Regimens, Adherence, and Adverse Events: The Role of the Pharmacist in Asthma Management

Asthma is a heterogeneous condition that affects both children and adults. While the clinical presentation of asthma may vary between patients, it typically manifests as chronic airway inflammation with fluctuating respiratory symptoms and expiratory flow over time. Symptoms include wheezing, coughing, shortness of breath, and chest tightness, which may be triggered by environmental allergens, weather changes, exercise, and viral infections, among other causes.^1-4

In addition to its direct burden on patients, asthma also represents a significant economic burden in the United States. Approximately 10.9 million missed workdays were attributed to asthma in 2018, and approximately 898,000 emergency department visits and 94,000 hospitalizations listed asthma as the primary cause in 2020, with the estimated annual health care cost due to asthma listed at $50.3 billion.⁵

Collaborative health care efforts are needed to effectively manage asthma in both inpatient and outpatient settings, and pharmacists play a key role in optimizing treatment plans in patients with asthma. Although treatment options for asthma have increased in recent years, inhaler devices remain the cornerstone of asthma management. Pharmacists have the unique opportunity to provide patients with detailed education on inhalers by explaining the different types of devices, demonstrating and correcting inhaler technique, and identifying ways to improve adherence.^2,6

Different Devices and Treatment Regimens

It is important for patients to understand that different medications are used in maintenance inhalers compared to reliever inhalers, as maintenance inhalers target long-term control and rescue inhalers target short-term relief. As medication experts, pharmacists can educate and counsel patients on various aspects of their medications, including the name, indication, directions for use, and potential adverse effects, in addition to highlighting the differences between each inhaler. These interventions help prevent medication misuse and subsequent suboptimal treatment due to errors such as using fast-acting inhalers as maintenance treatment and long-acting inhalers as rescue treatment.

Pharmacists can also help provide patients with clarification on treatment regimens that may be unfamiliar to them, such as maintenance and reliever therapy (MART). By allowing the same inhaler device to be used for both maintenance and rescue treatment, MART inhaler devices offer many benefits to patients, such as limiting confusion between multiple devices, reducing cost from purchasing multiple inhalers, and lowering potential risk of exacerbation. Patients may need explicit orienting and clear explanation of the purpose of such therapy, especially if they had previously used separate inhalers devices to manage their asthma.³

Whether starting patients on new inhalers or following up with patients who have been using the same inhaler for years, pharmacists are essential in educating patients on proper inhaler technique. For example, metered-dose inhaler (MDI) devices require coordination with pressing down on the canister and taking a slow, deep breath. If coordination deficiencies are observed, pharmacists can recommend a spacer or nebulizer to improve medication delivery to the lungs or suggest an alternative device.^7-9

MDI devices also require shaking before each dose (to properly disperse the medication) and priming before the first dose or after the inhaler has not been used in a long time (to allow the correct dose to subsequently be administered to the patient).⁹ By confirming that patients are completing these critical steps, pharmacists can ensure that patients receive their full dose of medication and are not escalating therapy unnecessarily in the setting of poor technique.

Unlike MDI devices, dry powder inhaler (DPI) devices require a fast, deep breath, as there is no button that will propel the medication into their lungs. Therefore, pharmacists play a crucial role in confirming that patients have adequate breath strength to take a fast, deep breath or coaching patients on how to take a more forceful breath through real-time demonstration with a DPI.⁹

Soft mist inhaler (SMI) devices slowly release medication through a mist, requiring a slow, deep breath like the MDI devices. However, patients who use SMI devices must have adequate grip strength to twist the inhaler to load each dose. Pharmacists can optimize treatment regimens by recommending alternative inhalers for patients who have low grip strength, which may include older adults, patients with arthritis, and patients with movement disorders such as Parkinson disease.⁹

Strategies to Improve Adherence

Improving adherence is also a key component of managing asthma. By conducting comprehensive medication histories, pharmacists can identify patients who struggle taking their medications as prescribed and recommend switching to similar inhalers that require fewer administrations per day. For example, fluticasone/vilanterol (Breo Ellipta; GSK) requires 1 inhalation each day and may be preferred to budesonide/formoterol (Symbicort; AstraZeneca), which requires 2 inhalations twice daily.^10,11

Adherence can also be heavily influenced by medication cost, which serves as another major area for pharmacist intervention. By reviewing patients’ insurance plans and drug formularies, pharmacists can identify potential access barriers and recommend specific inhalers that are covered or provide coupons to enhance medication affordability.

