Improve Asthma Management with Triple Inhaled Therapy

Key Takeaways

Inhaled corticosteroids and long-acting β-2 agonists are first-line asthma treatments, but many patients remain uncontrolled.
Long-acting muscarinic antagonists are underused despite their potential to address exacerbations and airway dysfunction.
Survey of 314 clinicians showed mixed views on inhaled triple therapy, with 35.7% considering it valid and 30.9% rarely prescribing it.
Most clinicians prioritize inhalation therapy optimization before biologics, with divided opinions on combining biologics with ITT.
Expiratory flow limitation is crucial in therapy selection, indicating a need for better integration of research into clinical practice.

Many patients do not attain sufficient disease control with inhaled corticosteroids in combination with long-acting β-2 agonists and remain vulnerable to exacerbations.

Asthma is a chronic lung condition characterized by swelling, excess mucus, and muscle tightening around the airways.Symptoms include episodes of coughing, wheezing, chest tightness, and shortness of breath.¹ The Global Initiative for Asthma (GINA) outlines asthma treatment that aims to achieve disease control, prevent airway damage, reduce future exacerbation risks, and minimize medication side effects.^2,3

Set of asthma inhalers for asthma and COPD patients on table. Pharmaceutical product is used to treat lung inflammation and prevent asthma attack symptoms

Inhaled corticosteroids in combination with long-acting beta-2 agonists are the first line treatment | Image credit: Orawan | stock.adobe.com

Inhaled corticosteroids (ICS) in combination with long-acting b-2 agonists (LABA) are the first line of treatment for asthma patients.^1,2 Despite these treatments, many patients do not attain sufficient disease control and remain vulnerable to exacerbations. This may stem from poor treatment adherence, improper inhaler technique, or disease severity.² Long-acting muscarinic antagonists (LAMA) are recommended as an additional therapy to ICS-LABA in uncontrolled asthma, but prescribers tend to underuse LAMA in this setting despite its ability to treat exacerbation propensity, airflow limitation, neuronal plasticity, small airway dysfunction, mucus hypersecretion, and neutrophilic airway inflammation.^2,3

Study results published in Pulmonology Pharmacology and Therapeutics examined the results of a questionnaire investigating the usage of inhaled triple therapy (ITT). The surveyors divided the results into 3 subgroups²:

Specialist attitudes toward the timing, methods, and results involved in prescribing ITT
The correlation between ITT and biologic therapies
Clinicians’ perceived value for the effectiveness of ITT in asthma management

In total, 314 clinicians from 47 countries and different economic classes answered the questionnaire. In total, 35.7% agreed that ITT can be considered a valid therapeutic option for their patients, with 30.9% stating that they rarely or never prescribed it.² Roughly 67% of participants agreed that ITT improves lung function, whereas 15% disagreed and 17.8% were undecided. Additionally, 84.7% emphasized the importance of ITT in a single inhaler.²

The majority of specialists (89.2%) agreed that optimizing inhalation therapy to achieve symptom control should precede the use of biologics. Among the physicians surveyed, 49.7% believed that biologics should always be administered alongside ICS-LABA treatment. However, opinions on combining biologics with ITT were almost evenly split: 42.6% supported it, 39.2% opposed it, and 18.2% were neutral.²

About the Author

Tori L. Fournier, BSc, is a student in the medical writing certificate program at the University of Connecticut.

As for perceived value in ITT effectiveness, most specialists (79.6%) recognized expiratory flow limitation as a crucial factor in selecting the optimal therapeutic strategy for patients. This functional parameter was acknowledged by 84.7% of clinicians when prescribing inhalation therapy, whereas only 2.2% expressed minimal agreement. Physicians also identified several traits as predictors of a favorable response to ITT, including decreased lung function (20.1% of all traits listed), small airway dysfunction (16.4%), and pulmonary remodeling (11.3%). These were followed by glucocorticoid resistance (9.4%) and neutrophilic inflammation (9.3%).²

The study highlights clinicians' mixed perspectives about ITT, emphasizing the need for further initiatives to bridge the gap between research findings and routine clinical practice.

REFERENCES

1. Asthma Treatment. Asthma and Allergy Foundation of America. Updated June 2021. Accessed January 29, 2025. https://aafa.org/asthma/asthma-treatment/

2. Bagnasco D, Ansotegui I, Baiardini I, et al. Triple inhaled therapy in asthma: beliefs, behaviours, and doubts. Pulm Pharmacol Ther. 2024;87:102333. doi:10.1016/j.pupt.2024.102333

3. 2024 Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma. Updated 2024. Accessed January 29, 2025. https://ginasthma.org/wp-content/uploads/2024/05/GINA-2024-Strategy-Report-24_05_22_WMS.pdf