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How FeNO helps stop the overuse of SABA in asthma

Over-reliance on short-acting β2-agonists (SABA) may indicate poor asthma control and increase the risk of adverse patient outcomes. Some people are collecting more than 50 canisters a year when the standard is one or two!1,2 In this article, we look at the facts and how clinicians can help address this urgent issue during routine asthma care.

Research estimates that around a third of asthma patients collect three or more SABA prescriptions a year, indicating a lack of use of controller medication, with its associated risk of exacerbation and asthma-related death.2,3 For some, this number can creep up to one or more reliever inhalers a month, meaning an over-reliance on quick-fix measures instead of addressing the cause of their symptoms for better long-term health.

The SABA use In Asthma programme, known as SABINA, is a global initiative which examines health data to assess how patients are using asthma medication. The research findings show similar results between developed countries and across disease severities.4 Charity Asthma + Lung UK agrees, saying it believes around one million asthma patients in the UK alone are relying on reliever medications.5

Airway inflammation in asthma

As well as patient education around the correct use of controller medication, healthcare providers are encouraged to help asthma sufferers address the underlying cause of their asthma. Using SABA three times a week or more is a sign of untreated inflammation in the airways so of course encouraging adherence with inhaled corticosteroids (ICS) is vital.3 However, it’s also important to teach patients about airway inflammation because, for many, that is the main cause of asthma symptoms. Being better informed should help patients understand how and why controller medication helps.

Airway inflammation contributes to airway obstruction and airflow limitation by swelling the bronchial muscles. This causes the symptoms of asthma, such as wheeze, cough, breathlessness and chest tightness.3 Up to 84% of asthma patients are believed to have Type 2 airway inflammation, which is particularly associated with exacerbations.6

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Type 2 inflammation is mainly driven by interleukins IL-4, IL-5 and IL-13. These cytokines are involved in the recruitment and production of immunoglobulin E (IgE), eosinophils and nitric oxide (NO), which is released in exhaled breath as FeNO (fractional exhaled nitric oxide).7

Elevated FeNO values are associated with 3.2x greater risk of exacerbations when compared to low FeNO levels.8 However, targeting and treating airway inflammation, such a key characteristic of asthma, has been proven to be effective in reducing that risk and is easily measured with point-of-care FeNO testing.9

Why test FeNO?

FeNO levels correlate directly with the amount of inflammation in the lungs and it’s a convenient biomarker thanks to the ease with which it can be tested during a routine check-up. Clinicians generally use a desktop device known as a FeNO analyser. The results should be almost immediate, meaning clinicians can start to optimise asthma therapy straight away. Using FeNO-guided asthma management to improve treatment and adherence like this has been proven to reduce exacerbations by up to 50%.9

Let’s look at the background. Research has shown that performing FeNO testing enabled physicians to confidently optimise treatment in asthma patients.10,11 A single-blind, placebo-controlled trial, carried out by Smith et al in 2005, involved clinicians who adjusted ICS dosage based either on FeNO measurements or standard care. Patients were then followed up for 12 months. The final daily dose of fluticasone (used as an ICS) was 40% lower in the FeNO group, whilst the exacerbation rate decreased by 45%. The study concluded that tailoring therapy with FeNO testing could significantly reduce ICS dosage without compromising asthma control.10

Up to 80% of patients are not adherent to their controller medication, which may lead to a loss of control of airway inflammation and, again, increased risk of exacerbation.12 Non-adherence can occur through missed doses or incorrect inhaler technique, with FeNO levels usually higher in non-adherent patients.6 Many studies have looked at how FeNO testing can be used to uncover non-adherence. One of the most recent, published by Heaney et al in 2019, showed that FeNO levels reduce by up to 50% in four days when patients take their medication as prescribed.11

FeNO testing is a straightforward way to keep on top of airway inflammation and control asthma for the long term. Analysis with a device such as NIOX VERO® is quick and gives reliable results within two minutes for fast access to answers that may transform asthma care.

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1. Royal College of Physicians (RCP). Why asthma still kills: the National Review of Asthma Deaths (NRAD). 2014.
2. Nwaru BI et al. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020 Apr 16;55(4):1901872.
3. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention, 2022. Available from
4. Quint JK. SABINA: An international programme describing overuse of short-acting β2-agonists in asthma and related clinical outcomes. Poster presented at the 2021 ICPRG conference in Dublin.
5. Press release, Asthma + Lung UK
6. Heaney LG et al. Eosinophilic and noneosinophilic asthma: an expert consensus framework to characterize phenotypes in a global real-life severe asthma cohort. Chest. 2021;160(3):814-830.
7. Kuruvilla ME et al. Understanding asthma phenotypes, endotypes, and mechanisms of disease. Clin Rev Allergy Immunol. 2019 Apr;56(2):219-33.
8. Busse, W.W et al. Baseline FeNO as a prognostic biomarker for subsequent severe asthma exacerbations in patients with uncontrolled, moderate-to-severe asthma receiving placebo in the LIBERTY ASTHMA QUEST study: a post-hoc analysis. The Lancet Respir Med. 2021:9(10): pp.1165-1173.
9. Petsky HL et al. Tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils): a systematic review and meta-analysis. Thorax. 2018;73(12):1110-9.
10. Smith AD et al. Use of exhaled nitric oxide measurements to guide treatment in chronic asthma. N Engl J Med. 2005;352(21):2163-73.
11. Heaney LG et al. Medical Research Council UK Refractory Asthma Stratification Programme (RASP-UK). Remotely monitored therapy and nitric oxide suppression identifies nonadherence in severe asthma. Am J Respir Crit Care Med. 2019;199(4):454-464.
12. Rifaat N et al. The golden factor in adherence to inhaled corticosteroid in asthma patients. Egypt J Chest Dis Tuberc. 2013;62:371-376.