“I just need another blue inhaler — I get through them, but they sort me out”

Frequent reliever (SABA) use is a RED-FLAG marker of poorly controlled asthma and increased risk of severe attacks and asthma DEATH — not a benign request: using 3 or more SABA inhalers a year is associated with more exacerbations and a reliever needed more than twice a week needs review (MHRA Drug Safety Update, April 2025), and the National Review of Asthma Deaths (RCP, 2014) found that many of those who died had been prescribed more than 12 relievers in the previous year, with preventer under-use. So a 7th salbutamol in 12 months with little preventer use demands ASSESSMENT, not a quick reissue. Assess control rather than accept "I feel fine" (NICE NG245: prescription records and a validated questionnaire such as the Asthma Control Test): symptom and reliever frequency, night waking, activity limitation, exacerbations and oral-steroid courses, and prior attacks/A&E/admissions/ICU (the strongest predictors of future risk) — frequent SABA use IS uncontrolled asthma even when normalised. Explain that the inhaled CORTICOSTEROID preventer treats the underlying airway inflammation and reduces attacks and deaths whereas the reliever only masks symptoms, and explore why the preventer is not taken (steroid beliefs, "only when bad", no perceived benefit, poor technique, access) — correcting the dangerous "fine on the blue" misconception. Optimise the regimen per NICE NG245: after addressing adherence, technique and triggers, move someone not controlled on low-dose ICS plus SABA to low-dose ICS–FORMOTEROL MART (a single inhaler used daily and as reliever, so every reliever puff delivers anti-inflammatory ICS; as-needed ICS/formoterol alone is the starting point for new diagnoses), reducing SABA reliance and exacerbations — the marks are in recognising risk and optimising, not adding another blue inhaler. Check inhaler technique, identify triggers (smoking/allergens/NSAIDs/occupational), provide a personalised asthma action plan, check flu vaccine eligibility (Green Book chapter 19), and arrange proactive review (moderate-dose MART, then objective tests and specialist advice, if still uncontrolled). Reframe SABA overuse clearly but without frightening the patient into disengagement, and safety-net for attacks.