Optimising inhaler therapy through pharmacist-led asthma clinic reviews

Asthma is a respiratory condition marked by symptoms such as coughing, wheezing, shortness of breath and chest tightness, affecting both children and adults. It is the most common chronic disease among children^​1​. The causes of asthma are diverse, including lifestyle choices, such as smoking, environmental factors, weather conditions and exposure to mould. Second-hand smoke causes significant inflammation and respiratory issues shortly after exposure^​2,3​. Identifying triggers is crucial for effective management.

Treatment has traditionally included inhaled corticosteroids (ICS) and short-acting bronchodilators (SABA). In the UK, around 7.2 million people have asthma, leading to a 5-year average of 1,507 deaths in 2022^​4,5​. NHS England data, published in 2024, show a 7% rise in emergency admissions for respiratory diseases, highlighting the need for improved asthma management^​6​. The data also revealed that hospital stays for asthma can cost between £1,516 and £2,473 per night^​7​, which suggests that a 50% reduction in admissions could save the NHS around £9.8m^​7​.

Current National Institute for Health and Care Excellence guidelines advocate for anti-inflammatory reliever (AIR) therapy and maintenance and reliever therapy (MART)^​8​. Additional information on treatment approaches can be found in ‘Asthma: diagnosis, harm prevention and treatment optimisation’. A Medicines and Healthcare products Regulatory Agency (MHRA) alert, published in 2025, emphasised the risks associated with excessive SABA use — particularly salbutamol and terbutaline — and urged adherence to updated guidelines^​9​. The alert also underscored the risks of their excessive use, prompted by the National Review of Asthma Deaths (NRAD), published in May 2014. This report revealed that over two-thirds of the 195 asthma-related deaths within one year were preventable^​10​, highlighting the need for improved asthma care.

This article will cover the importance of inhaler optimisation, with suggestions for how this can be achieved, and provide a strategy for reducing inappropriate prescribing of SABA in primary care.

Why is optimising inhaler therapy important?

The effective use of inhaler therapy is essential for managing asthma, as it reduces the risk of exacerbations that can lead to hospital admissions and lowers mortality rates associated with poorly controlled asthma. The results of a UK study, published in 2021, indicated that optimising inhaler technique can significantly decrease exacerbation rates and hospital admissions, with a 37% reduction in moderate-to-severe exacerbations noted after technique optimisation^​11​. In addition, the results of a 2021 Cochrane systematic review and meta-analysis showed that patients receiving AIR therapy have a 65% reduced risk of hospitalisation and emergency department visits for asthma exacerbations, as well as a 55% reduced risk of needing courses of steroid tablets compared with SABA alone^​12​.

Optimising asthma therapy enhances patients’ quality of life, allowing them to engage in activities with family and friends while reducing work absences^​13​.

How can inhaler therapy be optimised?

To support inhaler therapy optimisation, it is crucial to engage patients in comprehensive discussions that empower them in their treatment. This dialogue improves their understanding of asthma, which is vital for achieving control and minimising risks associated with poor asthma control (i.e. hospital admission)^​14​.

According to the findings of a 2025 review, 50–90% of users make at least one critical error with inhaler technique — for example, poor coordination or inadequate inspiratory flow^​15​. See ‘How to help patients optimise their inhaler technique’ for more information. Despite educational efforts and advancements in inhaler devices, there is minimal improvement in error rates^​15,16​, highlighting the need for regular patient interactions in community pharmacies, hospitals and GP settings. Community pharmacy services, such as the new medicine service (NMS), are essential for focusing on inhaler technique and patient engagement^​17​.

Using spacer devices with metered-dose inhalers (MDIs) enhances drug delivery and can help avoid unnecessary increases in medication doses, particularly for patients with poor inhaler technique. Current NICE guidelines favour short-acting bronchodilators, delivered via MDIs with spacers, for managing acute attacks unless life threatening^​8​.

Optimising inhaler therapy reduces the risk of poor asthma control and over-treatment with inhaled corticosteroids (ICS)^​18​. Adjusting a patient’s ICS regimen to an AIR therapy approach can minimise long-term risks of oral steroid treatment, such as osteoporosis and oral thrush^​19​.

Concerns about long-term inhaler use are common. The results of an international retrospective analysis of 1,312 patients, published in 2022, demonstrated that 40% of patients worry about the effects, while 36% fear dependency. Addressing these concerns can improve adherence^​20​.

