Still Recommending Albuterol for Asthma? Time for an Update
Matthew F. Watto, MD: Welcome back to The Curbsiders . I'm Dr Matthew Frank Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams.
Paul N. Williams, MD: Matt, how are you?
Watto: I'm doing well. Paul, we recently discussed asthma management with Dr Cyrus Askin. He's a homegrown pulmonologist, I would say.
Williams: Dr Askin is a longtime Curbsiders team member. I just had the occasion to listen to the episode. Typically, I try not to rewatch our episodes if I can help it because I hate listening to my own voice, but man, he did a good job with this topic. It's a really strong and comprehensive episode.
Watto: And he has his own podcast, Critical Care Time. Now, Paul — I heard that albuterol is dead. Can you tell me about that? Because albuterol is what I give to all my patients as first line. I tell them not to mess with any other asthma medications.
Williams: That's right: Albuterol is dead, at least in regards to asthma. I think we've all seen (and probably still have) a lot of patients with mild intermittent asthma who have an albuterol inhaler, that they may or may not use, that's been on their medication list for 20,000 years.
We should have moved past that paradigm at this point, Matt. The 'new' guidelines— I say 'new' but they've been around for over 5 years now, at this point —
Watto: Yeah, we covered this in 2019.
Williams: Exactly. So that idea of using short-acting beta-agonist (SABA) monotherapy is verboten. We should not be doing that anymore. SABA monotherapy leaves the airways unprotected from inflammation and the outcomes of SABA monotherapy alone are not great. What you want is a little bit of inhaled corticosteroid (ICS) to reduce the inflammation in addition to the bronchodilation.
ICS with formoterol (ICS/FORM) is the new albuterol, and we can talk about whether we're using this only as a rescue medication or as a controller or as both — all of which are okay, but you want to have the ICS there because patients just don't do as well on SABA monotherapy. They end up with worse exacerbations and more hospitalizations.
Watto: Using ICS with formoterol, a long-acting beta-agonist (LABA), is prioritized because it has a quick onset of action. There is an ICS, budesonide, that is commonly paired with formoterol. The pairing of budesonide with albuterol, a SABA, has also been advertised recently and I've noticed that it's on some formularies. We asked Dr Askin about his opinion on pairing budesonide with a LABA vs a SABA, and he prefers the LABA formoterol. However, in some cases, patients may only have access to albuterol with inhaled steroids. So, I guess having some inhaled steroid is better than none.
Williams: Dr Askin even gave us very hesitant permission to have an ICS plus albuterol as needed as a rescue inhaler in extreme circumstances. But again, you want that ICS in there as your base note.
Watto: In my experience, the ICSs by themselves are not that cheap compared with the combination therapy, so it almost doesn't make sense to not go with the ICS/FORM option. But I know there are some patients that just can't afford the formoterol-containing formulation, so you may just be stuck there.
Paul, I heard there's some nonpharmacologic measures we can take to improve asthma symptoms. Do you have any favorites?
Williams: I loved a lot of points that Dr Askin made at the end of the episode when we started talking about nonpharmacologic measures. He talked specifically about how exercise is a potential trigger. He doesn't even use the term exercise-induced asthma because he feels like that gives a signal to patients that they should stop exercising, and it turns out that patients do better when they exercise — as is the case in almost every circumstance. Instead, he identifies exertion as a potential asthma trigger, as opposed to exercise-induced asthma. Then, as physicians, we just treat asthma appropriately and the patient should still be encouraged to exercise, as that will help them have better health outcomes overall.
We also spent a fair amount of time talking about weight loss. Patients with obesity have poor asthma control and more frequent exacerbations. Even in his pulmonology clinic, he has conversations with patients about medications for weight loss and therapeutic lifestyle changes.
And in the primary care setting, especially, we should do the thing we're supposed to be doing anyway: vaccinating against viruses. Make sure COVID, influenza, and pneumococcal vaccinations are all up to date so we can protect our patients against potential infectious triggers, as best as we're able to. I thought that was a nice reminder that we should be making sure our patients are vaccinated, especially for our patients living with asthma. It's really important to be diligent about protecting our patients in that way.
Watto: In terms of asthma diagnosis, we had previous guests who weren't the biggest fans of spirometry. However, both the guidelines and Dr Askin support the use of spirometry as the gold standard for asthma diagnosis. Now, if you're in an extremely resource-limited setting and someone has a very classic presentation of asthma, treating them and then confirming diagnosis at later timepoint is probably alright to do. But if you're in a well-resourced setting, getting spirometry is the best course of action for most patients.
If your patient has no symptoms at the time of spirometry, that may be normal. In those cases, Dr Askin said he might go right to spirometry with methacholine and administer escalating doses of methacholine to try to induce some obstruction that you can detect on the test. Then, you would do the bronchodilator challenge after that to see if you can reverse the airway obstruction in order to make the diagnosis of asthma.
In some cases, Paul, you can even use peak expiratory flow to diagnose asthma in resource-limited settings. But that's not something I've done before.
Williams: No, neither have I. Every place I've practiced, both rural and urban, has had fairly easy access to pulmonary function testing, although I have not seen it conducted as consistently as it probably should be for our patients with asthma or presumed asthma.
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