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BMJ Open. 2019 Aug 14;9(8):e028995. doi: 10.1136/bmjopen-2019-028995.

Understanding reliever overuse in patients purchasing over-the-counter short-acting beta2 agonists: an Australian community pharmacy-based survey.

Author information

Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
Quality Use of Respiratory Medicines, Clinical Management, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia.
Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
Department of Respiratory Medicine, Concord Hospital, Concord, New South Wales, Australia.
Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.
Academic Primary Care, University of Aberdeen, Aberdeen, UK.



Overuse of asthma relievers is associated with significant adverse consequences. This study aimed to better understand the population purchasing and using short-acting beta agonists (SABA) over the counter (OTC); and compare the demographic, clinical and behavioural characteristics of those who overuse SABA with those who do not.


Real-world cross-sectional observational study in community pharmacy.


Of 412 participants ≥16 years requesting SABA OTC, 289 were SABA overusers (used SABA more than twice per week in the past 4 weeks).


Reliever use, Global Initiative for Asthma-defined control, healthcare utilisation, patterns of preventer use.


70.1% of participants were classified as SABA overusers, that is, reporting SABA use more than twice a week within the last 4 weeks, 73.6% reported not using a preventer daily and only 81.6% reported a doctor diagnosis of asthma. SABA overusers were more likely to have moderate-severe nasal symptoms (80.8% vs 63.0%, p<0.001) and a diagnosis of depression (11.1% vs 5.7%, p<0.001), when compared with SABA non-overusers. A higher proportion of SABA overusers had uncontrolled asthma (59.0% vs 15.4%, p<0.001), were more likely to use oral corticosteroids to manage worsening asthma symptoms (26.2% vs 13.5%, p<0.01) and visit the doctor for their asthma in the past 12 months (74.5% vs 62.5%, p<0.01), when compared to SABA non-overusers.


This study uncovers a hidden population of people who can only be identified in pharmacy with suboptimal asthma, coexisting rhinitis, poor preventer adherence and, in some cases, no asthma diagnosis.


asthma; chronic airways disease; respiratory medicine (see thoracic medicine)

Conflict of interest statement

Competing interests: VK received honoraria from AstraZeneca, GlaxoSmithKline and Pfizer. MJP reports personal fees and non-financial support from AstraZeneca, personal fees from GlaxoSmithKline and personal fees from Boehringer Ingelheim. DBP: a board membership with Aerocrine, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis and Teva Pharmaceuticals; consultancy agreements with Almirall, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Meda, Mundipharma, Napp, Novartis, Pfizer, Teva Pharmaceuticals and Theravance; grants and unrestricted funding for investigator-initiated studies (conducted through Observational and Pragmatic Research Institute) from UK National Health Service, British Lung Foundation, Aerocrine, AKL Research and Development, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, Pfizer, Respiratory Effectiveness Group, Takeda, Teva Pharmaceuticals, Zentiva and Theravance; payment for lectures/speaking engagements from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Meda, Merck, Mundipharma, Novartis, Pfizer, Skyepharma, Takeda and Teva Pharmaceuticals; payment for manuscript preparation from Mundipharma and Teva Pharmaceuticals; payment for the development of educational materials from Novartis and Mundipharma; payment for travel/accommodation/meeting expenses from Aerocrine, Boehringer Ingelheim, Mundipharma, Napp, Novartis, Teva Pharmaceuticals and AstraZeneca; funding for patient enrolment or completion of research from Chiesi, Teva Pharmaceuticals, Zentiva and Novartis; stock/stock options from AKL Research and Development, which produces phytopharmaceuticals; owns 74% of the social enterprise Optimum Patient Care, UK, and 74% of Observational and Pragmatic Research Institute, Singapore; and is peer reviewer for grant committees of the Medical Research Council, Efficacy and Mechanism Evaluation programme and Health Technology Assessment. SBA: a member of the Teva Pharmaceuticals Devices International Key Experts Panel; received research support from Research in Real Life; payment for lectures/speaking engagements and for developing educational presentations from Teva and Mundipharma; received honoraria from AstraZeneca, Boehringer Ingelheim and GlaxoSmithKline for her contribution to advisory boards/key international expert forum.

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