Paradoxes in current asthma management

1In step 1 treatment, a SABA bronchodilator alone is recommended despite the fact that asthma is a disease of chronic airway inflammation with increased inflammation at the times of exacerbations.
2In step 1 treatment, the patient has autonomy and their perception of treatment as needed to control symptoms is accepted, whereas at higher asthma treatment steps it is assumed that patients will adopt a fixed-dose approach.
3There is a switch in recommendation from using a SABA alone as-needed at step 1 to advising an ICS fixed-dose regimen at step 2 and minimising SABA use. The medication that treats the underlying disease, which patients are encouraged to take (the ICS) is not the one that the patient perceives is benefitting them (the SABA), which they are now discouraged from taking.
4There is a different safety message in the advice given for the use of SABA and LABA within the guidelines; SABA alone being safe and LABA alone being unsafe.
5There is a dislocation between patients' understanding of “asthma control” and the frequency, impact and severity of their symptoms.

SABA: short-acting β2-agonist; ICS: inhaled corticosteroid; LABA: long-acting β2-agonist.