Breath of Fresh Air: Feature Articles

Chapter 8: Inhaled Bronchodilators: Regular or As-Needed?

If you thought that you might have recently seen your Asthma Center physician on the evening news or quoted in the newspapers, you are probably right. Drs. Jeffrey Drazen and Elliot Israel, along with other asthma specialists from around the country, wrote an an important scientific article on their asthma research that was published in the prestigious medical journal, the New England Journal of Medicine. The study that they reported asked the question: if you have mild asthma, is it better to take your albuterol (brand names: Proventil® and Ventolin®) inhaler regularly (four times a day) or only as needed for relief of asthmatic symptoms?

Before discussing what they discovered in their study, it is worth reviewing why they and many other physicians wanted to know the answer to this particular question. First of all, most persons with asthma have mild asthma. The answer to this question is relevant to the treatment of the majority of persons with asthma, and since there are more than 17 million persons with asthma in this country, it has an impact on many lives.

Second, previous reports had suggested that regular use of beta-agonist bronchodilators (of which albuterol is one example) might have a harmful effect on asthma. In particular, one study from New Zealand investigating the beta-agonist bronchodilator, fenoterol, found that regular use led to worse breathing capacity and more frequent asthmatic attacks than "as needed" use. Although fenoterol is not sold in the United States, it was possible that other beta-agonist bronchodilators, including albuterol, might have the same effect.

Third, many patients are now taking a long-acting beta-agonist bronchodilator, salmeterol (brand name: Serevent®). Twice daily dosing of salmeterol amounts to regular use of a beta-agonist bronchodilator. If it were in some way harmful to take albuterol four times daily, one might suspect potential harmful effects from regular use of salmeterol.

With this background, Drs. Drazen and Israel and others conducted an experiment at multiple hospitals in which one half of the persons with mild asthma were assigned to take an albuterol inhaler four times daily regardless of their asthma symptoms (as well as additional doses, if needed) and the other half were instructed to use an albuterol inhaler only if they had symptoms of asthma needing relief with a medication. More than 250 persons participated in this 16-weeks' study.

Research done in New Zealand raised the possibility that regular use of one inhaled bronchodilator (fenoterol) might be harmful to asthma control.

The answer provided by this study is that there is no advantage— and no disadvantage—to using an albuterol inhaler on a regular schedule regardless of symptoms. Regular use was not associated with worse control of asthma or more asthmatic attacks, but it also did not improve control of asthma or decrease the frequency of attacks. This study proved that among persons with mild asthma, regular use of beta-agonist bronchodilators is not harmful, but it is also unnecessary. You do just as well if you take the bronchodilator only when needed to relieve symptoms.

This important new study found no harmful effect – and no benefit – to regular use of albuterol in mild asthma.

In recent years we have come to divide asthma medicines into two broad categories: "controllers" and "relievers." Controllers need to be taken on a regular schedule every day to prevent symptoms of asthma and reduce the likelihood of attacks. Antiinflammatory medications such as the inhaled steroids are examples of asthma "controllers"; they should be taken on a regular basis regardless of symptoms. Albuterol is an example of an asthma "reliever." It relieves symptoms of asthma for approximately 4-6 hours after its use. It can be taken if symptoms develop and omitted if they are absent.

Thanks to the research in which our Asthma Center played a major role, we now know that taking a reliever such as albuterol on a regular schedule several times a day is not necessary. It costs more to do so and does not improve your asthma. We also know that regular use of inhaled albuterol does not aggravate your asthma in any way.

Albuterol is a ‘reliever” medication. It should be used as needed for relief of asthmatic symptoms and need not be taken on any regular schedule.