BACKGROUND: Because of risk of severe asthma exacerbations, current Global Initiative for Asthma recommendations advise against use of short-acting beta-agonists (SABAs) alone as the first step in treating mild asthma. It is unclear if everyone with mild asthma carries equal risk for severe asthma exacerbations. RESEARCH QUESTION: Is there a subgroup of patients with mild asthma with very low risk of severe asthma exacerbations? STUDY DESIGN AND METHODS: This study cohort used administrative claims data for patients ages 2 to 18 years with intermittent asthma enrolled in Ohio Medicaid Managed Care Plans for 3 consecutive years. A low-risk group was identified for the first 2 years; in the third year, risk of severe asthma exacerbations was compared among the low-risk group and the rest of the cohort. RESULTS: A total of 13,208 patients met inclusion criteria. In the third year, among 3,935 low-risk patients, rates of asthma hospitalization, emergency department visits, and urgent care visits for those with 0 to 2 SABA canisters dispensed per year were 3 (0.08%), 37 (0.97%), and 21 (0.55%), respectively, with a relative risk of hospitalization of 0.17 (95% CI, 0.06-0.52) and a relative risk of severe asthma exacerbation of 0.18 (95% CI, 0.13-0.27) compared with high-risk patients. In the low-risk cohort, the number of patients needed to treat to prevent 1 hospitalization was 5,535. The cost to prevent 1 hospitalization using a single inhaler of inhaled corticosteroids per year was $779,716. INTERPRETATION: Our results show that among patients with mild asthma, there is a subgroup of low-risk patients with lower risk of hospitalization and severe asthma exacerbation in which current Global Initiative for Asthma recommendations for first-step treatment may neither be needed nor cost-effective.

https://journal.chestnet.org/article/S0012-3692(25)05124-4/fulltext