Adult asthma — KFP-style written assessment

KFP 1 (10 marks)

A 33-year-old teacher has used a salbutamol inhaler alone for two years, roughly twice weekly, with symptoms waking her about once a month. She has never had a preventer. Dispensing records show four salbutamol inhalers dispensed in the past twelve months. ^{[1] [2]}

1. What treatment change does current GINA guidance support, and why is SABA-only no longer acceptable? (4) ^{[1] [2]}
2. Name the trial evidence underpinning this change, with one key result. (3) ^[3]
3. Her dispensing pattern shows four relievers per year. What does reliever over-use signal, and what should you check before issuing another script? (3) ^[5]

Model answers

1. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting beta2-agonist because of the risks of SABA-only treatment and SABA over-use; all adults should receive ICS-containing therapy — taken regularly or, in mild asthma, as combination ICS-formoterol as needed. For her mild profile (Steps 1–2), as-needed low-dose budesonide-formoterol as the reliever is the preferred Track 1 regimen. ^{[2] [1]}
2. Novel START: a 52-week randomised open-label trial in adults with mild asthma showed as-needed budesonide-formoterol cut the annualised exacerbation rate versus as-needed albuterol (0.195 vs 0.400; relative rate 0.49; 95% CI 0.33–0.72) and did not differ significantly from budesonide maintenance plus as-needed albuterol (relative rate 1.12). Aggregated trial evidence puts severe-exacerbation reduction at ≥60% versus SABA alone. ^{[3] [2]}
3. Reliever over-use marks elevated exacerbation risk and unmet anti-inflammatory need — over half of Australian adults obtained three or more SABA inhalers in a year, and only 13.3% used an anti-inflammatory reliever. Before another script: check inhaler technique (only 42% of ICS users recalled a technique check in 12 months), adherence to any controller, and whether the step needs escalation. ^[5]