Clinical Question: Does triple inhaler therapy improve outcomes over dual inhaler therapy in patients with moderate to severe asthma?
Background: For patients with moderate and severe asthma, an inhaled corticosteroid (ICS) and long-acting beta agonist (LABA) are foundational agents in management. Current guidelines, such as the National Asthma Education and Prevention Program, reserve the addition of a long-acting muscarinic antagonist (LAMA) to late stages in asthma management.
Study Design: Meta-analysis of 20 randomized clinical trials from 2017-2020
Setting: Authors included randomized clinical trials comparing dual-inhaler therapy to triple-inhaler therapy in adults and children with moderate to severe asthma from a highly inclusive list of reference databases from November 2017 to December 8, 2020, without a language restriction.
Synopsis: This high-quality meta-analysis of 20 randomized clinical trials from 2017-2020 evaluated outcomes in patients with moderate to severe asthma on triple inhaler therapy with ICS, LABA, and LAMA as compared to dual therapy with ICS and LABA.
Triple inhaler therapy was found to increase time to severe asthma exacerbation compared to dual inhaler therapy, with a slight improvement in FEV1. No differences in asthma-specific quality of life or mortality were identified. Although dry mouth and dysphonia are associated with LAMA therapy, there was no increase in treatment-related or serious adverse events.
This study demonstrates the potential benefits of adding a LAMA to reduce severe exacerbations in the moderate to severe asthma population.
Bottom Line: Since the outcome of severe exacerbation often means an admission to the hospital, hospitalists should consider triple inhaler therapy to reduce future severe exacerbations, and therefore admissions, in patients with moderate to severe asthma without concern for risk of harm.
Citation: Kim LHY, et al. Triple vs dual inhaler therapy and asthma outcomes in moderate to severe asthma: A systematic review and meta-analysis. JAMA. 2021;325(24):2466–79.
Dr. Magee is an assistant professor of medicine at the University of Virginia School of Medicine, Charlottesville, Va.