The popular asthma drug, Ventolin, seems to have rung its bell, at least in the UK. More asthma sufferers are using new drugs as doctors steer them away from the traditional blue inhaler, the popular Ventolin, and health officials are urging all providers to stop prescribing the traditional blue inhaler to asthma patients. The reason is that scientists have discovered that the little blue pump that millions of people have relied on can actually make the condition worse. Blue inhalers, medically called short-acting beta-2 agonists, relieve symptoms such as wheezing, coughing and shortness of breath, but do not help prevent the inflammation that causes the symptoms. As such, these inhalers should not be used daily. Therefore, according to the latest guidelines from the British Thoracic Society and NICE (the UK’s National Institute for Health and Care Excellence), patients are now offered an anti-inflammatory symptom relief inhaler (AIR), which is only used when symptoms occur. Those with more severe asthma are prescribed a regular maintenance and symptom relief inhaler (MART), which is used daily to help prevent and treat symptoms. Previously, patients were usually only prescribed blue inhalers to relieve symptoms, resulting in alarming overuse of a drug intended for occasional use only.
– Relying only on blue inhalers can increase the risk of serious seizures. On the other hand, these newer treatments address the cause of asthma and help patients achieve better control and have fewer emergencies. This is a life-saving change in the treatment of asthma – believes Professor Richard Russell, president of the British Thoracic Society. However, he adds that the transition to a new, safer and more effective therapy is not without difficulties. Namely, many patients fall for misleading claims about the risks of long-term steroid treatment and are reluctant to give up their blue inhalers, and many doctors continue to prescribe them as the only therapy.
We have a milder approach
The Croatian Pulmonology Society of the Croatian Medical Association and the Croatian Thoracic Society published Croatian guidelines for the treatment of asthma in 2023, with the GINA strategy accepted as the basis, but with adaptation to the Croatian regulatory framework.
– This means that even in our country there is a clear departure from understanding asthma as a disease that is treated only with a bronchodilator (β2 agonist), that is, with the “old blue inhaler”, according to the concept in which the basis of treatment is anti-inflammatory therapy, inhaled corticosteroids. However, the Croatian guidelines are not completely identical to the latest British model, in which the so-called “Ventolin-free” approach. In our country, salbutamol can still be used as a medicine for rapid relief of symptoms in certain therapeutic steps, but it should not be the only and dominant therapy for asthma. Croatian guidelines clearly state that insufficient intake of drugs for disease control with increased use of Ventolin leads to intensification of inflammation in the respiratory tract and bronchial hyperreactivity and increased risk of morbidity and mortality – explains Dr. Antun Koprivanacspecialist in internal medicine and subspecialist in pulmonology.
The same direction: inflammation should be treated
In other words, it is moving in the same direction, but not necessarily at the same speed and not exactly on the same regulatory path as in the UK. GINA 2025 recommends that asthma is no longer treated only with a β2 agonist as needed and specifies a low dose of inhaled corticosteroid with formoterol in one inhaler as the preferred symptomatic drug (reliever) for adolescents and adults, as it reduces the risk of severe acute exacerbations of the disease compared to regimes in which the symptomatic drug is Ventolin. The 2024 UK NICE/BTS/SIGN guidelines further formalized this turn towards the AIR and MART regimes. Croatian practice relies on the same pathophysiological principles, asthma is an inflammatory disease and inflammation should be treated. However, the recommendations are adapted to the availability, approvals and prescription of drugs in our healthcare system – says our expert.
Patient resistance
However, there are also challenges in the implementation of the new guidelines. To what extent doctors adhere to this, it is difficult to say precisely without a national registry or a publicly available analysis of prescriptions per patient. However, as our interlocutor says, the Croatian guidelines themselves warn that there is a gap between recommendations and everyday practice, especially in primary health care, and state that more than fifty percent of patients are poorly controlled. One of the reasons they point out is the excessive prescription of Ventolin and insufficient prescription of the basic anti-inflammatory drug, i.e. inhaled corticosteroid.
