Learning outcomes

At the end of this article, you will be able to:

• Appraise GINA guidance on the use of inhaled short-acting β2 agonists (SABA);
• Compare current SABA prescribing and dispensing in your pharmacy against the updated GINA guidelines;
• Describe the uses and benefits of an asthma action plan; and
• Review and develop resources in your practice to support patients with asthma in using their asthma action plan effectively.

 

Did you see the October IPU Review? A CPD article on the GINA Global Strategy for Asthma Management and Prevention was featured in the October IPU Review. It provided an overview of the update, with a focus on how it relates to Irish community pharmacy.

The Global Initiative for Asthma (GINA) collaborates with healthcare professionals, patient representatives, and public health officials worldwide to reduce asthma prevalence, morbidity, and mortality.

Our CPD article in last month’s IPU Review provided a summary of the 2025 update to the GINA Global Strategy for Asthma Management and Prevention. This month’s article will explore the value of asthma action plans and highlight practical tools and resources for supporting patients.

 

GINA Guidance on the use of short-acting beta2-agonists

GINA has significantly revised its stance on the use of inhaled short-acting beta2 agonists (SABA) in asthma management. Historically, SABAs were widely used as first-line relievers for acute symptoms. However, GINA now discourages SABA-only treatment due to growing evidence of associated risks.

Key recommendations from GINA:

• Avoid SABA-only treatment: GINA emphasises that relying solely on SABAs increases the risk of severe exacerbations and asthma-related mortality;
• Preferred reliever strategy: The use of low-dose inhaled corticosteroid (ICS)–formoterol as both a controller and reliever is now recommended (Track 1);
• Alternative approach: SABAs may be used as relievers, but only alongside a regular controller (for example, daily ICS) (Track 2); and
• Monitor SABA use: Overuse (for example, more than three canisters per year — which averages to 1.5 doses per day) is a marker of poor asthma control and increased risk of emergency care.

  Image 1: GINA 2025 — Track 1 and Track 2 approach

Critical appraisal:

• Evidence-based shift: The guidance is grounded in robust clinical evidence showing that SABA overuse correlates with poor outcomes. This marks a paradigm shift from symptom relief to inflammation control;
• Patient safety focus: By prioritising ICS-formoterol, GINA aims to reduce reliance on bronchodilators and improve long-term asthma control; and
• Clinical implications: Healthcare providers must reassess prescribing habits, educate patients on the risks of SABA overuse, and promote adherence to controller therapy.

 

Risk factors for asthma exacerbations

Uncontrolled asthma symptoms increase the risk of exacerbations. Factors associated with increased risk, even in patients with few symptoms:

• SABA over-use (≥3 canisters of salbutamol per year);
• Inadequate ICS (not prescribed, or poor adherence or incorrect inhaler technique);
• Comorbidities (obesity, chronic rhinosinusitis, GORD, confirmed food allergy, pregnancy);
• Exposures (smoking, vaping, air pollution, allergen exposure);
• Psychosocial or socioeconomic problems;
• Low lung function;
• High blood eosinophils or FeNO; and
• History of severe exacerbations.

People with infrequent symptoms can still have severe, life-threatening, or fatal exacerbations.

 

SABA prescribing in practice

The MHRA in the UK recently released a Drug Safety Update to remind healthcare professionals and patients of the risk of severe asthma attacks and increased mortality associated with overuse of SABA with or without anti-inflammatory maintenance therapy in patients with asthma.  The update is available at gov.uk/drug-safety-update, and search for the title, ‘Short-acting beta 2 agonists (SABA) (salbutamol and terbutaline): reminder of the risks from overuse in asthma and to be aware of changes in the SABA prescribing guidelines’.

The EMA Pharmacovigilance Risk-Assessment Committee (PRAC) concluded in 2022 that changes were needed in the SPC and PL of SABA inhalers. The text was updated to include:

• Patients who are prescribed regular anti-inflammatory therapy (for example, inhaled corticosteroids) should be advised to continue taking their anti-inflammatory medication even when symptoms decrease, and they do not require reliever inhaler;
• Increasing use of short-acting bronchodilators, in particular beta-2 agonists, to relieve symptoms indicates deterioration of asthma control, and patients should be warned to seek medical advice as soon as possible. Under these conditions, the patient’s therapy plan should be reassessed;
• Overuse of short-acting beta-agonists may mask the progression of the underlying disease and contribute to deteriorating asthma control, leading to an increased risk of severe asthma exacerbations and mortality; and
• Patients who take more than twice a week ‘as needed’ salbutamol, not counting prophylactic use before exercise, should be re-evaluated (i.e., daytime symptoms, nighttime awakening, and activity limitation due to asthma), for proper treatment adjustment, as these patients are at risk for overuse of salbutamol.

An audit carried out in a GP setting in Co. Tipperary in 2023, to check for compliance with the new GINA Guidelines, found that 62 patients (43 per cent) were prescribed ≥3 SABA inhalers per year (available at researchgate.net, conference paper, ‘An audit of prescriptions of short-acting beta-agonist inhalers among asthma patients in an Irish GP setting’).

In the pharmacy setting, reviewing dispensing records to identify patients who have received three or more SABA inhalers in the past year can help flag those at increased risk of poor asthma control. Flagged patients could be invited for an asthma review to explore frequency of use, use of ICS or ICS-formoterol, inhaler technique, and other risk factors such as smoking or vaping status. Patients with signs of poor control can be referred for GP review. Pharmacists can play a key role by identifying patients who are not using their prescribed ICS or ICS-formoterol therapy and providing targeted education on the importance of inhaled corticosteroids in asthma control, as well as the risks associated with excessive reliance on SABA inhalers. Patients with signs of poor control can be referred for GP review.

 

Image 2: GINA assessment of asthma control and clinical visits in adults, adolescents and children 6-11 years

 

Asthma Action Plans

The Asthma Society of Ireland offers downloadable action plans, which are a great resource to use with patients in the pharmacy.  An Asthma Action Plan helps patients manage their asthma effectively. It is a step-by-step guide to help patients manage their asthma and recognise when it’s getting worse. Patients can keep their Asthma Action Plan updated by bringing it to every asthma-related appointment, including visits to A&E, GP, nurse, and consultant. The editable action plans can be downloaded from the Asthma Society website at asthma.ie > Health professionals.

Pharmacists can assist patients in completing and updating their asthma plans, which include a green zone representing their daily medication and symptom-free routine, a yellow zone indicating early warning signs, and a red zone representing emergency symptoms and when to seek urgent care.

Image 3: Example of Asthma Action Plan

 

Source: asthma.ie

 

Conclusion

Pharmacists play a vital role in supporting patients with asthma to use their asthma action plans effectively. To enhance this support, pharmacy teams should review and develop accessible resources within their practice. This includes ensuring printed or digital copies of asthma action plans are readily available, offering brief consultations to help patients understand and personalise their plans, and integrating prompts into dispensing systems to identify patients who may benefit from a review. Staff training on asthma management and inhaler technique can further empower pharmacists to guide patients through their action plans confidently.

Collaborating with local GPs and asthma nurses to align messaging and follow-up care, and signposting resources available from the Asthma Society of Ireland, ensures continuity and reinforces the importance of proactive asthma self-management.   The IPU Community Pharmacy Committee are running a health promotion campaign, in conjunction with the Asthma Society of Ireland, regarding the overuse of short-acting beta agonist (SABA) inhalers – please see the Medication Optimisation article  for further information.