In 2011 the British asthma guidelines recommended for the first time that long-acting beta agonists (LABAs) should be prescribed in fixed dose combination inhaled corticosteroid (ICS)/LABA inhalers in the treatment of asthma.1 This represented a revision to the 2009 BTS guidelines in which LABAs were recommended if used with ICS, either as separate inhalers or as a combination ICS/LABA inhaler.2 The revision was based on the evidence that LABAs have the potential to increase the risk of asthma mortality when used by patients with unstable asthma without concomitant ICS therapy or scheduled medical review,3 that there is no evidence of an increased risk of asthma mortality with combination ICS/LABA inhaler therapy in asthma,4 and that it is only with combination ICS/LABA products that it could be guaranteed that LABA monotherapy can be avoided.5 It recognised that the use of separate inhalers inevitably results in periods of LABA monotherapy in a proportion of patients, because patients who are poorly adherent to prescribed ICS therapy may continue using their LABA inhaler for symptomatic relief.5–7

The extent to which this may occur is now described in an audit of prescribing from a Scottish GP database, reported in this edition of the journal by Morales et al.8 Of the 29% of patients with asthma who were prescribed a LABA during the 2006 calendar year, about one in four were prescribed a LABA in the form of a separate inhaler …