Kerry Reller 0:29

Hey, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller.

Kerry Reller 0:34

Today, we're gonna talk about asthma a little bit, and this is all by myself, so get ready. All right.

Kerry Reller 0:41

So for decades, the asthma reflex has been simple. You start wheezing, coughing, or feeling tight in your chest, and you reach for albuterol. Some people call that the blue inhaler, maybe the red inhaler. If you're thinking, whatever color it was that somehow people define it by the color, so ProAir was red, blue was typically Ventolin, and generics can look totally different. So today, I wanna talk about, the medication strategy, not necessarily the color of the inhaler.

Why Asthma Rescue Treatment Is Changing

Kerry Reller 1:12

Kerry Reller 1:12

We know that albuterol works, and it can make you feel dramatically better very quickly, but asthma isn't only tight airways. It's also inflammation, and the big change in modern asthma care is that we're increasingly asking why would we treat the squeeze and leave the inflammation behind? And all this talk about inflammation on social media and things like that, this is, super important, especially as we attack this from an asthma standpoint.

Kerry Reller 1:42

So asthma has some guidelines that are developed every so often, and they are called the Global Initiative for Asthma Strategy, the GINA guidelines. And they released a guidelines this year in 2026, and it's very clear that adults, adolescents, and children about 6 to 11 should not be treated with SABA, or short-acting bronchodilators agonists alone, so not just albuterol. They should be receiving ICS-containing treatment, so that's inhaled corticosteroids at the same time.

Kerry Reller 2:18

So today, we're gonna talk about what changed, what air therapy means, where Airsupra, this new drug, fits, and what this actually means for the inhaler that is sitting in your purse, your backpack, your desk drawer, your glove compartment, basically everywhere.

Kerry Reller 2:33

So first, let's talk about the old reflex.

Why Albuterol Alone May Not Be Enough

Kerry Reller 2:38

So Albuterol is a short-acting beta agonist or SABA. Its job is bronchodilations to open that airway. When airway muscles tighten, Albuterol helps relax the muscles, and that's why it can feel so dramatic and yet so reassuring at the same time. The problem is what it doesn't do. So it doesn't treat that inflammation that is part of asthma. The GINA 2026 guidelines go further than simply saying, "Don't overuse Albuterol." It says that SABA-only treatment is not even recommended anymore. So regular SABA use can increase airway hyperresponsiveness and airway inflammation and can actually reduce that bronchodilator response. So it's not good to use that often and by itself.

Kerry Reller 3:26

So here's a number worth knowing. Dispensing three or more 200-dose SABA canisters, AKA Albuterol, in a year is associated with a higher risk of severe exacerbations. Very high use, like 12 or more canisters in a year, is associated with markedly increased risk of asthma death. That doesn't mean Albuterol is a bad drug. It just means that Albuterol alone is an incomplete asthma treatment.

Kerry Reller 3:53

So to understand why, you have to understand two things that are happening in asthma. So this is really the whole episode in one slide. So asthma

The “Squeeze” and the “Fire” of Asthma

Kerry Reller 4:03

has a squeeze ch-ch mechanism, squeezing tight chest, and a fire. The squeeze is that bronchospasm. The smooth muscle around the airways tighten. Albuterol is pretty excellent at relieving that, okay? But then underneath is the fire. Airway inflammation, swelling, mucus, and hyperreactivity. That is what an inhaled corticosteroid, or basically an ICS addresses. So my favorite analogy is albuterol alone can be like silencing the smoke alarm, but without putting out the fire. So the alarm stops screaming, so you feel reassured, but the underlying problem may still be there. So feeling better is not the same thing as having treated the inflammation.

Kerry Reller 4:48

So that brings us to the big new term that I want you to know, which is AIR. So Gina uses that acronym AIR, A-I-R, but you say it just like the word air. It stands for anti-inflammatory reliever. The concept is beautifully simple. So when symptoms make you reach for relief, that same rescue strategy that you've always used as an inhaled uh, the broncho- the SABA, now it's giving you an inhaled corticosteroid. So this is important. So

What Is AIR Therapy?

Kerry Reller 5:19

AIR is the category or concept. AIRsupra is a brand name medication that fits into that ICS-SABA version of that concept, but they're not really the same word. So behaviorally, this makes a lot of sense. We can tell a person who feels perfectly well to remember a controller every single day.

