The Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) recently made paradigm-shifting recommendations regarding inhaler management in asthma. GINA now recommends that combination inhaled corticosteroid (ICS)-formoterol inhalers replace short-acting β-agonists as the preferred reliever therapy at all steps of management. While the most recent NAEPP guidelines did not review reliever ICS-formoterol usage in mild asthma, they similarly recommend single maintenance and reliever therapy (SMART) at Steps 3-4 of asthma management. Despite these recommendations, many clinicians-particularly in the United States (US)-are not prescribing new inhaler paradigms. Clinician-level reasons for this implementation gap remain largely unexplored.
Guided by a dissemination and implementation science framework, we conducted in-depth interviews of clinicians regarding the facilitators of, and barriers to, prescribing reliever ICS-formoterol in mild asthma and within SMART.
Community and academic primary care providers, pulmonologists, and allergists who reported regularly caring for adults with asthma were interviewed. Interviews were recorded, transcribed, qualitatively coded, and analyzed using the Consolidated Framework for Implementation Research (CFIR). Interviews were continued until theme saturation.
Among 20 interviewed clinicians, only 6 clinicians described regularly prescribing ICS-formoterol inhalers as a reliever inhaler (either alone or within SMART). Significant barriers to new inhaler approaches included concerns surrounding a lack of Food and Drug Administration labeling for ICS-formoterol as a reliever therapy, a lack of awareness regarding a patient’s formulary-preferred ICS-long-acting β-agonist choices, the high cost of combination inhalers, and time constraints. Facilitators to utilizing new inhaler approaches included clinicians’ beliefs that the latest inhaler recommendations are simpler, more congruent with real-world patients’ behavior, and that a potential change in management strategy would offer a valuable opportunity for shared decision making.
While new guidelines exist in asthma, many clinicians described significant barriers to utilizing them including medico-legal issues, pharmaceutical formulary confusion, and high drug costs. Nonetheless, most clinicians believed the latest inhaler approaches would be more intuitive for their patients and offer an opportunity for patient-centered collaboration and care. Stakeholders may find these results useful in future attempts to increase the real-world adoption of recent asthma recommendations.

Copyright © 2023. Published by Elsevier Inc.