Other ways to improve patient adherence include assessing dispense reports for signs of noncompliance, utilizing the teach-back method with patients and/or family members assisting with treatment, and encouraging shared decision-making with patients in choosing an inhaler device that is best for them.

Anticipate and Address Adverse Events

Pharmacists also contribute significantly to asthma management through interventions to minimize adverse effects and drug interactions. For example, higher doses and longer durations of inhaled corticosteroids (ICS) are associated with a higher risk of side effects including bruising, pneumonia, and osteoporosis. Incorrect technique with ICS-containing inhalers (eg, not rinsing the mouth with water after each dose) can also cause medication to stay in the mouth and throat rather than entering the lungs, which increases the risk of developing thrush and dysphonia.¹² For these reasons, pharmacists play an important role in encouraging use of the minimum effective ICS dose once asthma control is achieved and addressing concerns related to technique, adherence, and triggers before recommending higher ICS doses.

Medication management can be improved further by checking whether patients are taking any other medications that can have potential drug–drug interactions. For example, cytochrome P450 3A4 inhibitors such as ketoconazole, ritonavir, and clarithromycin can increase serum concentrations of ICS medications, increasing the risk of ICS adverse events. Patients with cardiovascular comorbidities may also be taking non-selective ß blockers, which block ß-2 receptors in addition to ß-1 receptors and interfere with bronchodilation.^13,14

Conclusion

Asthma represents a major disease state in which pharmacists can make significant interventions to improve patient care. Pharmacists make valuable contributions to asthma management by educating patients on inhaler devices, techniques, and adherence, as well as making recommendations to the health care team to address medication costs, adverse events, and drug interactions.

Pharmacists remain key players in asthma management, and their role will continue to grow as more medical therapies are developed for the treatment of this widespread and heterogeneous disease state.

REFERENCES

1. Dharmage SC, Perret JL, Custovic A. Epidemiology of asthma in children and adults. Front Pediatr. 2019;7:246. doi:10.3389/fped.2019.00246

2. Asthma. World Health Organization. May 6, 2024. Accessed January 8, 2026. https://www.who.int/news-room/fact-sheets/detail/asthma

3. Global strategy for asthma management and prevention, 2025. Global Initiative for Asthma. Updated November 15, 2025. Accessed January 8, 2026. https://ginasthma.org/wp-content/uploads/2025/11/GINA-2025-Update-25_11_08-WMS.pdf

4. Asthma management guidelines: focused updates 2020. National Institutes of Health. Updated February 4, 2021. Accessed January 8, 2026. https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates

5. Asthma trends and burden. American Lung Association. Updated July 15, 2024. Accessed January 8, 2026. https://www.lung.org/research/trends-in-lung-disease/asthma-trends-brief/trends-and-burden

6. Bridgeman MB, Wilken LA. Essential role of pharmacists in asthma care and management. J Pharm Pract. 2021;34(1):149-162. doi:10.1177/0897190020927274

7. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4):1008-1015. doi:10.1378/chest.114.4.1008

8. Tzeng YF, Chiang BL, Chen YH, Gau BS. Health literacy in children with asthma: a systematic review. Pediatr Neonatol. 2018;59(5):429-438. doi:10.1016/j.pedneo.2017.12.001

9. Maricoto T, Monteiro L, Gama JMR, Correia-de-Sousa J, Taborda-Barata L. Inhaler technique education and exacerbation risk in older adults with asthma or chronic obstructive pulmonary disease: a meta-analysis. J Am Geriatr Soc. 2019;67(1):57-66. doi:10.1111/jgs.15602

10. Symbicort [prescribing information]. AstraZeneca; Updated June 2010. Accessed January 8, 2026. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021929s021lbl.pdf

11. Breo Ellipta [prescribing information]. GlaxoSmithKline; Updated May 2023. Accessed January 8, 2026. https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/204275s022lbl.pdf

12. Foster JM, Aucott L, van der Werf RHW, et al. Higher patient perceived side effects related to higher daily doses of inhaled corticosteroids in the community: a cross-sectional analysis. Respir Med. 2006;100(8):1318-1336. doi:10.1016/j.rmed.2005.11.029

13. Raissy HH, Kelly HW, Harkins M, Szefler SJ. Inhaled corticosteroids in lung diseases. Am J Respir Crit Care Med. 2018;187(8):798-803. doi:10.1164/rccm.201210-1853PP

14. Morales DR, Lipworth BJ, Donnan PT, Jackson C, Guthrie B. Respiratory effect of beta-blockers in people with asthma and cardiovascular disease: population-based nested case control study. BMC Med. 2017;15(1):18. doi:10.1186/s12916-017-0781-0