Kerry Reller 5:37

But what is the inhaler they almost never forget? The one that they reach for when they can't breathe. AIR therapy links the anti-inflammatory treatment to that symptom-driven behavior. So There are two major versions of anti-inflammatory rescue. The first is ICS formoterol. So ICS, remember, inhaled corticosteroid plus formoterol. So formoterol is a bronchodilator with a rapid enough onset to be used for relief. And this is the basis of GINA's preferred, track one. So they got two different tracks on recommendations for asthma treatment. The second is the ICS/SABA, an inhaled corticosteroid paired with a short-acting bronchodilator, such as albuterol, and Airsupra is one of the United States examples of what we're gonna talk about with that. So it's the same principle, just different medications, and you can't assume that every combination inhaler can be used as a rescue inhaler.

What Is Airsupra and How Does It Work?

Kerry Reller 6:37

Kerry Reller 6:37

So let's look at Airsupra specifically because this is where the concept becomes very tangible. So Airsupra makes this very easy to visualize because there are literally two medications in the inhaler. First albuterol, that's the familiar SABA or short-acting beta agonist. It rapidly re- relaxes the airway smooth muscle, that squeeze, and the second is budesonide. That's an inhaled corticosteroid. It treats airway inflammation. It's treating that fire. So I often like to say that it's albuterol on steroids, which is exactly what it is. So the label dose is actually two actuations, AKA two inhalations, which together delivers about 180 micrograms of albuterol and 160 micrograms of budesonide. It's used as needed for asthma symptoms and to reduce the exacerbation risk. The maximum is six doses or 12 inhalations in 24 hours. So Airsupra is not your daily maintenance inhaler. A patient may still need a maintenance inhaler or controller therapy depending on how bad their asthma is, and one critical point that we're gonna come back to that is that Airsupra is FDA approved in the United States, but only for adults 18 and older. It probably just means they haven't done the clinical trial yet on the adolescents and children.

Kerry Reller 7:52

So does adding that steroid to the rescue inhaler actually change outcomes? Yes. So

What the MANDALA Trial Found

Kerry Reller 7:58

let's start with looking at this trial that they did called MANDALA. So the MANDALA was published in the New England Journal of Medicine in 2022. There were patients with moderate to severe asthma who were already receiving maintenance therapy. So the question was: When they need rescue treatment, does adding budesonide to albuterol make a difference compared with albuterol alone? So it did. So the higher dose albuterol-budesonide combination reduced the risk of severe exacerbation by 26% compared with albuterol alone That's the key point. Same moment of symptoms, same need for bronchodilation, but when the rescue medication also delivered anti-inflammatory therapy, severe attacks went down. But then comes the patient who says, "Okay, but that's not me. I only have mild asthma."

Why “Mild” Asthma Can Still Be Serious

Kerry Reller 8:51

Kerry Reller 8:51

So this is one of my favorite parts of this discussion because I think the word mild can get us into trouble. So when I tell a patient, "You have mild asthma," what do they hear? They hear, "This isn't dangerous. I don't really need to worry about it." But mild symptoms don't mean zero risk. GINA specifically warns that people with infrequent or mild symptoms can still have severe or even fatal exacerbations if they're treated only with the SABA.

Kerry Reller 9:22

So I want you to separate these kind of two ideas. How do you feel most days and your future risk are not exactly the same thing. A person can go days or weeks with feeling fine and then get a viral infection, an allergen exposure, or another trigger like a chemical irritant and have significant exacerbation. So GINA summarizes that ICS-containing treatment, including as-needed low-dose ICS formoterol, as-needed low-dose ICS SABA, or daily low-dose ICS, that they substantially reduce severe exacerbation risk compared with SABA alone.

Kerry Reller 10:00

And that's exactly why they did a BATURA or B-A-T-U-R-A, they name all these studies was such an important study. So in that BATURA study that was published in 2025, it gets right at this mild asthma population. So severe exacerbations occurred in 5.1% of the albuterol-budesonide group versus 9.1% with albuterol alone. That's about 47% lower relative risk. The annualized severe exacerbation rate was also about 53% lower, and systemic corticosteroid exposure was lower, too. So that's clinically meaningful because every oral steroid burst has a cost. We don't want patients repeatedly needing prednisone if we can prevent those exacerbations upstream. And the trial was stopped early after, pre-specified efficacy cri- criteria were met. So when someone tells me, "I only use my albuterol once in a while," my response isn't that they necessarily have severe asthma. It's that occasional symptoms don't automatically mean albuterol-only rescue is the safest strategy.

Kerry Reller 11:09

So how did GINA translate this whole body of evidence into actual treatment?

