the medicine as a dry powder instead of a spray.
There are some inhalers that can act as both preventer and reliever. This means that if someone needs to take an extra dose because they are getting symptoms, they also get an extra dose of preventer to help treat the cause of those symptoms. Not all preventers can do this and we would suggest someone should speak with their GP, nurse or pharmacist if they are unsure.
Asthma + Lung UK
Asthma + Lung UK is the only charity in the UK fighting for everyone with a lung condition, aiming for a world where everyone can breathe with healthy lungs. We fund research. We provide advice and support for the 12 million people who will get a lung condition during their lifetime. We campaign for clean air and we campaign for better NHS diagnosis and treatment. For further information visit asthmaandlung.org.uk
1 – Asthma + Lung UK Fighting back: Transforming asthma care in the UK Available at: https://www.blf.org.uk/sites/default/files/Fighting%20back_V3.pdf
Asthma + Lung UK surveyed 8,300 people from September 2021 to January 2022 about their experiences with asthma. Of this number, 215 responses were by people under 18, or by those who care for them.
More than one in five (21%) people we surveyed said they had used six or more relievers in the last year. We used this data to assess the risk of overreliance on reliever inhalers in the general asthma population. This is 5.4 million people (Estimate from Health survey for England, 2001; Scottish Health survey, 2003; Welsh Health survey, 2005/6; Northern Ireland Health and Wellbeing survey, 2005/6. Data accessed via UK Data Service: https://ukdataservice.ac.uk/)
2 – Asthma + Lung UK Asthma data visualisations Available at: https://www.asthma.org.uk/support-us/campaigns/data-visualisations/
3 – Eurostat Causes of death – standardised death rate by NUTS 2 region of residence Available at: https://ec.europa.eu/eurostat/databrowser/view/HLTH_CD_ASDR2__custom_2203967/default/table?lang=en
4 – Asthma + Lung UK Fighting for Breath: Strategy to 2027 https://www.asthmaandlung.org.uk/sites/default/files/2023-01/ALUK_Fighting_for_Breath_Strategy_to_2027_report_v6.pdf