Some patients may be resistant to initiating or optimising ICS dosages, particularly after a recent diagnosis or poor control. It is vital to inform patients about the risks of exacerbations and the potential need for oral prednisolone. A standard moderate-to-high ICS dose provides fewer side effects than oral prednisolone^​21​.

Awareness of individual trigger factors is crucial for optimising inhaler therapy. For example, during high pollen counts, a MART regimen may be appropriate, while a return to an AIR approach may be beneficial during periods of lower trigger exposure^​2​. Supporting patients exposed to mould is also crucial, as it can trigger asthma attacks and worsen control. This personalised strategy may help to enhance patients’ understanding and ownership of their inhaler therapy^​2​.

What do the recent guideline changes recommend?

The joint NICE, Scottish Intercollegiate Guidelines Network and British Thoracic Society (BTS) guidance on asthma treatment have notably recommended a decrease in the dependence on SABA inhalers for most patients^​8​. The treatment algorithm for the pharmacological management of asthma in individuals aged 12 years and over can be seen here. For a summary of the main recommendations, see Box 1^​8​.

The budesonide/formoterol evidence considered by NICE is based on dry powder inhalers (DPI). If a DPI is intolerable, a metered-dose inhaler (MDI) can be used. If control improves but remains inadequate, consider leukotriene receptor antagonists (LTRA) or long-acting muscarinic antagonists (LAMA) alternatives^​8​.

Using a long-acting bronchodilator such as formoterol — lasting at least 12 hours — in AIR and MART regimens significantly lowers severe asthma attack rates compared with short-acting bronchodilators such as salbutamol (4–6 hours)^​22​. The combination of ICS and formoterol enhances asthma control and reduces exacerbations^​23​.

Additionally, the joint guidance emphasises pre-treatment optimisation. Underlying causes of uncontrolled symptoms, including alternative diagnoses and environmental factors, should be addressed before treatment optimisation^​8​.

A summary of the main recommendations relating to children can be seen in Box 2^​8​.

Protocol to reduce prescribing of SABA

A collaborative effort among healthcare professionals (HCPs) is essential for effective implementation of the new NICE and BTS guidelines. Adhering strictly to NICE and BTS guidelines is critical, as deviations may result in poor asthma control and increased appointment burdens^​8​.

The author suggests the following protocol to reduce the prescribing of SABAs in GP surgeries.

Initial steps

During GP clinical meetings, discussions should be held with pharmacists to strategise on addressing high SABA prescribing rates and mitigating risks of hospital admissions in asthmatic patients. These discussions should address barriers to a standardised approach, recognising the varied experiences and treatment preferences among clinicians.

Pharmacists can play a central role in developing user-friendly asthma protocols featuring algorithms for easy application during consultations, especially for long-term condition (LTC) asthma reviews.

The following interventions based on NICE/BTS guidance should be considered:

• Incorporating recommended first-line inhalers based on therapy initiation, such as MART/AIR combinations;
• Prioritising options with a lower carbon footprint, such as DPIs;
• The benefits of MART/AIR therapy should be emphasised, while the longer duration of action provided by formoterol and its corticosteroid properties should be discussed with patients^​8​.

Identifying patients

Once a general strategy has been established and suitable protocols developed, a standardised review of asthma patients — particularly those with poor control of their inhaler therapy — should be undertaken. The intervals of such reviews are to be agreed with the respiratory prescribing lead of the associated practice.

Identifying patients with high SABA usage is critical. Pharmacy teams can search the patient medication record system for those with over six SABA prescriptions in a year, ensuring timely reviews. Tracking patients who have not had asthma reviews in the past year encourages outreach and scheduling for long-term condition reviews, supporting effective asthma management protocol implementation by the LTC clinician team.

Reviews

Asthma reviews should ideally be face-to-face for accurate assessments of inhaler technique and education about new regimens, using visual aids such as images of inflamed lungs to help patients better understand their condition and the benefits of treatment^​24​. For patients who are unable to attend in person, remote reviews with supportive information sent electronically can be arranged.

Implementing safety netting within the protocol is essential for establishing appropriate actions and follow-ups after therapy changes. Key safety protocols, such as advising patients to call 999 after six puffs of their inhaler, should align with local asthma guidelines. Information leaflets detailing actions during an asthma attack can be provided post-changes in inhaler therapy and can be accessed via Asthma + Lung UK^​25​.