Understanding GINA’s Two Asthma Treatment Tracks

Kerry Reller 11:15

GINA gives us two treatment tracks, but don't get hung up on memorizing them, and don't really worry about this. So track one is the preferred method. That's the reliever. The reliever in that method is lo- low-dose ICS formoterol, and in selected mild asthma, it can be used as needed. At higher steps, it can be used as both maintenance and reliever therapy. They call that MART, maintenance and reliever, M-A-R-T, maintenance and reliever therapy often called SMART, so in the United States. So That's track one, okay? Track two is the alternative pathway. So in twenty twenty-six, this is important, so low dose ICS-SABA can itself be used as the anti-inflammatory reliever. And if a combination ICS-SABA isn't available and SABA is used, GINA actually recommends incorporating ICS rather than leaving the patient exposed to SABA alone.

Kerry Reller 12:07

So that is gonna take some new practice, not just for providers, but definitely for the patients who are grabbing for that albuterol. You now need to grab for the albuterol and a anti-inflammatory or ICS, inhaled corticosteroid, medication like Flovent, which no longer exists but basically another inhaled corticosteroid.

Kerry Reller 12:28

So this common philosophy is what matters. So when asthma symptoms are telling you the disease is active, don't treat only the muscle spasms and ignore the inflammation. So you may be wondering why formoterol, this drug, keeps getting kind of special treatment. formoterol is a long-acting beta agonist. Sh- SABA is short-acting beta agonist, and LABA is long-acting beta agonist. So formoterol is a long-acting beta agonist, but unlike some other LABAs, it has a rapid onset. So that combination, so it's fast enough for relief and long-acting enough for maintenance. That's what makes it useful in these strategies, and that's actually why it's actually preferred over, the one the other options that aren't as fast-acting and long-acting.

Kerry Reller 13:17

This is why you can't look at any steroid LABA inhaler and decide to use it as rescue. So the evidence is specifically tied to formoterol-containing regimens. Just to avoid another misconception LABA therapy in asthma should be paired with inhaled corticosteroids. So we're not talking about LABA monotherapy. Those medicines on their own were given a black box warning. So they really are supposed to be combined with the inhaled corticosteroid for asthma patients.

Kerry Reller 13:45

So now let's

What Should You Do With Your Current Rescue Inhaler?

Kerry Reller 13:46

make this practical. What should somebody listening actually do with the inhaler they already have? So please don't go home and throw away all your albuterol because you heard this episode. So instead, know what you actually use. Don't tell me, "I have the red one," or, "I have the blue one." Bring it in, take a picture, know the name of the medication. Ask your clinician, "Does my current rescue strategy treat inflammation too? Is an AIR strategy appropriate for me?" Remember, AIR is anti-inflammatory reliever. So is your current strategy an AIR or anti-inflammatory reliever strategy, and is it appropriate for me?

Kerry Reller 14:30

So inhaler technique really matters as well, so you don't wanna forget about your technique. So GINA specifically recommends watching patients use their inhaler. Sometimes the best medication in the world isn't working because most of it is landing on the tongue, or the technique doesn't match the device. Now, in a busy clinic, it's very hard to have, the time to do this, so I highly recommend if you are concerned about it that you bring it in and we work on it with you for sure. And I'll just tell a story because I definitely have had a patient who we thought we were, treating him with his Albuterol, this is obviously before these new guidelines, for rescue inhaler, and turns out he was not even putting the inhaler in his mouth. He would just spray it into the air and try to take a whiff of it and think he was using it correctly. It was the cutest thing, but it was also sad to know that we did not teach him to do it correctly and we just assumed. So you can never assume. So please bring your inhalers so we can practice using them in the office if needed.

Kerry Reller 15:28

But anyway, it's very important for also to tell us how often you're actually using the inhaler. Increasing rescue use is definitely something we need to know, and it tells us, something about your asthma. I always ask, "How often are you using it?" And they say, "Oh, every now and then." I'm like let's be specific. Are you using it more than twice a week?" And if it's more than twice a week, then it's often not controlled enough and we need to do something else, right?

Kerry Reller 15:53

So this gets into another reason why AIR therapy is so interesting, and that is real human behavior too. This is one of the most interesting points in the expert discussion that I reviewed while preparing this episode. So we physicians can prescribe the perfect daily regimen, but patients are human. When they're feeling great, daily adherence often slips. So when they can't breathe, they remember the rescue inhaler. So AIR therapy is elegant because it takes advantage of that behavior. So symptoms trigger, the patient's instinct is to reach for that relief, and now we have to make sure that relief also contains anti-inflammatory treatment. So that doesn't eliminate the need for maintenance therapy in people who need it, and it doesn't eliminate the basics, which is technique, adherence, managing triggers, smoking, vaping, rhinitis, reflux, obesity, medication access, and whether the diagnosis is even correct. Hopefully, you're doing a pulmonary function, a pheno, maybe even getting those blood eosinophils. But the inhaler is just part of the plan, not the entire plan. It is just, once again, a tool in the toolbox of all the things. Even lifestyle modifications are very important to manage asthma.

