The wrong best-seller

A reliever inhaler is not the same as a treatment. When millions of Indians reach for the blue puffer — or worse, a home nebuliser — several times a week, the country is not winning the battle against asthma. It is quietly losing it.

A market signal that should worry us

In most industries, a brand making it to the top 20 is a moment for champagne. In Indian respiratory medicine, the rise of a short-acting beta-agonist combined with ipratropium — a salbutamol-or-levosalbutamol-plus-ipratropium duo, henceforth SABA+SAMA — into that elite club should occasion something closer to alarm. A bronchodilator is a rescue tool. When a rescue tool becomes a chart-topper, the obvious question is: rescue from what, and how often?

The economics is straightforward. A medicine ranks high because many people buy it, often. For chronic-controller medicines such as inhaled corticosteroids (ICS), high sales would be encouraging — they would suggest that more asthmatics are receiving the anti-inflammatory therapy that prevents attacks. For a reliever like SABA+SAMA, however, the same signal carries the opposite meaning. Each extra canister sold is, on the population scale, evidence that someone, somewhere, could not breathe.

What the global evidence actually says

The Global Initiative for Asthma (GINA), the field’s reference body, made a paradigm shift in 2019 that has hardened with every annual update since. Its 2024 and 2025 strategy reports are unambiguous: adults and adolescents with asthma should never be treated with a short-acting beta-agonist alone. Every patient, regardless of severity, requires an inhaled corticosteroid as part of their regimen. The reason is biological. SABA opens the airway for a few hours; it does nothing for the underlying inflammation that causes the airway to narrow in the first place. Used alone, it masks the disease while the disease worsens.

The evidence underwriting that shift is some of the most consistent in modern respiratory medicine. The SABINA programme — a series of observational studies covering more than a million patients across 25-plus countries — has shown the same dose-response curve wherever it has looked. In Sweden, patients dispensed three or more SABA canisters in a year had measurably higher rates of severe exacerbations and all-cause mortality than those who used fewer. In Canada, the adjusted risk of a severe attack rose by roughly a third among over-users. The global SABINA III analysis found that patients prescribed three to five SABA inhalers a year suffered about 40% more severe exacerbations than those prescribed one or two; the curve climbed steeply from there.

India is not an outlier in this data — it is squarely inside it. The Indian subset of SABINA III found that roughly one in four asthmatics seen in clinic had been over-prescribed SABA in the preceding twelve months. The primary-care arm of the same study showed that almost 45% of asthma patients across SABINA III sites received three or more SABA canisters a year, and more than one in five purchased SABA over-the-counter on top of what was prescribed. Almost six in ten were partially or completely uncontrolled. Nearly four in ten had suffered at least one severe exacerbation in the past year.

“A reliever inhaler rising into India’s top 20 brands is not a sign that asthma is being treated. It is a sign that asthma is being chased.”

Why the SABA+SAMA combination is a particular concern

Adding ipratropium — a short-acting anti-muscarinic, hence the “SAMA” — to salbutamol or levosalbutamol does not change the basic problem. The combination is genuinely useful in the emergency room during a severe acute attack, where guidelines from GINA and others support its short-term use. It is not designed for, and was never meant to be, the daily backbone of asthma care.

Yet that is increasingly how it is used in Indian homes. The combination is cheap, easy to obtain, available in nebuliser solution as well as inhaler, and — critically — it works fast. A patient who wheezes after climbing a flight of stairs takes a puff, feels relief within minutes, and concludes that they have managed their condition. They have not. They have postponed it. The underlying eosinophilic inflammation, untouched by either component of the combination, continues to remodel their airways. The next attack will be larger, and the dose required to relieve it will be larger still.

The clinical literature is blunt about where this road ends. A 2024 post-hoc analysis of SABINA III found that any over-the-counter SABA purchase, in addition to a prescription, was associated with worse asthma control and a higher incidence of severe attacks. The harm is not theoretical. It is measured in hospital admissions, in courses of oral steroids — themselves implicated in osteoporosis, diabetes and pneumonia when repeated — and, in the worst cases, in funerals that should never have happened.

The quiet medicalisation of the middle-class home

The other story buried in the sales figures is the nebuliser. Twenty years ago, the device was found mainly in hospital wards and a few specialist clinics. Today it sits on the kitchen counters of middle-class apartments across Lucknow, Pune and Coimbatore, an entry-level model costing less than a smartphone. It is, in many homes, the default response to any cough, any wheeze, any seasonal chest tightness in a child or grandparent. The respules — the unit-dose plastic vials — are almost invariably salbutamol or levosalbutamol, often with ipratropium, sometimes with budesonide as an afterthought.

