‘Pharmacists are crucial to the safe use of medicines, chronic disease management and public health delivery. Investing in them is investing in stronger health systems,’ he said.
Advice around flagging SABA-only asthma patients, guiding them to new therapies for optimal management, and correcting inhaler technique.
Ever had those red flags when a patient is having multiple short-acting beta2-agonist (SABA) inhalers dispensed within a short timeframe? Or they’re taking salbutamol alone on multiple days of the week? And what about older patients who were told it was okay to use salbutamol frequently – and now it’s not?
How can pharmacists help these patients gain control over their disease? Or prevent them reaching the 1 g lifetime limit of oral corticosteroid use?
Pharmacist and asthma educator Sherri Barden MPS – who runs her own asthma, hay fever, eczema and chronic obstructive pulmonary disease, APLUS Pharmacy Education business – has heard it all. Routine inquiries about symptom frequency, reliever use and adherence during each pharmacy encounter is a good method, she says, of recognising if suboptimal control is worthy of timely intervention or referral.
Long-term solo SABA users
Patients who ‘just want the blue puffer’ may be the subject of a difficult conversation, according to Ms Barden. ‘Community pharmacists can reframe the conversation by encouraging their staff to firstly explain to the patient that salbutamol or terbutaline are a Pharmacist Only medicine and that the pharmacist will be with them shortly to discuss.’
She encourages pharmacists to use ‘a patient-centred, non-judgemental approach that links the discussion to the person’s goals and wellbeing’. Opening lines for long-term SABA users such as ‘Is this for asthma?’ and ‘I see you’re here for your reliever. Can I check how your asthma has been going lately?’ are recommended.
Another approach could start as: ‘There are some important updates to asthma care in adults and adolescents that could help you breathe easier and prevent flare-ups.’
Using brief symptom assessment tools such as the Asthma Control Test (ACT) and offering a collaborative plan can help make the conversation supportive rather than confrontational, Ms Barden suggests.
Importantly, patients should be advised that SABAs will continue to be available over the counter from pharmacists, but that the newer recommendations require a prescription. MedsChecks or Home Medicines Reviews can also provide opportunities to assess or reassess control, look at triggers or comorbidities contributing to poor control, review adherence and technique, and perform the ACT to track progress over time.
Up to 80% of people with asthma also have allergic rhinitis, Ms Barden points out. So it’s essential to assess or ask people about the upper airway.
If rhinitis ‘is not adequately controlled with the right information and quality use of medicines, it may contribute to poor asthma control’.
Ms Barden recommends the teach-back method for correct inhaler technique using either a placebo device or, better still, suggest the patient have a dose of their medicine with the pharmacist watching, who could then build follow-up and monitoring into routine practice.
National Asthma Council instructional videos for home use and ancillary labels –“Quick and Deep” for dry powder inhalers and “Slow and Steady” for metered dose or soft mist inhalers – reinforce the correct breathing method, Ms Barden says. They also act as ongoing prompts and conversation starters regarding technique.
Clear criteria for escalation, she stresses, should trigger a timely referral to a GP, nurse practitioner or respiratory specialist. In this way, patient progress can be measured, trends identified early, and care escalated if needed.
AP spoke to two pharmacists about interventions with patients with sub-optimal asthma control.
Case 1
David Peachey MPS
Partner/Pharmacist
Hatton & Laws Pharmacy and Priceline Pharmacy Launceston Plaza, Launceston, TAS
Mr B, a regular patient, repeatedly presented earlier than expected for salbutamol purchased as a Pharmacist Only medicine. There was no evidence of preventer use. He described increasing breathlessness and wheeziness, finding it harder to manage everyday activities like walking up the street. He was relying heavily on his SABA inhaler and had not had a recent GP review. This was a clear red flag that his asthma was not under control. His inhaler technique may also have been a factor, especially if copied from someone using it incorrectly.
Approaching Mr B in a supportive, non-judgemental way, I said: ‘I can see you might be experiencing some worsening of your breathing. I’d like to help you improve this. Let’s have a quick catch up in the consult room.’
I find open-ended questions most effective, particularly when patients are struggling. For example: ‘Would you be able to show me how you use your inhaler?’ or ‘Have you used a spacer before? I can show you what it does and how it works.’ Framing it as a way to improve breathing capacity, rather than criticising technique, makes patients more receptive.
When patients are hesitant, I focus on curiosity and reassurance rather than criticism. I explained to Mr B: ‘There are better and easier treatments available now such as anti-inflammatory relievers and a maintenance preventer and reliever in one device.
‘Using a Ventolin inhaler every week may cause side effects to your heart and lungs without you noticing. That might mean talking to your GP about an asthma plan and working together on inhaler technique today.’
By showing patients I am available anytime, I keep the door open, even if they aren’t ready to change immediately. Through this process, I was able to review and improve Mr B’s inhaler technique. Once he gained confidence using a spacer and making small adjustments, his reliance on salbutamol reduced.
Over time, he engaged more with his GP, which led to spirometry and a step-up in therapy with a preventer. Each small success built trust and transformed his asthma management from sub-optimal to stable, effective therapy.
The key lesson is that inhaler technique checks and supportive communication can significantly improve asthma outcomes. Many patients don’t realise how much salbutamol they are using or the risks of long-term reliance.
By engaging with open questions, demonstrating devices, and linking patients back to their GP, pharmacists can guide safer, more effective asthma care while building enduring patient trust.
Case 2
Joanna Luong MPS
Community Pharmacist
PSA Trainer and Assessor
Brisbane, QLD
Poorly managed asthma in the pharmacy is a common presentation. One standout case involved a man requesting over-the-counter salbutamol for his 20-year-old son. When I checked the dispense history, I saw salbutamol had been supplied monthly, always as a Pharmacist Only medicine, with no preventer prescribed and no record of any past clinical interventions.
Frequent reliever use can indicate uncontrolled asthma and may implicate poor inhaler technique. Patient education and collaborative care with a doctor was evidently warranted, to support the quality use of medicines and optimise management.
The man waited impatiently. I was careful my tone didn’t suggest misuse or poor self-management ability by his son. In a friendly, conversational manner, I said: ‘I’ve had many people coming in lately with asthma flare-ups due to the recent weather change. Has your son found that certain triggers worsen his symptoms? I can see he’s had Ventolin dispensed several times over the last couple of months.’
The question was closed, but the context prompted an elaboration of the response, which was that his son ‘usually just uses his inhaler a couple of times a week and that keeps everything under control’.
While acknowledging their satisfaction with their current level of control, I emphasised that, commonly, asthma management can be optimised even in people who consider their asthma well-controlled, and that along with proper inhaler technique, quality of life could be much improved including fewer episodes of wheeziness disrupting their daily activities.
‘Would your son have time at some point to come in for a quick chat so we can check his technique and discuss the updated Australian guidelines for asthma management?’ I asked.
As expected, there was some resistance. I gently reminded the father that guidelines evolve with research, and advice received several years ago may no longer be current, which is why regular medical reviews are recommended, and that my role was to help guide patients in making informed decisions about their health care.
Even though the conversation did not lead to change that day, keeping the conversation supportive and respectful meant he left the pharmacy open to future discussions.
I documented the intervention in the son’s dispense record so my colleagues and I could continue the conversation on subsequent visits. This ongoing engagement helped build rapport, and the father eventually persuaded his son to see his doctor, who prescribed a preventer inhaler now used regularly.
How we communicate can be just as important as what we say.