Kerry Reller 17:07

So now parents listening are probably asking the obvious question, what about kids? Because I told you that medicine wasn't, covered So the big concept also applies to children. Asthma is inflammatory, and GINA says ages, children ages 6 to 11 should not be treated with SABA alone, so not just albuterol. So GINA 2026 includes ICS-containing approaches for this age group, including anti-inflammatory reliever strategies depending on the child's step and available inhalers. So definitely all of the relievers are taking combined with the anti-inflammatory approach.

Kerry Reller 17:42

So this is exactly where I don't want parents taking an adult algorithm and applying it to themselves, but pediatric dosing devices and evidence and FDA labeling are different. They have to do the studies in the kids too. There can also be difference between an international guideline recommendation and what a specific inhaler is FDA-approved for to do in the United States. So the takeaway for parents is not go get the adult rescue inhaler. It's ask whether your child's asthma plan includes appropriate anti-inflammatory treatment.

Kerry Reller 18:12

And that brings me back to Air Supra specifically. So Air Supra specifically is FDA-approved for adults 18 and older because it, and it contains albuterol plus budesonide. So even though I forgot and tried to send it in for a patient recently, it is only FDA-approved for adults. So even though the anti-inflammatory reliever concept extends into pediatric asthma care, that doesn't make Air Supra a pediatric medication just yet. Yet. So this is a distinction I really want to make clear because it's easy to hear GINA recommendations that ICS containing rescue in kids and jump to the wrong conclusions about a specific product. So always match the medication, the dose, the device, the age indication, and the asthma plan to the individual patient.

Kerry Reller 18:59

So before we finish, I want to zoom back out to something even more fundamental. So one more pearl from those GINA guidelines and from the expert discussion I reviewed is that we have to make sure we're treating asthma in the first place. So asthma can be both over-diagnosed and under-diagnosed. So cough, shortness of breath, exercise symptoms, vocal cord or laryngeal problems, rhinitis, and other conditions can overlap. So when possible, objective evidence such as spirometry, AKA your breathing test, and variable expiratory airflow should support the diagnosis. So sometimes that's obviously harder to do in kids because they usually can't work the spirometer till they're about kindergarten age. But this does matter because if somebody is repeatedly inhaling rescue medication for symptom that, for symptoms that aren't actually asthma, escalating the inhaler is not solving the problem. And once the diagnosis is established, assess both the symptom control and the future risk.

Three Things to Remember About Modern Asthma Care

Kerry Reller 20:00

Kerry Reller 20:00

So if you remember nothing else from this episode, remember these three things. Number one, asthma is an inflammatory disease, even if your symptoms aren't happening every day. And even if the etiology or different type of asthma, it's still inflammatory, okay? Number two, GINA says, GINA 2026 says SABA only treatment should not be our asthma strategy. So modern treatment makes sure patients receive inhaled corticosteroid-containing therapy. So no more albuterol alone. That's the SABA. No more albuterol alone. Combine it with the steroid. And number three, albuterol is not obsolete. It works very well at what it does. The problem is relying on an albuterol alone and assuming that because the wheeze went away, we've treated the asthma. So the rescue inhaler is evolving from something that only opens the airway into something that can open the airway and address inflammation. And that gives me my favorite way to end this conversation. Rescue used to mean open the airway, and now increasingly rescue means open the airway and treat the inflammation at the same time. So don't just relieve the squeeze, put out the fire.

Kerry Reller 21:16

So if you have asthma, especially if you've been carrying the same Albuterol rescue inhaler for years, this is a great question for your next visit. Is my current rescue inhaler still the best strategy for me? So don't change your medication based on podcast, but do use this information to start a conversation with your healthcare provider, and make sure that you have an up-to-date written asthma action plan.

Kerry Reller 21:37

And, if this episode has helped you understand your asthma differently, share it with someone who still thinks of asthma treatment as simply grab the Albuterol, and make sure you're following the Get Healthy Tampa Bay podcast for more practical conversations about your health.

Kerry Reller 21:52

Once again, this podcast is for education and not a substitute for individualized medical advice. I hope this brings up some great conversations and maybe some people coming back to discuss their asthma care with their provider and trying to get the new best updated medical care to mitigate any, downstream effects of not putting out that fire. So stay tuned for next week's episode, and thank you so much for tuning in to the Get Healthy Tampa Bay podcast.

Kerry Reller 22:19

Get healthy, Tampa Bay. Bye, everybody