– This does not mean that doctors do not know the guidelines, but that in real life there are numerous problems: patients’ habits, the feeling of security with the “blue Ventolin pump”, insufficient adherence, improper inhalation technique, the time burden of surgeries and sometimes insufficiently clear distinction between a medicine for quick relief and a medicine that controls the disease – explains Dr. Koprivanac.
It’s not a “bad drug,” but it doesn’t cure inflammation
Our interlocutor warns that the results of studies showing that old Ventolin inhalers can worsen the outcome should be interpreted cautiously, but seriously.
– The problem is not that salbutamol is a “bad drug” per se. It is a very effective bronchodilator and can quickly relieve bronchospasm. The problem is that salbutamol does not treat the underlying inflammation of the airways. If the patient relies only on salbutamol, the symptoms are temporarily relieved, but the inflammatory activity of the disease remains untreated. In other words, the problem is both in the way it works and in the way it is used. Croatian recommendations state that the frequent, long-term use of salbutamol in high doses when asthma control is lost can lead to worsening of eosinophilic inflammation of the bronchi and greater bronchial hyperreactivity if salbutamol is not taken together with a basic anti-inflammatory drug – says Dr. Koprivanac, adding that the newer concepts, AIR and MART, are also available in our clinical practice in the form of combinations of inhaled corticosteroids and formoterol. At the same time, he emphasizes that MART cannot be performed with any combination of inhaled corticosteroid and long-acting β2 agonist. Formoterol is key to this concept because it has both a quick onset of action and a long-lasting effect.
No panic
We should definitely go in the direction of reducing reliance on Ventolin monotherapy, our interlocutor believes, but warns that this should not be done automatically and without assessing the patient. – If patients use only Ventolin, especially if they use it often, it is a clear sign that the therapy needs to be reviewed. If someone needs Ventolin multiple times a week, uses multiple inhalers per year, or has nighttime symptoms, acute exacerbations, or activity limitation, that is not satisfactory asthma control. In such cases, anti-inflammatory therapy should be introduced or optimized. On the other hand, if the patient has good control of the disease on therapy that complies with the guidelines, regularly takes an inhaled corticosteroid or a combination of an inhaled corticosteroid and a long-acting β2 agonist, uses the inhaler correctly, has no acute exacerbations and rarely uses Ventolin, a change is not always necessary just because there is a newer concept – points out Dr. Koprivanac. He also says that patients who are prescribed Ventolin should not panic, but should understand what this inhaler means. If used infrequently, with regular anti-inflammatory therapy with an inhaled corticosteroid and under the supervision of a physician, it can be part of a treatment plan. However, if Ventolin is the only therapy or if the patient uses it frequently, this is a reason for examination, assessment of asthma control and a change in the treatment plan.
Listen to your doctor
The patient must not stop the therapy on his own, but it is also not good to resist the change if the doctor assesses that he needs an anti-inflammatory approach. This, as our interlocutor points out, is particularly important because a significant percentage of patients still resist the use of inhaled corticosteroids due to unjustified fear.
– This fear is mostly exaggerated when we talk about the low and medium doses used in modern asthma inhalers. Inhaled corticosteroids are not the same as taking long-term systemic corticosteroid tablets. When used by inhalation, the drug acts predominantly locally in the respiratory tract, with significantly less systemic exposure. Of course, there are side effects, especially with higher doses and long-term use, for example hoarseness or oropharyngeal candidiasis, so it is important to rinse the mouth, use the correct inhalation technique and use the lowest effective dose – says Dr. Koprivanac.
The most important thing, he concludes, is to convey the message to patients that the goal is not to get rid of “Ventolin” at all costs, but to avoid it being the only or main therapy for asthma. – Asthma is basically an inflammatory disease of the airways. A bronchodilator such as Ventolin can quickly open the airways, but anti-inflammatory therapy with inhaled corticosteroids reduces the risk of deterioration, emergency interventions, hospitalizations and death – says Dr. Koprivanac.