Adjustments can accommodate specific patient needs, such as face-to-face reviews for those aged under 18 years or with cognitive impairments. The protocol may include inhaler demonstrations with placebo inhalers and links sent to patients. If in-person visits are not possible, alternatives such as phone discussions or digital communications can be effective. Although, in-person visits are preferred to best facilitate discussion and inhaler technique optimisation.

Language barriers can be addressed through the use of translators available in primary care, along with multilingual patient resources that cater to the patient’s preferred language^​26​. For individuals with disabilities, such as visual or hearing impairments, supportive aids and translators can facilitate effective communication during consultations. For example, Asthma + Lung UK offers action plan leaflets written in their associated languages that can be provided to patients^​25​.

Follow up

Follow-up appointments after therapy changes can be scheduled for four weeks later, with instructions for patients to contact the practice sooner if issues arise. Notifications from community pharmacies via the NMS service further support follow-ups and integration into the protocol.

Additional considerations

Prior to implementing the protocol, refresher training on the updated guidelines is critical. This training could occur during clinical meetings, emphasising the role of pharmacists in supporting adherence to both updated and existing guidelines for chronic conditions.

All clinicians should have access to the protocol, ensuring visibility during consultations, such as displaying it on notice boards and providing laminated hard copies.

Addressing patient concerns

Patients frequently express concerns about changes to their asthma treatment, particularly regarding the discontinuation of SABA inhalers after implementing the MART/AIR regimen. Research, published in 2023, showed that while SABAs provide rapid relief, over-reliance can lead to poorer self-perceptions of health and asthma control, with many users unaware that frequent use may worsen their condition and lead to psychological dependency^​27​.

Patients with anxiety may fear that stopping SABA will intensify their symptoms owing to a perceived unavailability of relief. Additionally, SABA overuse can cause side effects, such as palpitations and insomnia, potentially worsening anxiety. It’s vital to conduct thorough reviews for these patients and consult with senior clinicians when necessary^​9​. Reassuring patients that SABA is not being entirely removed but replaced with a more effective treatment can help ease fears. Following up soon after implementing the MART/AIR regimen can provide reassurance, enabling patients to feel supported during the transition.

Implementing peak flow measurements can further illustrate the benefits of the new regimen compared with previous therapies. If available, FeNO testing can provide additional reassurance regarding asthma control improvements post-therapy optimisation per NICE guidelines^​8​.

Another common concern is regarding increased corticosteroid intake with the new steroid-based regimen. It is important to explain the equivalent systemic steroid intake between inhaled and oral steroids and the risks associated with oral corticosteroids during unstable asthma. This discussion should highlight the long-term risks of poor asthma management, such as airway remodelling and permanent lung damage^​28​. Patients can be informed of the risks of lung damage that potentially could be irreversible with their current poor asthma control of their current therapy, which can translate to poorer quality of life, and increased risk of mortality, which can be reduced through appropriate optimisation of their current therapy^​29​.

Considerations for complex cases

There will be instances where front-line treatment fails to achieve disease control even when adherence and inhaler technique is good. In such cases, alternative options should be explored, including the potential introduction of LAMA or LTRA, such as Montelukast (Singulair; Organon & Co.), if appropriate. According to NICE guidelines, it is important to consider referring these patients to specialist asthma care, which can be facilitated through discussions with the respiratory lead at the GP surgery and during asthma multidisciplinary team (MDT) meetings within primary care^​8​.

For patients with cognitive impairments, the MART/AIR regimen may be too complex to implement effectively. In these instances, simplifying the treatment plan is advisable — this could be done by considering LAMA/LTRA in conjunction with current ICS and SABA therapy. Such cases should also be discussed within the MDT to create a personalised and appropriate action plan^​30​.

Some patients may refuse all available treatment options for asthma control, opting to continue with their current inhaler therapy, such as SABA monotherapy. In such cases, it is crucial to engage in thorough discussions within the local MDT, ensuring that the risks associated with current inhaler therapy are clearly communicated to patients.

If your primary care network includes an asthma pop-up clinic, this can be utilised for patients who have not responded well to standard treatments, allowing for further investigations and input from local specialist respiratory clinicians.

Maintaining competency throughout the review process for all asthmatic patients is crucial. It is also important to refer patients to other clinicians when necessary, ensuring that the actions remain within your professional scope of practice.