A Call for the United States to Accelerate the Implementation of Reliever Combination Inhaled Corticosteroid–Formoterol Inhalers in Asthma
James G. Krings, Joe K. Gerald, Kathryn Blake, Jerry A. Krishnan, Helen K. Reddel, Leonard B. Bacharier, Anne E. Dixon, Kaharu Sumino, Lynn B. Gerald, Ross C. Brownson, Stephen D. Persell, Conrad J. Clemens, Katherine M. Hiller, Mario Castro, Fernando D. Martínez
Abstract
Asthma management has undergone a paradigm shift that is underutilized by real-world clinicians, particularly in the United States (US). Trials containing approximately 30,000 patients over 20 years have demonstrated the benefits of new inhaler approaches. In mild asthma, reliever usage of an inhaled corticosteroid (ICS) with formoterol (a unique rapid-onset long-acting β-agonist) provides quick symptom relief and is substantially more effective at preventing asthma exacerbations than short-acting β-agonist (SABA) monotherapy. In moderate/severe asthma using an ICS-formoterol inhaler on both a maintenance and reliever basis (single maintenance and reliever therapy [SMART]) is more effective at preventing severe exacerbations than traditional asthma management. As a result, the Global Initiative for Asthma (GINA) now calls for the preferential use of ICS-formoterol inhalers on a reliever basis at all steps of management. The US-based National Asthma Education and Prevention Program (NAEPP) guideline published in 2020 did not review as-needed ICS-formoterol in mild asthma, but similarly recommends SMART at Steps 3-4 within their management paradigm. In this article we review the latest asthma recommendations and the rationale for the recommendation/guideline changes. We then acknowledge and name the barriers to utilizing these new inhaler approaches that exist in real-world practice, particularly in the US. Using the tools of implementation science, we call for the asthma field to urgently work to ameliorate these barriers . Finally, while admittedly controversial, we call for consideration of the prescription-to-over-the-counter transition of low-dose budesonide formoterol in the US. This transition could expand medication access, reduce unopposed use of SABAs, and provide a more acceptable safety net for patients, as compared to aerosolized epinephrine, which is currently the only available OTC reliever inhaler in the US.