Current perspectives on β2-adrenergic receptor agonists in asthma: navigating from track to track within GINA recommendations.

INTRODUCTION: Asthma treatment has long relied on short-acting β2-adrenergic receptor (β2-AR) agonists (SABA) such as salbutamol for as-needed relief, often without concurrent anti-inflammatory therapy. Emerging data link frequent SABA use to higher exacerbation rates and mortality. Current recommendations organize asthma treatment into Track 1, with as-needed inhaled corticosteroid (ICS)/formoterol used also as maintenance-and-reliever therapy, and Track 2, with SABA or ICS/SABA reliever plus separate maintenance; Track 1 is identified as the preferred option.

AREAS COVERED: This review evaluates β2-AR agonist use within the Track 1/Track 2 context. Randomized trials show as-needed ICS/formoterol reduces severe exacerbations more than SABA-based regimens, without a detectable mortality signal. Large observational evidence indicates that 3-5 SABA canisters per year already associates with increased mortality, with higher risk at 6-10 and ≥11 canisters per year. Contemporary trials and real-world studies reveal many patients on SABA-centered or fluticasone furoate/vilanterol regimens may reach these exposure levels, whereas ICS/formoterol regimens produce lower reliever use and fewer exacerbations.

EXPERT OPINION: Where ICS/formoterol is accessible, Track 1 should be the default strategy. Clinicians should minimize SABA overuse, prioritize ICS/formoterol regimens, and advocate policies improving access to reduce preventable morbidity and mortality.