This is medicalisation, not medicine. The instinct to act is admirable; the action chosen is wrong. A nebuliser delivers a dose of bronchodilator that is several times what a metered-dose inhaler provides, with proportionally more systemic absorption — tremor, tachycardia, sleep disturbance — and none of the disease-modifying benefit that an inhaled steroid offers. Worse, the ritual of nebulisation tends to displace, rather than complement, the slower, less dramatic discipline of taking a controller every morning. A puff that does nothing visible loses out, in the household economy of attention, to a mask that produces visible mist and audible relief.

The consequence is a generation of Indian patients, particularly children, learning that asthma is something to be put out like a fire, repeatedly, rather than prevented like a slow leak. Pulmonologists have begun calling it the “nebuliser-in-every-home” phenomenon. The phrase is benign. The trajectory is not.

Why people stay on the wrong drug: the price floor

If the case against SABA-only and SABA+SAMA-only treatment is so clear, why do so many Indian patients remain on it? The answer, in many cases, is not ignorance. It is arithmetic.

An inhaled corticosteroid combined with a long-acting beta-agonist (ICS+LABA) — the regimen that GINA actually recommends — has, until recently, cost several hundred rupees a month in India. For a daily-wage labourer in Uttar Pradesh, or a retired schoolteacher on a pension, that is the difference between adherence and abandonment. The patient, asked to choose between a 60-rupee SABA inhaler that visibly works and a 400-rupee controller whose benefit is the absence of symptoms three months later, makes a rational, tragic choice. The price floor of correct treatment has, for two decades, kept millions of Indians on the wrong rung of the therapeutic ladder.

This is the failure that sits at the centre of #RTI — Right To Inhalation, the cause I have built my working life around. The argument is straightforward: in a country where roughly 35 million people live with asthma, the cost of a controller inhaler should not be the rate-limiting step on the path to controlled disease. At my own company, Bayu Healthcare, we priced our ICS+LABA dry-powder inhaler at ₹99 for 30 capsules as a deliberate break with that unwritten price floor. (I say this as disclosure, not as an advertisement: the argument holds whoever makes the inhaler.) A patient who can afford a 60-rupee SABA canister can afford a 99-rupee month of disease-modifying therapy. The barrier dissolves.

“A patient who can afford a 60-rupee reliever can afford a 99-rupee month of disease-modifying therapy. The barrier dissolves.”

What needs to change, and by whom

Reversing a national habit will take more than one company’s pricing strategy, however significant. Three constituencies have work to do.

For prescribers, particularly the primary-care physicians who write the first script for the vast majority of Indian asthmatics, GINA’s Track 1 recommendation — as-needed ICS-formoterol, or in cost-constrained settings, a daily low-dose ICS with a SABA reliever — should now be the default. Writing a SABA-only or SABA+SAMA-only prescription for a patient with diagnosed asthma is, in 2026, a guideline deviation that needs justification.

For pharmacists, the over-the-counter sale of a third, fourth or fifth SABA canister to the same customer in a year is not a transaction. It is a public-health signal. Pharmacy chains, particularly the organised ones, have the data to spot SABA over-purchasers and to suggest a physician review. The SABINA III over-the-counter analysis suggests roughly one in five asthmatics is topping up their prescription through this channel; intercepting that pattern would prevent a measurable number of hospital admissions a year.

For patients and families, the message is harder but more important. Relief is not the same as treatment. A puffer that works in two minutes is not better than a puffer that works over two months — the two are doing different things. The presence of a nebuliser in the house does not lower the bar for what counts as well-managed asthma; if anything, it raises the obligation to ensure that controller therapy is also in place.

Reading the chart differently

It is tempting, when a brand from one’s category makes the top 20, to celebrate. The chart suggests reach, awareness, success. But the chart for a reliever inhaler is a temperature reading for a country’s respiratory health, and right now the reading is high. A SABA+SAMA combination at the top of the Indian pharmacopoeia tells us that millions of our compatriots are reaching for the wrong tool, several times a week, for a disease whose correct treatment has been settled science for half a decade.

The fix is not a mystery. It is an inhaled corticosteroid, taken daily, at a price the patient can sustain. India now has that option. The remaining task is to make sure that the next time a brand cracks the top 20 of the Indian pharmaceutical chart, it is the right one.